浅镇静,要多浅

浅镇静，要多浅？“….ButwhatIseethesedaysareparalyzed,sedatedpatients,Lyingwithoutmotion,appearingtobedead,exceptfortheMonitorsthattellmeotherwise.”ThomasL.Pettyayoungpoliopatient.Copenhagen1952当今镇静所关注的问题CritCareMed2013;41:263–306成人ICU患者维持轻度镇静可改善临床预后目标：轻度镇静2002需要根据患者情况设置镇静目标RationalesforlightSedationCritCareMed2013;41:263–306对成人ICU患者，维持轻度镇静可改善临床预后（如缩短机械通气时间及ICU住院时间）（B）Benefitfromlightsedation机械通气时间ICU住院时间死亡率也可能降低谵亡的发生率LightversusdeepsedationonmentalhealthaftercriticalillnessCritCareMed2009;37:2527–2534Design:随机,非盲,对照试验.Setting:单中心三级医院.Patients:需要机械通气的成人ICU患者.Interventions:患者随机分成轻度镇静组(患者清醒配合,Ramsay评分1-2,n=69)or深度镇静组(患者嗜睡,外界刺激能醒,Ramsay评分3-4,n=68).•区别什么是浅镇静和深镇静.•解释浅镇静的临床预后.•临床试验研究.ProportionoftimespentontargetRamsaysedationgoalRamsay1–2,白色柱子体Ramsay3–4,黑色柱状体CritCareMed2009;37:2527–2534死亡率,住院时间,器官衰竭,机械通气时间CritCareMed2009;37:2527–2534Lancet2010;375:475–80Lancet2010;375:475–80轻度镇静还是不镇静?Procedures(Nosedation)Thisgroupreceivedmorphineinbolusdoses(2·5or5mgi.v)asneeded.Ifdeliriumwassuspected,intravenoushaloperidolwasgivenasbolusdoses(1,2·5,or5mg),butifthepatientstillseemeduncomfortableafterthistreatment,thepatientwassedatedwithpropofolfor6h.Lancet2010;375:475–80Sedativesandmorphineusagemg/kg/hrNosedation(n=55)sedation(n=58)Propofol0(0–0·515)0·773(0·154–1·648)Midazolam0(0–0)0·0034(0–0·0240)Morphine0·0048(0·0014–0·011)0·0045(0·002–0·0064)Halopiredol0(0–0·0145)0(0–0)评价镇痛+浅镇静过度镇静+镇痛Lancet2010;375:475–80镇静组Propofol实际给与量：54.11mg/hr(中位数)=1%propofol5-6ml/hr还有咪唑安定+吗啡=至少有50%患者是过度镇静Lancet2010;375:475–80避免过度镇静造成的不良影响Theincidenceofsub-optimalsedationintheICU:asystematicreview•Jackson所进行一项荟萃分析发现，即使在控制相对严格的随机对照研究中（RCT），不恰当镇静的患者比例仍可能高达60%以上。•进一步分析发现，所有入选文献所报道过度镇静的发生率从2.8-44%不等。CriticalCare2009,13:R204CriticalCare2009,13:R204Theincidenceofsub-optimalsedation过度镇静的发生率例数过度镇静Payen,20071,381258(57%)of451ptsonsedationday2;169(48%)of355ptsonday4;109(41%)of266ptsonday6Martin,200630520ICUs42.6%of49ptssedated24-72hours,39.5%of157ptssedated72hours,43.9%of57ptsunderweaninghadsignificantlydeepersedationWeinert,200727412,414assessments.111pts(40%)had≥1ratingofoversedation.Overallbetween40%and60%forover-sedationCriticalCare2009,13:R204深镇静与MV病人预后MV（hr)317167ICU(Days)19.19.9Outcome(%)16.715.3Non-optimalOptimalMasciaMF,CCM2000镇静负作用ICU获得性感染发生率Nseiretal.CriticalCare2010,14:R30FORSEVEREAGITATION,Lorazepam1-2mgIM/IV!DailyinterruptionofsedativesinfusionincriticallyillpatientswithMVKressJP,etal.NEnglJMed2000;342:1471-7缩短机械通气天数CritCareMed2005;33:120–127)ThealgorithmwasbasedonregularassessmentsofconsciousnessandtolerancetotheICUenvironmentandwasdesignedtoachievetoleranceandmaintainahighlevelofconsciousnessSedationalgorithmincriticallyillpatientswithoutacutebraininjuryTreatmentprotocolsICU=intensive-careunit.SAT=spontaneousawakeningtrial(interruption).SBT=spontaneousbreathingtrialGirardTD,etal.Lancet2008;371:126–34OutcomesGirardTD,etal.Lancet2008;371:126–34Survivalat1yearGirardTD,etal.Lancet2008;371:126–34OutcomesFreeofMV(days)Lancet2010;375:475–80Lightsedationlookslike“our”dream.浅镇静不能过浅2013年PAD临床指南•保持轻度镇静水平可以增加生理应激反应，但同时不增加心肌缺血的发生率（B）•对于此类患者，镇静深度与心理应激反应的相关性尚不清楚（C）sympatheticNerveMedullaAdrenalineNon-adrHeartVesselsBronchiSystematicstressresponsesBeneficialHarmfulβ-endorphin镇静/镇痛药物与休克组织损伤Ratswererandomlyreceivednormalsaline(1mL/h),1mg/kg/hror10mg/kg/hrpropofolafterhaemorrhagicshock.ClinicalandExperimentalPharmacologyandPhysiology(2008)35,766–774LightsedationprotectorgansfrominflammatoryinjuryClinicalandExperimentalPharmacologyandPhysiology(2008)35,766–774PlasmaepinephrinealterationsinnearbedconsciouspatientsduringCPR00.511.522.50分钟10分钟4小时24小时图2血浆肾上腺素浓度变化(ng/ml)对照组N=13心理护理组N=13镇静组N=14李秦中国危重病急救医学2008;20:193-196CPR时邻床清醒患者心律失常发生情况病例数心律失常例数（百分率）总例数室上速房性早搏室性早搏短阵室速对照组2622（84.6）22（84.6）5（19.2）7（26.9）0（0）心理组3318（54.5）16（48.5）6（18.1）4（12.1）1（3.0）镇静组286（21.4）6（21.4）0（0）2（7.1）0（0）P值0.050.010.010.050.05-----李秦，中国危重病急救医学2008;20:193-196SequentialUseofMidandPropforLong-TermSedationinPostoperativeMVPtsAnesthAnalg2003;96:834–8TheincidenceofagitationduringWake-up例数躁动例数（%）镇静过程中唤醒过程中异丙酚346(17.7)8（23.5）咪唑安定365(13.9)19（52.8）序贯241(4.2)7（29.2）合计9412（12.7）34（36.1）χ2值(P值)2.362(0.336)7.164(0.031)刘京涛马朋林解放军医学杂志2008;33(8)950-952Cases(%)ofBPandHRvariation分组例数镇静过程中唤醒过程中血压心率血压心率异丙酚343(8.82)3(8.82)3(8.82)4(11.8)咪唑安定362(5.56)3(8.33)13(36.1)12(33.3)序贯241(4.17)1(4.17)3(12.5)2(8.33)合计946(6.38)7(7.45)19(20.2)18(19.2)χ2值(P值)0.509(0.79)1.097(0.68)9.26(0.012)7.69(0.03)刘京涛马朋林解放军医学杂志2008;33(8)950-952Memory,anxiety,depressionandPTSDinMVpatients5daysand2monthspost-ICUN=226Kaplan-MeierCurvesforTimetoSuccessfulExtubationInterruptionNoInterruptionyesJAMA.2012;308(19):1985-1992Problemsin“Nosedation”•Deliriumwasrecordedin11(20%)patientsintheinterventiongroupand4(7%)inthecontrolgroup(p=0・0400).•Haloperidolwasusedmorefrequentlyintheinterventiongroup(n=19)thaninthecontrolgroup(n=8;p=0・0100).Lancet2010;375:475–80Deliriumdurationandmortalityinlightlysedated,mechanicallyventilatedintensivecarepatients•Design:Prospectivecohortanalysis.•Setting:Patientsfrom68ICUsinfivecountries.•Patients:354ICUpatients•Interventio