ICU镇痛镇静iPAD指南__培训课件.ppt

SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group: Dexmedetomidine vs midazolam for sedation of critically ill patients: A randomized trial. JAMA 2009; 301:489–499 2B的推荐 +2：A weak recommendation: in favor of an interv- ention implied that the benefits of the intervention likely outweighed the risks , but that task force members were not confident about these trade-offs, either because of a low quality of evidence or because the trade-offs between risks and benefits were closely balanced. B：Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. 选择非苯二氮卓类？ 有限证据基础之上的 弱程度推荐 Agitation and Sedation 镇静剂的选择需考虑： 个体化的适应症和镇静方案 药物的临床药理学（起效、失效时间及副作用） 费用 急性有机磷农药中毒， 经积极治疗后病情好转， 神志清楚，脱机拔管， 血流动力学稳定，但 仍时有躁动 您会如何镇静？ 选择何种镇静药物？ 高脂血症致重症急性胰 腺炎患者, IAP 28cmH2O,A/C模式: FiO2 90-100%, PEEP12-15cmH2O, Vt 400ml, f 20-24bpm, 监 测Pplat 30-32cmH2O, 人 机对抗 您又会如何镇静？ 选择何种镇静药物？ Agitation and Sedation 推荐轻度镇静，是否适合所有患者？ 重度ARDS 肺复张/HFV 重型颅脑外伤 严重颅内高压 心外科术后 严重心衰 深度镇静的需求 原发病与 临床情况 镇静 深度 镇静 时长 个体化的镇静方案 个体化的药物选择 Clinical Pharmacology of Sedatives Midazolam 镇静 催眠 抗焦虑 顺行性遗忘 抗惊厥 无镇痛作用 长期给药、老年、肝肾功能障碍者可能苏醒延迟 Propofol 镇静 催眠 抗焦虑 止吐 剂量依赖性抗惊厥 无镇痛作用 长期给药导致苏醒延迟 Adverse Effects Midazolam 呼吸抑制 低血压 Propofol 呼吸抑制 低血压 注射痛 高甘油三脂血症 胰腺炎 过敏反应 PRIS Dexmedetomidine 选择性α2-受体激动剂 镇静、镇痛、抗交感活性 无抗惊厥作用 清醒镇静，呼吸抑制极弱 低血压、心动过缓 15分钟内起效，1小时内达最大镇静效果 Cost 6项关于采用苯二氮卓类药物镇静对患者ICU 花费影响的研究中，仅有1项结果提示：应用 咪达唑仑镇静的ICU花费高于右美托咪定组。 Dasta JF, Kane-Gill SL, Pencina M, et al: A cost-minimization analysis of dexmedetomidine compared with midazolam for long-term sedation in the intensive care unit. Crit Care Med 2010; 38:497–503 No benzodiazepine has all the ideal characteristics one would wish for in a sedative But all benzodiazepines do share one desirable characteristic: They are inexpensive Benzodiazepines are inexpensive, safe, and familiar to physicians and are readily adjusted to patient symptoms