2015-PAD指南与阿片类镇痛药在ICU中的合理使用-liudong-酒泉.ppt

Intensive Care Med (2011) 37:469–476 A total of 11 randomised controlled trials, comparing remifentanil with another opioid or hypnotic agent in 1067 critically ill adult patients, were identified from the Cochrane controlled trials register and EMBASE and MEDLINE databases, and subjected to meta-analysis. Remifentanil was associated with a reduction in the time to tracheal extubation after cessation of sedation (weighted-mean-difference )2.04 h (95% CI )0.39 to )3.69 h); p = 0.02). Remifentanil was, however, not associated with a significant reduction in mortality (relative risk 1.01 (95% CI 0.67–1.52); p = 0.96), duration of mechanical ventilation, length of intensive care unit stay, and risk of agitation (relative risk 1.08 (95% CI 0.64–1.82); p = 0.77) when compared to an alternative sedative or analgesic agent. The current evidence does not support the routine use of remifentanil as a sedative agent in critically ill adult patients. PAD Care Bundle Barr J, et al. Crit Care Med. 2013;41:263-306. A PAIN AGITATION DELIRIUM Assess pain ≥ 4x/shift prn Preferred pain assessment tools: Patient able to self-report → NRS (0-10) Unable to self-report → BPS (3-12) or CPOT (0-8) Patient is in significant pain if NRS ≥ 4, BPS 5, or CPOT ≥ 3 Assess agitation, sedation ≥4x/shift prn Preferred sedation assessment tools: RASS (-5 to +4) or SAS (1 to 7) NMD→ suggest using brain function monitoring Depth of agitation, sedation defined as: Agitated if RASS = +1 or +4, or SAS + 5 to 7 Awake and calm if RASS = 0, or SAS = 4 Lightly sedated if RASS = -1 to -2, or SAS = 3 Deeply sedated if RASS = -3 to -5, or SAS = 1 to 2 Assess delirium Q shift prn Preferred delirium assessment tools: CAM-ICU (+ or -) ICDSC (0 to 8) Delirium present if: CAM-ICU is positive ICDSC ≥ 4 Treat pain within 30’ then reassess: Non-pharmacologic treatment-relaxation therapy Pharmacologic treatment: Non-neuropathic pain → IV opioids +/- non- opioid analgesics Neuropathic pain → gabapentin or c