icu譫妄及abcde集束化預(yù)防方案

1、南華大學(xué)附屬第一醫(yī)院ICU 王橋生Delirium -譫妄第1頁，共85頁。內(nèi)容譫妄的流行病學(xué)譫妄概念、主要特征和分類譫妄的目前關(guān)注情況譫妄的危害譫妄的風險因素譫妄評估及診斷譫妄的預(yù)防譫妄預(yù)防的集束化方案-ABCDE方案譫妄治療第2頁，共85頁。流行病學(xué)Delirium occurs in up to 80% of patients admitted to intensive care units. Although under-diagnosed, delirium is associated with a significant increase in morbidity and mort

2、ality in critical patients.ICU患者譫妄發(fā)生率接近80%盡管譫妄診斷不足，譫妄與明顯增加危重患者發(fā)病率和病死率相關(guān)第3頁，共85頁。流行病學(xué)Delirium is common in the ICU, affecting 60% to 80% of mechanically ventilated patients and 20% to 50% of nonmechanically ventilated patients譫妄在ICU很常見60-80%機械通氣患者發(fā)生譫妄20-50%非機械通氣患者發(fā)生譫妄第4頁，共85頁。內(nèi)容譫妄的流行病學(xué)譫妄概念、主要特征和分類譫妄的

3、目前關(guān)注情況譫妄的危害譫妄的風險因素譫妄評估及診斷譫妄的預(yù)防譫妄預(yù)防的集束化方案-ABCDE方案譫妄治療第5頁，共85頁。概念Delirium in the intensive care unit (ICU) represents an acute form of organ dysfunction,which manifests as a rapidly developing disturbance of both consciousness and cognition that tends to fluctuate throughout the course of a day譫妄以急性器官

4、功能障礙為表現(xiàn)形式：傾向于1天內(nèi)波動性的、迅速發(fā)展的意識和認知紊亂。第6頁，共85頁。譫妄的主要特征The American Psychiatric Association (APA)Diagnostic and Statistical Manual of Mental Disorders,fourth edition, text revision (DSM-IV) defines 4 key features of delirium:(1) disturbance of consciousness with reduced awareness of the environment and i

5、mpaired ability to focus, sustain, or shift attention; (2) altered cognition (eg, impaired memory, language disturbance, or disorientation) or the development of a perceptual（知覺） disturbance (eg, hallucinations（幻覺）, delusions（妄想）, or illusions（錯覺）) that is not better accounted for by preexisting or

6、evolving dementia（癡呆）; 第7頁，共85頁。譫妄的主要特征(3) disturbance that develops over a short period of time (hours to days) and tends to fluctuate during the course of the day;(4) evidence of an etiologic factor (ie, delirium due to general medical condition, substance-induced delirium, delirium due to multipl

7、e causes, or delirium not otherwise specified) 第8頁，共85頁。譫妄分類-發(fā)病時間The classification of delirium can be subdivided by course over time and motor subtypes. 1.The terminology, according to the course over time, includesa) prevalent (if it is detected at the time of admission); b) incident (if it emerge

8、s during the hospital length of stay); and c) persistent (if the symptoms persist over time)第9頁，共85頁。譫妄分類-運動亞型2.The terminology according to motor subtypes includes a) hyperactive delirium (in which there is an increase in the psychomotor activity and agitation, with attempts to remove invasive devi

9、ces); b) hypoactive delirium (characterized by psychomotor slowing, apathy(淡漠), lethargy（昏睡） and a decrease in response to external stimuli); and c) mixed delirium (with unpredictable fluctuation of symptoms between the first two subtypes)第10頁，共85頁。譫妄分類3.Additional definitions are described, which i

10、nclude subsyndromal delirium （亞臨床譫妄）and delirium superimposed on dementia（譫妄疊加癡呆）第11頁，共85頁。譫妄分類-根據(jù)ICDSC評分工具4.defined its presence, using the Intensive Care Delirium Screening Checklist(ICDSC), in a population from an ICU. The ICDSC assigns a score from 0 to 8 points, delirium : a score 4 subsyndroma

11、l delirium: a score between 1 and 3 第12頁，共85頁。內(nèi)容譫妄的流行病學(xué)譫妄概念、主要特征和分類譫妄的目前關(guān)注情況譫妄的危害譫妄的風險因素譫妄評估及診斷譫妄的預(yù)防譫妄預(yù)防的集束化方案-ABCDE方案譫妄治療第13頁，共85頁。目前ICU譫妄關(guān)注情況第14頁，共85頁。鎮(zhèn)靜和譫妄評估現(xiàn)狀第15頁，共85頁。使用現(xiàn)有譫妄評估方法的頻率第16頁，共85頁。ICU譫妄評估的障礙第17頁，共85頁。護理人員對譫妄評估的看法第18頁，共85頁。內(nèi)容譫妄的流行病學(xué)譫妄概念、主要特征和分類譫妄的目前關(guān)注情況譫妄的危害譫妄的風險因素譫妄評估及診斷譫妄的預(yù)防譫妄預(yù)防的集束化方

12、案-ABCDE方案譫妄治療第19頁，共85頁。譫妄的危害increased risk for prolonged mechanical ventilation, catheter removal,self-extubation, and the need for physical restraints.In addition, delirium predisposes patients（有譫妄傾向患者） to longer hospital stays, with greater health care costs, increased risk of death during the hos

13、pitalization, and increased odds of institutionalization following discharge.Even after hospital discharge, the amount of time a patient has been delirious in the ICU predicts long-term cognitive impairment, physical disability, and death up to a year later.第20頁，共85頁。第21頁，共85頁。第22頁，共85頁。第23頁，共85頁。第2

14、4頁，共85頁。第25頁，共85頁。第26頁，共85頁。內(nèi)容譫妄的流行病學(xué)譫妄概念、主要特征和分類譫妄的目前關(guān)注情況譫妄的危害譫妄的風險因素譫妄評估及診斷譫妄的預(yù)防譫妄預(yù)防的集束化方案-ABCDE方案譫妄治療第27頁，共85頁。ICU譫妄的風險因素The average medical ICU patient has 11 or more risk factors for developing delirium,11which can be divided into baseline (predisposing) and hospital-related (precipitating) fac

15、tors第28頁，共85頁。第29頁，共85頁。第30頁，共85頁。內(nèi)容譫妄的流行病學(xué)譫妄概念、主要特征和分類譫妄的目前關(guān)注情況譫妄的危害譫妄的風險因素譫妄評估及診斷譫妄的預(yù)防譫妄預(yù)防的集束化方案-ABCDE方案譫妄治療第31頁，共85頁。譫妄評估ICU理想的譫妄評估工具 the scale used in this environment must a) have the capacity to evaluate the primary components of delirium (for example, awareness, inattention, disorganized thou

16、ght and fluctuation course); b) must have proven validity and reliability in ICU populations; c) must involve a fast and easy evaluation; and d) should not necessitate the presence of psychiatric professionals第32頁，共85頁。ICU譫妄評估工具1.the Confusion Assessment Method-ICU (CAM-ICU)把RASS評分整合到CAM-ICU確定有效的兩個版

17、本：葡萄糖牙版本和英國版本2.the Intensive Care Delirium Screening Checklist(ICDSC)第33頁，共85頁。CAM-ICU臨床特征評價指標精神狀態(tài)突然改變患者是否出現(xiàn)精神狀態(tài)的突然改變？過去24h是否有反常行為或起伏不定（如時有時無或者時而加重時而減輕）？過去24h鎮(zhèn)靜評分（SAS或MAAS）或昏迷評分（GCS）是否有波動？注意力散漫患者是否有注意力集中困難？患者是否有保持或轉(zhuǎn)移注意力的能力下降？患者注意力篩查（ASE）得分多少（如：ASE的視覺測試是對10個畫面的回憶準確度；ASE的聽覺測試患者對一連串隨機字母讀音中出現(xiàn)“A”時點頭或捏手示意

18、）？若患者已經(jīng)脫機拔管，需要判斷其是否存在思維無序或不連貫。常表現(xiàn)為對話散漫離題、思維邏輯不清或主題變化無常思維無序若患者在帶呼吸機狀態(tài)下，檢查其能否正確回答以下問題：（l）石頭會浮在水面上嗎？（2）海里有魚嗎？（3）一磅比兩磅重嗎？（4）你能用錘子砸爛一顆釘子嗎？在整個評估過程中，患者能否跟得上回答問題和執(zhí)行指令：（1）你是否有一些不太清楚的想法？（2）舉這幾個手指頭（檢查者在患者面前舉兩個手指頭）。（3）現(xiàn)在換只手做同樣的動作（檢查者不用再重復(fù)動作）意識程度變經(jīng)(指清醒以外的任何意識狀態(tài)，如：警醒、嗜睡、木僵或昏迷)清醒：正常、自主的感知周圍環(huán)境，反應(yīng)適度警醒：過于興奮嗜睡：磕睡但易于喚醒

19、，對某些事物沒有意識，不能自主適當?shù)慕徽?，給予輕微刺激就能完全覺醒并應(yīng)答適當?；杷弘y以喚醒，對外界部分或完全無感知，對交談無自主、適當?shù)膽?yīng)答。當給予強烈刺激時，有不完全清醒和不適當?shù)膽?yīng)答，強刺激一旦停止，又重新進人無反應(yīng)狀態(tài)?；杳裕翰豢蓡拘?，對外界完全無意識，給予強烈刺激也無法進行交流第34頁，共85頁。ICU譫妄診斷DSM-是目前譫妄最主要的診斷標準，較專業(yè)且繁瑣意識模糊評定法（CAM法）：包括4個方面1.急性起病，病程波動2.注意力障礙3.思維混亂4.意識清晰水平改變：清晰（陰性)、警惕、嗜睡、昏睡、昏迷診斷：1和2存在，加上3或者4的任意一條即為CAM(+),表示譫妄存在。敏感性86%

20、，特異性100%。第35頁，共85頁。葡萄牙版本of CAM-ICU第36頁，共85頁。English versions of CAM-ICU第37頁，共85頁。RASS評分第38頁，共85頁。第39頁，共85頁。譫妄評分工具有效性第40頁，共85頁。譫妄鑒別診斷第41頁，共85頁。內(nèi)容譫妄的流行病學(xué)譫妄概念、主要特征和分類譫妄的目前關(guān)注情況譫妄的危害譫妄的風險因素譫妄評估及診斷譫妄的預(yù)防譫妄預(yù)防的集束化方案-ABCDE方案譫妄治療第42頁，共85頁。非ICU患者譫妄預(yù)防第43頁，共85頁。ICU譫妄預(yù)防On the whole, the constellation（系列） of risk f

21、actors for delirium affecting individual ICU patients varies from patient to patient and thus an individualized strategy for delirium prevention should be sought3 risk factors in particular, sedatives, immobility, and sleep disruption, are widespread in the ICU第44頁，共85頁。通過鎮(zhèn)靜管理預(yù)防譫妄第45頁，共85頁。avoidance

22、 of benzodiazepines is an important strategy when seeking to both prevent delirium and reduce its duration.第46頁，共85頁。通過疼痛管理預(yù)防譫妄Pain is a modifiable risk factor for delirium, and inadequate pain control is a frequent cause for agitation in the ICU. When pain is not assessed and treated, patients may

23、be inappropriately given a sedative medication rather than an analgesic medication.第47頁，共85頁。In summary, these data suggest that opioids(阿片類) used to treat pain are protective against the development of delirium, whereas those used at doses high enough to cause sedation may increase the risk of deli

24、rium. Therefore, patients should undergo regular pain assessments, and when pain is detected effective doses of an analgesic（鎮(zhèn)痛） medication should be given, taking care to avoid inducing heavy sedation.第48頁，共85頁。ICU患者早期活動預(yù)防譫妄datas suggest a role for early mobility in the reduction of the duration of

25、 delirium among critically ill patients.第49頁，共85頁。改善睡眠預(yù)防譫妄Sleep deprivation is nearly universal for ICU patients, with the average ICU patient sleeping between 2 and 8 hours in a 24-hour period.第50頁，共85頁。Noise-reduction strategies (such as earplugs), normalizing day-night illumination(白天照明), minimiz

26、ing care-related interventions during normal sleeping hours, and interventions promoting patient comfort and relaxation are low risk and often inexpensive, and should be implemented to prevent delirium.第51頁，共85頁。藥物干預(yù)預(yù)防譫妄there are currently no medications approved by the US Food and Drug Administrati

27、on for the prevention or treatment of delirium.第52頁，共85頁。內(nèi)容譫妄的流行病學(xué)譫妄概念、主要特征和分類譫妄的目前關(guān)注情況譫妄的危害譫妄的風險因素譫妄評估及診斷譫妄的預(yù)防譫妄預(yù)防的集束化方案-ABCDE方案譫妄治療第53頁，共85頁。預(yù)防譫妄- ABCDE Approach Delirium in the ICU is frequently multifactorial, so it is unlikely that a single intervention can prevent or reduce delirium with regul

28、arity(規(guī)則性)Therefore, a bundled approach combining evidence-based practices in sedation management, ventilator weaning, delirium management, and early mobility and exercise, which is referred to as the ABCDE approach, has been proposed to improve multiple outcomes, including preventing and reducing the duration of delirium in the ICU第54頁，共85頁。What Is the ABCDE Bundle? The ABCDE bundle is multicomponent approach designed to improve patient outcome by facilitating clinical team collaboration, standardizing care processes