icu谵妄及abcde集束化预防方案

1、南华大学附属第一医院ICU 王桥生Delirium -谵妄第1页，共85页。内容谵妄的流行病学谵妄概念、主要特征和分类谵妄的目前关注情况谵妄的危害谵妄的风险因素谵妄评估及诊断谵妄的预防谵妄预防的集束化方案-ABCDE方案谵妄治疗第2页，共85页。流行病学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患者谵妄发生率接近80%尽管谵妄诊断不足，谵妄与明显增加危重患者发病率和病死率相关第3页，共85页。流行病学Delirium is common in the ICU, affecting 60% to 80% of mechanically ventilated patients and 20% to 50% of nonmechanically ventilated patients谵妄在ICU很常见60-80%机械通气患者发生谵妄20-50%非机械通气患者发生谵妄第4页，共85页。内容谵妄的流行病学谵妄概念、主要特征和分类谵妄的

3、目前关注情况谵妄的危害谵妄的风险因素谵妄评估及诊断谵妄的预防谵妄预防的集束化方案-ABCDE方案谵妄治疗第5页，共85页。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谵妄以急性器官

4、功能障碍为表现形式：倾向于1天内波动性的、迅速发展的意识和认知紊乱。第6页，共85页。谵妄的主要特征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（知觉） disturbance (eg, hallucinations（幻觉）, delusions（妄想）, or illusions（错觉）) that is not better accounted for by preexisting or

6、evolving dementia（痴呆）; 第7页，共85页。谵妄的主要特征(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页，共85页。谵妄分类-发病时间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页，共85页。谵妄分类-运动亚型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页，共85页。谵妄分类3.Additional definitions are described, which i

10、nclude subsyndromal delirium （亚临床谵妄）and delirium superimposed on dementia（谵妄叠加痴呆）第11页，共85页。谵妄分类-根据ICDSC评分工具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页，共85页。内容谵妄的流行病学谵妄概念、主要特征和分类谵妄的目前关注情况谵妄的危害谵妄的风险因素谵妄评估及诊断谵妄的预防谵妄预防的集束化方案-ABCDE方案谵妄治疗第13页，共85页。目前ICU谵妄关注情况第14页，共85页。镇静和谵妄评估现状第15页，共85页。使用现有谵妄评估方法的频率第16页，共85页。ICU谵妄评估的障碍第17页，共85页。护理人员对谵妄评估的看法第18页，共85页。内容谵妄的流行病学谵妄概念、主要特征和分类谵妄的目前关注情况谵妄的危害谵妄的风险因素谵妄评估及诊断谵妄的预防谵妄预防的集束化方

12、案-ABCDE方案谵妄治疗第19页，共85页。谵妄的危害increased risk for prolonged mechanical ventilation, catheter removal,self-extubation, and the need for physical restraints.In addition, delirium predisposes patients（有谵妄倾向患者） 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页，共85页。第21页，共85页。第22页，共85页。第23页，共85页。第2

14、4页，共85页。第25页，共85页。第26页，共85页。内容谵妄的流行病学谵妄概念、主要特征和分类谵妄的目前关注情况谵妄的危害谵妄的风险因素谵妄评估及诊断谵妄的预防谵妄预防的集束化方案-ABCDE方案谵妄治疗第27页，共85页。ICU谵妄的风险因素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页，共85页。第29页，共85页。第30页，共85页。内容谵妄的流行病学谵妄概念、主要特征和分类谵妄的目前关注情况谵妄的危害谵妄的风险因素谵妄评估及诊断谵妄的预防谵妄预防的集束化方案-ABCDE方案谵妄治疗第31页，共85页。谵妄评估ICU理想的谵妄评估工具 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页，共85页。ICU谵妄评估工具1.the Confusion Assessment Method-ICU (CAM-ICU)把RASS评分整合到CAM-ICU确定有效的两个版

17、本：葡萄糖牙版本和英国版本2.the Intensive Care Delirium Screening Checklist(ICDSC)第33页，共85页。CAM-ICU临床特征评价指标精神状态突然改变患者是否出现精神状态的突然改变？过去24h是否有反常行为或起伏不定（如时有时无或者时而加重时而减轻）？过去24h镇静评分（SAS或MAAS）或昏迷评分（GCS）是否有波动？注意力散漫患者是否有注意力集中困难？患者是否有保持或转移注意力的能力下降？患者注意力筛查（ASE）得分多少（如：ASE的视觉测试是对10个画面的回忆准确度；ASE的听觉测试患者对一连串随机字母读音中出现“A”时点头或捏手示意

18、）？若患者已经脱机拔管，需要判断其是否存在思维无序或不连贯。常表现为对话散漫离题、思维逻辑不清或主题变化无常思维无序若患者在带呼吸机状态下，检查其能否正确回答以下问题：（l）石头会浮在水面上吗？（2）海里有鱼吗？（3）一磅比两磅重吗？（4）你能用锤子砸烂一颗钉子吗？在整个评估过程中，患者能否跟得上回答问题和执行指令：（1）你是否有一些不太清楚的想法？（2）举这几个手指头（检查者在患者面前举两个手指头）。（3）现在换只手做同样的动作（检查者不用再重复动作）意识程度变经(指清醒以外的任何意识状态，如：警醒、嗜睡、木僵或昏迷)清醒：正常、自主的感知周围环境，反应适度警醒：过于兴奋嗜睡：磕睡但易于唤醒

19、，对某些事物没有意识，不能自主适当的交谈，给予轻微刺激就能完全觉醒并应答适当。昏睡：难以唤醒，对外界部分或完全无感知，对交谈无自主、适当的应答。当给予强烈刺激时，有不完全清醒和不适当的应答，强刺激一旦停止，又重新进人无反应状态。昏迷：不可唤醒，对外界完全无意识，给予强烈刺激也无法进行交流第34页，共85页。ICU谵妄诊断DSM-是目前谵妄最主要的诊断标准，较专业且繁琐意识模糊评定法（CAM法）：包括4个方面1.急性起病，病程波动2.注意力障碍3.思维混乱4.意识清晰水平改变：清晰（阴性)、警惕、嗜睡、昏睡、昏迷诊断：1和2存在，加上3或者4的任意一条即为CAM(+),表示谵妄存在。敏感性86%

20、，特异性100%。第35页，共85页。葡萄牙版本of CAM-ICU第36页，共85页。English versions of CAM-ICU第37页，共85页。RASS评分第38页，共85页。第39页，共85页。谵妄评分工具有效性第40页，共85页。谵妄鉴别诊断第41页，共85页。内容谵妄的流行病学谵妄概念、主要特征和分类谵妄的目前关注情况谵妄的危害谵妄的风险因素谵妄评估及诊断谵妄的预防谵妄预防的集束化方案-ABCDE方案谵妄治疗第42页，共85页。非ICU患者谵妄预防第43页，共85页。ICU谵妄预防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页，共85页。通过镇静管理预防谵妄第45页，共85页。avoidance

22、 of benzodiazepines is an important strategy when seeking to both prevent delirium and reduce its duration.第46页，共85页。通过疼痛管理预防谵妄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页，共85页。In summary, these data suggest that opioids(阿片类) 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（镇痛） medication should be given, taking care to avoid inducing heavy sedation.第48页，共85页。ICU患者早期活动预防谵妄datas suggest a role for early mobility in the reduction of the duration of

25、 delirium among critically ill patients.第49页，共85页。改善睡眠预防谵妄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页，共85页。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页，共85页。药物干预预防谵妄there are currently no medications approved by the US Food and Drug Administrati

27、on for the prevention or treatment of delirium.第52页，共85页。内容谵妄的流行病学谵妄概念、主要特征和分类谵妄的目前关注情况谵妄的危害谵妄的风险因素谵妄评估及诊断谵妄的预防谵妄预防的集束化方案-ABCDE方案谵妄治疗第53页，共85页。预防谵妄- 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(规则性)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页，共85页。What Is the ABCDE Bundle? The ABCDE bundle is multicomponent approach designed to improve patient outcome by facilitating clinical team collaboration, standardizing care processes