1
Patient-Focused Sedation and
Delirium Management in ICU
廖文進Wen-Jinn Liaw, MD, PhD
三軍總醫院麻醉部外科加護中心Surgical Intensive Care Unit, Department of Anesthesiology,
Tri-Service General Hospital
Wen-Jinn Liaw
Patient-Focused Sedation and
Delirium Management in ICU
� Introduction
– Patient-focused sedation
� Characteristics of critically ill patients
� Medication selection for ICU sedation
� Strategies to optimize ICU sedation
� Monitoring of sedation in ICU
� Delirium management in ICU
� Conclusion
2
Wen-Jinn Liaw
IntroductionIntroduction::
PatientPatient--Focused SedationFocused Sedation
Wen-Jinn Liaw Sessler CN et al. Semin Respir Crit Care Med 2001; 22:211–225.
3
Wen-Jinn Liaw
疼痛或躁動不治療造成的危險疼痛或躁動不治療造成的危險疼痛或躁動不治療造成的危險疼痛或躁動不治療造成的危險
�� 疼痛不治療疼痛不治療疼痛不治療疼痛不治療疼痛不治療疼痛不治療疼痛不治療疼痛不治療
–– increased endogenous increased endogenous
catecholamine activitycatecholamine activity
–– myocardial ischemiamyocardial ischemia
–– hypercoagulabilityhypercoagulability
–– hypermetabolic stateshypermetabolic states
–– sleep deprivationsleep deprivation
–– anxietyanxiety
–– deliriumdelirium
�� 躁動不治療躁動不治療躁動不治療躁動不治療躁動不治療躁動不治療躁動不治療躁動不治療
––病人自我傷害病人自我傷害病人自我傷害病人自我傷害病人自我傷害病人自我傷害病人自我傷害病人自我傷害
�� 拔除為生導管或裝置拔除為生導管或裝置拔除為生導管或裝置拔除為生導管或裝置拔除為生導管或裝置拔除為生導管或裝置拔除為生導管或裝置拔除為生導管或裝置
Wen-Jinn Liaw
急性照護時止痛與鎮靜的目的急性照護時止痛與鎮靜的目的急性照護時止痛與鎮靜的目的急性照護時止痛與鎮靜的目的
1.1. Reduce anxiety Reduce anxiety 減低焦慮減低焦慮減低焦慮減低焦慮減低焦慮減低焦慮減低焦慮減低焦慮
2.2. Prevent delirium Prevent delirium 避免妄想瞻望避免妄想瞻望避免妄想瞻望避免妄想瞻望
3.3. Enhance patient comfort Enhance patient comfort 增加舒適增加舒適增加舒適增加舒適增加舒適增加舒適增加舒適增加舒適
4.4. Induce sleep when required Induce sleep when required 誘導睡眠誘導睡眠誘導睡眠誘導睡眠誘導睡眠誘導睡眠誘導睡眠誘導睡眠
5.5. Provide adequate pain control Provide adequate pain control 控制疼痛控制疼痛控制疼痛控制疼痛控制疼痛控制疼痛控制疼痛控制疼痛
6.6. Facilitate mechanical ventilation Facilitate mechanical ventilation 協助機器通氣協助機器通氣協助機器通氣協助機器通氣協助機器通氣協助機器通氣協助機器通氣協助機器通氣
7.7. Induce appropriate level of amnesia Induce appropriate level of amnesia 誘導適當失憶誘導適當失憶誘導適當失憶誘導適當失憶誘導適當失憶誘導適當失憶誘導適當失憶誘導適當失憶
8.8. Optimize safety for patients and their caregiversOptimize safety for patients and their caregivers
有效增進病人與照顧者的安全有效增進病人與照顧者的安全有效增進病人與照顧者的安全有效增進病人與照顧者的安全有效增進病人與照顧者的安全有效增進病人與照顧者的安全有效增進病人與照顧者的安全有效增進病人與照顧者的安全
9.9. Facilitate communication with caregivers and family members Facilitate communication with caregivers and family members
促進照顧者與家屬的溝通促進照顧者與家屬的溝通促進照顧者與家屬的溝通促進照顧者與家屬的溝通促進照顧者與家屬的溝通促進照顧者與家屬的溝通促進照顧者與家屬的溝通促進照顧者與家屬的溝通
Purpose of Analgesia and Sedation in Acute Care Settings
4
Wen-Jinn Liaw
加護病房緩解焦慮的方法或策略加護病房緩解焦慮的方法或策略加護病房緩解焦慮的方法或策略加護病房緩解焦慮的方法或策略
�� Pharmacologic Pharmacologic 藥物藥物藥物藥物
– Opioids 嗎啡類嗎啡類嗎啡類嗎啡類
– Benzodiazepines
– Propofol
– Haloperidol
– Inhalational anesthetics
– Dexmedetomidine
– Barbiturates
�� Nonpharmacologic Nonpharmacologic 非藥物非藥物非藥物非藥物
– Behavior modification
– Cognitive restructuring
– Distraction 分散注意力分散注意力分散注意力分散注意力
– Hypnosis 催眠催眠催眠催眠
– Imagery 意象意象意象意象
– Music therapy 音樂治療音樂治療音樂治療音樂治療
– Patient education 病人教育病人教育病人教育病人教育
– Relaxation techniques
放鬆技巧放鬆技巧放鬆技巧放鬆技巧
Wen-Jinn Liaw
Patient-Focused Sedation
� A strategy of comprehensive structured
management that matches
– initial evaluation
– monitoring
– medication selection
– use of protocols
� with patient characteristics and needs
5
Wen-Jinn Liaw
Patient-Focused Sedation
� This is best accomplished through interdisciplinary management by
– physicians, nurses, and pharmacists.
� Frequent monitoring with validated tools improves communication among clinicians
– an important role in detecting and treating pain and
agitation while avoiding excessive or prolonged
sedation.
Wen-Jinn Liaw
Patient-Focused Sedation
�� May require deep sedationMay require deep sedation
– high-frequency oscillatory ventilation or prone positioning, or neuromuscular blockade (NMB)
� Patients who are receiving NMB require adequate sedation and analgesia, and periodic cessation of the NMB agent to assess adequacy of sedation and analgesia.
�� From endotracheal tube to tracheostomy tubeFrom endotracheal tube to tracheostomy tube
– less sedative and analgesic medication and
correspondingly fewer hours of deep sedation
�� Alcohol and substance abuse is associated with Alcohol and substance abuse is associated with
greater sedative drug requirements.greater sedative drug requirements.
6
Wen-Jinn Liaw
Characteristics of critically ill patientsCharacteristics of critically ill patients
Wen-Jinn Liaw
影響藥物分佈影響藥物分佈影響藥物分佈影響藥物分佈、、、、作用與代謝之因素作用與代謝之因素作用與代謝之因素作用與代謝之因素
� 分佈模式 (Compartment models)
� 分佈體積 (Volume of distribution)
� 蛋白質結合率 (Protein binding ratio)
� 細胞色素 (Cytochrome P450)
� 藥物交互作用(Interaction)
� 肝抽取率 (Hepatic extraction ratio)
年齡 (Age)
7
Wen-Jinn Liaw
Characteristics of critically ill patients
重症病人的生理特性重症病人的生理特性重症病人的生理特性重症病人的生理特性重症病人的生理特性重症病人的生理特性重症病人的生理特性重症病人的生理特性
� ↑↑↑↑ age
� ↓↓↓↓ protein binding
� ↑↑↑↑ total body water,
↓ fat body or ↓ lean body mass
� ↓↓↓↓ hepatic or ↓↓↓↓ renal function
� Hemodynamic instability
� Concurrent disease states
Wen-Jinn Liaw
Medication selection for ICU sedationMedication selection for ICU sedation
8
Wen-Jinn Liaw
玉山西峰山神廟
Wen-Jinn Liaw
理想的止痛與鎮靜藥物特性理想的止痛與鎮靜藥物特性理想的止痛與鎮靜藥物特性理想的止痛與鎮靜藥物特性
� Provide adequate sedation and pain control 效果好效果好效果好效果好
� Rapid onset of action 作用快作用快作用快作用快
� Rapid recovery after discontinuation 停後恢復快停後恢復快停後恢復快停後恢復快
� Minimal systemic accumulation 微量身體蓄積微量身體蓄積微量身體蓄積微量身體蓄積
� Minimal adverse effects 微量副作用微量副作用微量副作用微量副作用
� Without increasing overall health care costs 不增加成本不增加成本不增加成本不增加成本
–– ultraultra--shortshort--acting agentsacting agents such assuch as remifentanilremifentanil
–– agent other than agent other than propofolpropofol, , benzodiazepinesbenzodiazepines, and , and
opioidsopioids such as thesuch as the αααααααα22 adrenergic agonist adrenergic agonist
dexmedetomidinedexmedetomidine. .
9
Wen-Jinn Liaw
Analgesics in ICUAnalgesics in ICU
�� MorphineMorphine
�� FentanylFentanyl
� Hydromorphone
�� RemifentanilRemifentanil
� Sufentanil
� Alfentanil (Rapifen)
� Meperidine
(Pethidine, Demeral)
�� KetololacKetololac (Keto)
�� MidazolamMidazolam (Dormicum)
�� PropofolPropofol (Diprivan, Anesvan,
Recofol, Fresofol, Lipuro)
�� LorazepamLorazepam (Ativan, Neuropam,
Anxicam)
�� HaloperidolHaloperidol (Haldol, Binin-U,
Pandol)
�� DexmedetomidineDexmedetomidine
(Precedex)
Sedatives in ICUSedatives in ICU
Wen-Jinn Liaw
Ongoing sedationLorazepam: 1–4 mg IVP q 10–20 min until goal,
then q 2-6 hr scheduled + prn or
Propofol: start 5 mcg/kg/min, titrate q 5 min
until at goal (if ≥≥≥≥3 days, convert to lorazepam)
Ongoing sedationLorazepam: 1–4 mg IVP q 10–20 min until goal,
then q 2-6 hr scheduled + prn or
Propofol: start 5 mcg/kg/min, titrate q 5 min
until at goal (if ≥≥≥≥3 days, convert to lorazepam)
2002 SCCM Guidelines for ICU Sedation
Nonpharmacologic treatmentNonpharmacologic treatment
Use pain scale to assess for
pain and set goal for analgesia
Use pain scale to assess for
pain and set goal for analgesia
Use sedation scale to assess anxiety/agitation and set goal for sedation
Use sedation scale to assess anxiety/agitation and set goal for sedation
Use delirium scale to assess for delirium and set goal for delirium
Use delirium scale to assess for delirium and set goal for delirium
Hemodynamically unstable
Fentanyl: 25–100 mcg IVP q 5–15 min or
Hydromorphone: 0.25–0.75 mg IVP q 5–15 min
Hemodynamically stable
Morphine: 2–5 mg IVP q 5–15 min
Repeat until pain controlled, then
scheduled doses + prn
Hemodynamically unstable
Fentanyl: 25–100 mcg IVP q 5–15 min or
Hydromorphone: 0.25–0.75 mg IVP q 5–15 min
Hemodynamically stable
Morphine: 2–5 mg IVP q 5–15 min
Repeat until pain controlled, then
scheduled doses + prn
Acute agitation
Midazolam: 2–5 mg IVP q 5–15 min until acute event controlled
Acute agitation
Midazolam: 2–5 mg IVP q 5–15 min until acute event controlled
Haloperidol: 2–10 mg IVP q 20–30 min,
then 25% of loading dose q 6 hr
Haloperidol: 2–10 mg IVP q 20–30 min,
then 25% of loading dose q 6 hr
Reassess all goals daily; titrate to maintain goal
Reassess all goals daily; titrate to maintain goal Jacobi et al. Crit Care Med 2002;30:119-141
10
Wen-Jinn Liaw
αααα-hydroxymidazolam
Midazolam
αααα-hydroxymidazolamconjugate
Flumazenil
Midazolam
Limit of detection
Seru
m c
on
cen
trati
on
(n
g/m
l)
Time (days)
Serum concentration time profile of midazolam and
metabolites in a patient with acute renal failure.
Bauer et al. Lancet 1995
Wen-Jinn Liaw
Morphine
� Morphine is the preferred analgesic agent
for critically ill patients.
– can induce histamine release
� Onset of action: 2-3 mins
� Duration: 4-5 hrs
� Half-life: 2-3 hrs to 4.5 hrs
� Initial dose: 0.05 mg/kg (2-10 mg)(over 5-15 mins)
� maintain: 1-4 mg/hr
11
Wen-Jinn Liaw
Fentanyl
� Fentanyl is the preferred analgesic agent
for critically ill patients with hemodynamic
instability.– 100-300 times potent as morphine
– high lipophilicity
� Onset of action: 5-6 mins
� Duration: 0.5-1 hr
� Half-life: 30-60 mins (9-16 hrs after prolonged dosing)
� Initial dose: 1-2 µg/kg
� maintain: 1-2 µg/kg/hr
Wen-Jinn Liaw
Midazolam (Dormicum)
� Midazolam is one of the preferred agents
only for the short-term (< 24hrs) treatment of
anxiety in the critically ill adult.– 96-98% protein bound
– high lipophilicity & short-acting
– compatibility with IV solutions
– stability in aqueous solutions
– absence of pain at the injection site
– less incidence of thrombophlebitis
– dose not suppress the adrenal gland
12
Wen-Jinn Liaw
Midazolam (continued)
� Onset of action: 1-3 mins
� Duration: 30-120 mins
� Elimination half-life: 1.2-12.3 hrs
� Initial dose: 0.03 mg/kg/hr (1-2 mg)
� maintain: 0.03-0.25 mg/kg/hr titrated to effect
� Active metabolite: α-hydroxymidazolam
� Antagonist: flumazenil
Wen-Jinn Liaw
Propofol
� Propofol is another preferred agents only
for the short-term (<24 hrs) treatment of
anxiety in the critically ill adult.
– ultra-short-acting general anesthetic
– 2,6-diisopropylphenol (alkyl phenol derivatives)
– oil-in-water emulsion [0.1 g fat (1.1 Kcal) /ml]
� 1.0 % propofol, 10% soybean oil, 2.25% glycerol,
1.2% egg phosphatide
13
Wen-Jinn Liaw
� anticonvulsant activity
� very little analgesic properties
� high lipophilicity & 98% plasma-protein bound
� ↓↓↓↓ cerebral blood flow (50%)( ↓↓↓↓ ICP) & ↓↓↓↓ cerebral metabolic oxygen requirements (18-36%)
�� Administration Guidelines: Administration Guidelines:
–– 1. Through a central vein1. Through a central vein
–– 2. Aseptic technique2. Aseptic technique
� disinfection of the rubber stopper
� avoiding excessive manipulation of the line
� discarding the vial and tubing within 12 h
� opened, unused propofol is discarded immediately.
Propofol (continued)
Wen-Jinn Liaw
� Onset of action: 1-2 mins
� Duration: 10-15 mins
� Elimination Half-life: 1.8-4.1 mins
� Terminal half-life: ~3 days
� Initial dose: 0.5-1 mg/kg/hr, titrated in
increments of 0.5 mg/kg every 5 to 10 mins
� maintain: 0.5-3 mg/kg/hr
Propofol (continued)
14
Wen-Jinn Liaw
Lorazepam
� Lorazepam is the preferred agent for the prolonged
treatment of anxiety in the critically ill adult.
– intermediate-acting benzodiazepine
– 90-96% protein bound & less lipophilic than diazepam
– causes less hypotension, lower in cost than midazolam
� Onset of action: 15-20 mins
� Duration: 6-8 hrs
� Elimination Half-life: 12-18 hrs
� Initial dose: 0.01-0.1 mg/kg (1-2 mg)
� maintain: intermittent IV bolus or continuous infusion
Wen-Jinn Liaw
Haloperidol
� Haloperidol is the preferred agent for the treatment
of delirium in the critically ill adult.
– A butyrophenone neuroleptic drug
– Indication for continuous infusion
� ≥ 8 boluses of 10-mg within 24 hrs or > 10 mg/hr for 5
consecutive hrs
� Onset: 30-60 mins (duration of 4-8 hrs)
� Elimination Half-life: 33 hrs
� Initial dose: 2-10 mg IV
� maintain: the dosage is repeated every 2-4 hrs
or infusion with 10 mg/hr
15
Wen-Jinn Liaw
Dexmedetomidine
� A highly selective αααα2-adrenergic agonist
– αααα2:αααα1 ratio of about 1600:1. By comparison, clonidine has a αααα2:αααα1
ratio of about 220:1.
– The most frequently reported adverse effects were hypotension,
bradycardia, and dry mouth.
– No significant respiratory depression in conventional clinical doses
– 94% protein bound
� Onset: 20-30 mins (duration of 4-8 hrs)
� Elimination Half-life:
– t1/2β: 2-3 hr with hepatic glucuronidation and conjugation
� Infusion dose: loading 1 µg/kg, then 0.2-0.7 µg/kg/hr
Wen-Jinn Liaw
Pharmacokinetic of Precedex
� Target Plasma Concentration 0.6 µg/L
LiverMetabolism
95% renalRoute of elimination
2 hrElimination T1/2
6 minDistribution T1/2
0.495 L/h*kgClearance
1.33 L/kgVolume of distribution at
steady-state
5.1 µµµµg/L.hArea under the plasma
concentration-time curve
16
Wen-Jinn Liaw
Less Morphine Need
Arain SR, et al. Anesth Analg. 2004;98:153-158.
Wen-Jinn Liaw
Benzodiazepines Propofol Opioids Dexmedetomidine Haloperidol
Sedation √√√√ √√√√ √√√√ √√√√ √√√√
Alleviate anxiety1,2 √√√√ √√√√
Analgesic Properties1-4 √√√√ √√√√
Promote arousability
during sedation2-4 √√√√
Facilitate ventilation during weaning2-4 √√√√
No respiratory depression1-4 √√√√ √√√√
Control delirium1-4 √√√√ √√√√
Comparison of Clinical Effects
1Blanchard AR. Postgrad Med. 2002;111:59-74. 2Kamibayashi T, et al Anesthesiology. 2000;95:1345-1349.
3Maze M. et al. Anesthetic Pharmacology: Physiologic Principals and Clinical Practice. Churchill Livingstone; 2004. 4Maze M, et al. Crit Care Clin. 2001;4:881.
17
Wen-Jinn Liaw
Prolonged weaning1 √√√√ √√√√ √√√√ *
Respiratory
depression1 √√√√ √√√√ √√√√
Hypotension1-3 √√√√ √√√√ √√√√ √√√√ √√√√
Constipation1 X
Deliriogenic √√√√ √√√√ √√√√
Tachycardia1 Morphine
Bradycardia1 Fentanyl √√√√ √√√√
Comparison of Adverse Effects
*Excluding remifentanil1Harvey MA. Am J Crit Care. 1996;5:7-16.
2Aantaa R, et al. Drugs of the Future. 1993;18:49-56.3Maze M. Crit Care Clin. 2001;4:881;
Benzodiazepines Propofol Opioids Dexmedetomidine Haloperidol
Wen-Jinn Liaw
Ranges Reported in Healthy Patients* and ICU Patients
Systemic Clearance
(mL/kg/min)EliminationHalf-life (hr)Agent
Potential for Accumulation
Comparison of Pharmacokinetics
1Wagner BKJ, et al. Clin Pharmacokinet. 1997;33:426-453;2Khan ZP, et al. Anaesthesia. 1999;54:146-165;
3Bhana N, et al. Drugs. 2000;59:263
8.6-15.06.9-36.0Fentanyl1 Hepatic impairment
0.32-0.64 mL/hr/kg2Dexmedetomidine3
1.9-4.36-23Clonidine217-316.3-32Propofol1
1.2-4.110-15 Lorazepam1
4.3-6.63.4-11Midazolam1
0.4-0.921-120Diazepam1
10-1328-38Haloperidol1
Hepatic/renal insufficiency
Hepatic/renal insufficiency
Hepatic insufficiency
Hepatic insufficiency
Hepatic insufficiency
Renal insufficiency
–
*Healthy patients: no renal or hepatic disease.
18
Strategies to Optimize ICU SedationStrategies to Optimize ICU Sedation
Wen-Jinn Liaw
玉山北峰氣象站玉山北峰氣象站玉山北峰氣象站玉山北峰氣象站
19
Wen-Jinn Liaw
Protocols to Optimize Sedation
� The use of protocols is a key component of
management:
– reductions in the duration of sedation, mechanical
ventilation, and ICU length of stay (LOS)
� a shorter half-life titrating medications to end-points
identified by sedation scales
� daily interruption of sedation
� intermittent rather than continuous therapy
� analgesia based therapy
– algorithms that proactively identify pain, agitation, and/or
patient/ventilator asynchrony.
� De-escalation
– Protocol-guided withdrawal
� avoid analgesic or sedative withdrawal
Wen-Jinn Liaw Kress et al. N Engl J Med 2000;342:1471-7
A Wake-Up Call in the Intensive Care Unit
20
Wen-Jinn Liaw
Daily interruption of sedative-drugs infusions decrease the duration of mechanical ventilation
Kress et al. N Engl J Med 2000;342:1471-7
Wen-Jinn Liaw
Daily interruption of sedative-drugs infusions decrease the length of stay
Kress et al. N Engl J Med 2000;342:1471-7
21
Wen-Jinn Liaw
☆ IV bolus of 2 mg, then
continuous IV infusion of
5 mg/hr ×××× 12 hr, then
4 mg/hr ×××× 12 hr, then
3 mg/hr thereafter for a
total of 3 days.
Residual effects: ≈≈≈≈ 10 hrs
☆ IV bolus of 2 mg, then
continuous IV infusion of
5 mg/hr for 3 days
Residual effects: ≥≥≥≥ 24 hrs
Barr and Donner, Crit Care Clin 1995
Optimal IV dosing strategiesOptimal IV dosing strategies
Mid
azo
lam
pla
sm
a c
on
ce
ntr
ati
on
(n
g/m
l)
Therapeutic
range
Time (min)
從北峰回眸望玉山主峰站從北峰回眸望玉山主峰站從北峰回眸望玉山主峰站從北峰回眸望玉山主峰站
Monitoring of sedation in ICUMonitoring of sedation in ICU
22
Wen-Jinn Liaw
Assessment of pain in ICU
� Behavior Rating Scales (1 & 2)
� Picture Scales (facial expressions)
� Hemodynamic parameters
� Behavioral Pain Scale (BPS)
� Critical Care Pain Observation Tool (CPOT)
Wen-Jinn Liaw
The facial expressions of
the Picture Scales:
23
Wen-Jinn Liaw
Behavioral Pain Scale
Scores from each of the three domains are summed, with a total score of 3 to 12.
Payen et al. Crit Care Med 2001, 29:2258-2263.
Wen-Jinn Liaw
Scores for each of the four domains are summed, with a total score of 0 to 8.
Critical Care Pain Observational Tool
Gelinas et al. Am J Crit Care 2006, 15:420-427.
24
Wen-Jinn Liaw
�� Ramsay Sedation Scale (RSS)Ramsay Sedation Scale (RSS) 19741974
�� Sedation Agitation Scale (SAS)Sedation Agitation Scale (SAS) 19941994
� Motor Activity Assessment Scale (MAAS) 19991999
� Vancouver Interactive and Calmness Scale 20002000
�� Richmond AgitationRichmond Agitation--Sedation Scale (RASS)Sedation Scale (RASS) 20022002
� Adaptation to Intensive Care Environment (ATICE) 20032003
� Minnesota Sedation Assessment Tool (MSAT) 20042004
� EEG, Bis, AEP
Assessment of sedation in ICU
Wen-Jinn Liaw
Ramsay Sedation ScaleRamsay Sedation Scale
Level Response
1 Anxious and agitated or restless or both
2 Cooperative, oriented, and tranquil
3 Responds only to verbal commands
4 Asleep with brisk response to light stimulus
5 Asleep with sluggish response to stimulus
6 Asleep with no response to stimulus
白天
晚上
Ramsay et al. Br Med J 2:656-659, 1974
25
Wen-Jinn Liaw
Level Response
7 Dangerous agitation: trying to remove tubes & catheters
6 Very agitated: biting endotracheal tube & needs restraints
5 Agitated: attempting to sit up & calm to verbal instruction
4 Calm and cooperative: awakens easily & follow commands
3 Sedated: awakens to verbal stimuli or gentle shaking
2 Very sedated: arouses to physical stimuli but does not communicate
1 Unarousable: no response to noxious stimuli
SedationSedation--Agitation Scale (SAS)Agitation Scale (SAS)
Riker et al. Crit Care Med 27:1325-1329, 1999
Wen-Jinn Liaw
Richmond agitationRichmond agitation--sedation scale (RASS) sedation scale (RASS)
躁動鎮靜評分表躁動鎮靜評分表躁動鎮靜評分表躁動鎮靜評分表躁動鎮靜評分表躁動鎮靜評分表躁動鎮靜評分表躁動鎮靜評分表
Sessler et al. Am J Respir Care Med 166:1338-1344, 2002
26
Wen-Jinn Liaw
記分 歸類用詞 敘 述
--------------------------------------------------------------------------------------------
+4 戰鬥性 明顯戰鬥性,暴力相向,對工作人員具有立即危險性
+3 非常躁動 拉扯或拔除導管或內管,具攻擊性
+2 躁動 經常無目的性動作,與人工呼吸器對抗
+1 煩躁 焦慮但其動作無攻擊性或不劇烈
0 警覺又安靜
-1 嗜睡 沒有完全警覺,但對言語反應保持清醒
(眼睛張開/眼神接觸) (超過10秒鐘)
-2 輕度鎮靜 短暫對言語反應時間(眼神接觸少於10秒鐘)
-3 中度鎮靜 對言語反應只有張眼或動一下(無眼神接觸)
-4 深度鎮靜 對言語無反應,但對身體刺激能張眼或動一下
-5 無法叫醒 對言語或身體刺激都沒有反應
Richmond agitationRichmond agitation--sedation scale (RASS) sedation scale (RASS)
躁動鎮靜評分表躁動鎮靜評分表躁動鎮靜評分表躁動鎮靜評分表躁動鎮靜評分表躁動鎮靜評分表躁動鎮靜評分表躁動鎮靜評分表
Wen-Jinn Liaw
Delirium Management in ICUDelirium Management in ICU
27
Wen-Jinn Liaw
玉山北峰氣象站玉山北峰氣象站玉山北峰氣象站玉山北峰氣象站
Wen-Jinn Liaw
� Delirium
– may be a marker for worse outcomes,
� increased incidence of posttraumatic stress disorder
(PTSD) and increased long-term mortality
– classical hyperactive delirium
� intermittent agitation, hallucinations, and disruptive
behavior
– hypoactive form appears to be more common in the ICU
– Precipitated factors
� CNS disorders, infections, hypoxia, pain, withdrawal
syndromes, electrolyte and metabolic disorders, and
various organ dysfunctions as well as a long list of
medications
28
Wen-Jinn Liaw
� Delirium
– Many cases of hypoactive or mixed delirium in the
ICU are related to the sedative effects of anxiolytic
and analgesic drugs,
� particularly lorazepam
� Strategies that emphasize using the lowest effective
sedative drug dose may help avoid delirium.
Wen-Jinn LiawCopyright restricions may apply. Ely et al. JAMA 2001;286:2703-2710.
CConfusion onfusion AAssessment ssessment MMethod for the ethod for the ICUICU ((CAMCAM--ICUICU))
The diagnosis of delirium requires the presence of acute
onset of changes or fluctuations in the course of mental
status, and inattention, and either disorganized thinking
or an altered level of consciousness.
29
Wen-Jinn Liaw
Haloperidol
� Haloperidol is the preferred agent for the treatment
of delirium in the critically ill adult.
– A butyrophenone neuroleptic drug
– Indication for continuous infusion
� ≥ 8 boluses of 10-mg within 24 hrs or > 10 mg/hr for 5
consecutive hrs
� Onset: 30-60 mins (duration of 4-8 hrs)
� Elimination Half-life: 33 hrs
� Initial dose: 2-10 mg IV
� maintain: the dosage is repeated every 2-4 hrs
or infusion with 10 mg/hr
Wen-Jinn Liaw
Incidence of ICU Delirium
Maldonado JR, et al. Anesthesiology. 2003; 99: A465.
De
liriu
m,
%
0
10
20
30
40
50
60
Dexmedetomidine Propofol Midazolam
• Evaluation of 90 patients
undergoing cardiac surgery
to determine the probability
of development of
postoperative delirium.
• Post-operative sedation with
dexmedetomidine may be
associated with a lower
incidence of delirium
compared with more
conventional forms of
sedation.
30
Wen-Jinn Liaw
Mechanism of action
Dexmedetomidine
負回饋負回饋負回饋負回饋
Precedex (Dexmedetomidine)
200Clonidine
1200Medetomidine
1600Dexmedetomidine
αααα2 /αααα1
selectivity
Drug
Wen-Jinn Liaw
Dexmedetomidine作用部位作用部位作用部位作用部位
�作用部位作用部位作用部位作用部位
– Brain (locus ceruleus)
第第第第4腦室底上角之色素隆凸腦室底上角之色素隆凸腦室底上角之色素隆凸腦室底上角之色素隆凸
– Spinal cord脊髓
– 交感神經
�中樞神經之作用中樞神經之作用中樞神經之作用中樞神經之作用
– Sedation鎮靜
– Anxiolysis抗焦慮
– Analgesia止痛
�交感神經之作用交感神經之作用交感神經之作用交感神經之作用���� Sympathetic activity
– � BP, � HR
Dexmedetomidine
Spinal Cord
LOCUSCERULEUS
FOURTHVENTRICLE
PONS
CEREBRUM
CEREBELLUM
31
Wen-Jinn Liaw61
Anxiolysis
αααα2B
X
Physiology of Dexmedetomidine
Kamibayashi T, et al. Anesthesiology. 2000;93:1346.
α2A, α2c Locus Ceruleus
α2B CNS-based thermoregulatory inhibition
αααα2B Cerebral vessels and peripheral vasculature
α2A Peripheral smooth-muscle cells
α2A Dorsal horn of the spinal cord
α2A Brainstem vasomotor center
Blocks cardioaccelerator nerve
Vagomimetic action
Wen-Jinn Liaw
Riker et al. JAMA. 2009; 301: 489-499.
33
Wen-Jinn Liaw
ConclusionConclusion
**Denotes components with evidence supporting their benefit.
Schweickert and Kress, Crit Care 2008
苦惱苦惱苦惱苦惱、、、、痛苦痛苦痛苦痛苦
清醒清醒清醒清醒 疼痛疼痛疼痛疼痛
給藥給藥給藥給藥
(察覺愁眉苦臉徵候察覺愁眉苦臉徵候察覺愁眉苦臉徵候察覺愁眉苦臉徵候)
Wen-Jinn Liaw
� Patient-focused care
– assessment of predisposing and precipitating factors,
– frequent monitoring,
– careful medication selection,
– and use of strategies to precisely target therapy to
defined end points and avoid sedation that is excessive
or prolonged.
� Identify delirium
– consider regular assessment of delirium, using a
validated delirium assessment instrument.
ConclusionConclusion
Top Related