1、南华大学附属第一医院ICU 王桥生Delirium-谵妄内容r谵妄的流行病学r谵妄概念、主要特征和分类r谵妄的目前关注情况r谵妄的危害r谵妄的风险因素r谵妄评估及诊断r谵妄的预防r谵妄预防的集束化方案-ABCDE方案r谵妄治疗流行病学rDelirium 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 mortality in cri
2、tical patients.rICU患者谵妄发生率接近80%r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流行病学rDelirium is common in the ICU,affecting 60%to 80%of mechanically ventilated patients and 20%to 50%of nonmechanically ventilated patientsr谵妄在ICU很常见r60-80%机械通气患者发生谵妄r20-50%非机械通气患者发生谵妄内容r谵妄的流行病学r谵妄概念、主要特征和分类r谵妄的目前关注情况r谵妄的危害r谵妄的风险因素r谵妄评估及
3、诊断r谵妄的预防r谵妄预防的集束化方案-ABCDE方案r谵妄治疗概念rDelirium 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 dayr谵妄以急性器官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
4、认知紊乱。谵妄的主要特征rThe American Psychiatric Association(APA)Diagnostic and Statistical Manual of Mental Disorders,fourth edition,text revision(DSM-IV)defines 4 key features of delirium:r(1)disturbance of consciousness with reduced awareness of the environment and impaired ability to focus,sustain,or shift
5、 attention;r(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 evolving dementia（痴呆）;谵妄的主要特征r(3)disturbance that devel
6、ops over a short period of time(hours to days)and tends to fluctuate during the course of the day;r(4)evidence of an etiologic factor(ie,delirium due to general medical condition,substance-induced delirium,delirium due to multiple causes,or delirium not otherwise specified)谵妄分类-发病时间rThe classificati
7、on of delirium can be subdivided by course over time and motor subtypes.r1.The terminology,according to the course over time,includesra)prevalent(if it is detected at the time of admission);rb)incident(if it emerges during the hospital length of stay);rand c)persistent(if the symptoms persist over t
8、ime)谵妄分类-运动亚型r2.The terminology according to motor subtypes includesr a)hyperactive delirium(in which there is an increase in the psychomotor activity and agitation,with attempts to remove invasive devices);rb)hypoactive delirium(characterized by psychomotor slowing,apathy(淡漠),lethargy（昏睡）and a decr
9、ease in response to external stimuli);rand c)mixed delirium(with unpredictable fluctuation of symptoms between the first two subtypes)谵妄分类r3.Additional definitions are described,which include rsubsyndromal delirium（亚临床谵妄）and rdelirium superimposed on dementia（谵妄叠加痴呆）谵妄分类-根据ICDSC评分工具r4.defined its pr
10、esence,using the Intensive Care Delirium Screening Checklist(ICDSC),in a population from an ICU.The ICDSC assigns a score from 0 to 8 points,rdelirium:a score 4 rsubsyndromal delirium:a score between 1 and 3 内容r谵妄的流行病学r谵妄概念、主要特征和分类r谵妄的目前关注情况r谵妄的危害r谵妄的风险因素r谵妄评估及诊断r谵妄的预防r谵妄预防的集束化方案-ABCDE方案r谵妄治疗目前ICU谵妄
11、关注情况镇静和谵妄评估现状使用现有谵妄评估方法的频率ICU谵妄评估的障碍护理人员对谵妄评估的看法内容r谵妄的流行病学r谵妄概念、主要特征和分类r谵妄的目前关注情况r谵妄的危害r谵妄的风险因素r谵妄评估及诊断r谵妄的预防r谵妄预防的集束化方案-ABCDE方案r谵妄治疗谵妄的危害rincreased risk for prolonged mechanical ventilation,catheter removal,self-extubation,and the need for physical restraints.rIn addition,delirium predisposes patie
12、nts（有谵妄倾向患者）to longer hospital stays,with greater health care costs,increased risk of death during the hospitalization,and increased odds of institutionalization following discharge.rEven after hospital discharge,the amount of time a patient has been delirious in the ICU predicts long-term cognitive
13、 impairment,physical disability,and death up to a year later.内容r谵妄的流行病学r谵妄概念、主要特征和分类r谵妄的目前关注情况r谵妄的危害r谵妄的风险因素r谵妄评估及诊断r谵妄的预防r谵妄预防的集束化方案-ABCDE方案r谵妄治疗ICU谵妄的风险因素rThe average medical ICU patient has 11 or more risk factors for developing delirium,r11which can be divided into baseline(predisposing)and hosp
14、ital-related(precipitating)factors内容r谵妄的流行病学r谵妄概念、主要特征和分类r谵妄的目前关注情况r谵妄的危害r谵妄的风险因素r谵妄评估及诊断r谵妄的预防r谵妄预防的集束化方案-ABCDE方案r谵妄治疗谵妄评估rICU理想的谵妄评估工具r the scale used in this environment must ra)have the capacity to evaluate the primary components of delirium(for example,awareness,inattention,disorganized thought
15、 and fluctuation course);r b)must have proven validity and reliability in ICU populations;rc)must involve a fast and easy evaluation;rand d)should not necessitate the presence of psychiatric professionalsICU谵妄评估工具r1.the Confusion Assessment Method-ICU(CAM-ICU)n把RASS评分整合到CAM-ICU确定有效的两个版本：葡萄糖牙版本和英国版本r
16、2.the Intensive Care Delirium Screening Checklist(ICDSC)CAM-ICU临床特征临床特征评价指标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）？若患者已经脱机拔管，需要判
17、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，对某些事物没有意识，不能自主
18、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ICU谵妄诊断rDSM-是目前谵妄最主要的诊断标准，较专业且繁琐r意识模糊评定法（意识模糊评定法（CAMCAM法）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%，特异性100%。葡
19、萄牙版本of CAM-ICUEnglish versions of CAM-ICURASS评分谵妄评分工具有效性谵妄鉴别诊断内容r谵妄的流行病学r谵妄概念、主要特征和分类r谵妄的目前关注情况r谵妄的危害r谵妄的风险因素r谵妄评估及诊断r谵妄的预防r谵妄预防的集束化方案-ABCDE方案r谵妄治疗非ICU患者谵妄预防ICU谵妄预防rOn the whole,the constellation（系列）of risk factors for delirium affecting individual ICU patients varies from patient to patient and thu
20、s an individualized strategy for delirium prevention should be soughtr3 risk factors in particular,sedatives,immobility,and sleep disruption,are widespread in the ICU通过镇静管理预防谵妄ravoidance of benzodiazepines is an important strategy when seeking to both prevent delirium and reduce its duration.通过疼痛管理预
21、防谵妄rPain 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 be inappropriately given a sedative medication rather than an analgesic medication.rIn summary,these data suggest that opioids
22、(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 delirium.rTherefore,patients should undergo regular pain assessments,and when pain is detected effective doses of an analgesic（镇痛）medication s
23、hould be given,taking care to avoid inducing heavy sedation.ICU患者早期活动预防谵妄rdatas suggest a role for early mobility in the reduction of the duration of delirium among critically ill patients.改善睡眠预防谵妄rSleep deprivation is nearly universal for ICU patients,with the average ICU patient sleeping between 2
24、 and 8 hours in a 24-hour period.rNoise-reduction strategies(such as earplugs),normalizing day-night illumination(白天照明),minimizing care-related interventions during normal sleeping hours,and interventions promoting patient comfort and relaxation are low risk and often inexpensive,and should be imple
25、mented to prevent delirium.药物干预预防谵妄rthere are currently no medications approved by the US Food and Drug Administration for the prevention or treatment of delirium.内容r谵妄的流行病学r谵妄概念、主要特征和分类r谵妄的目前关注情况r谵妄的危害r谵妄的风险因素r谵妄评估及诊断r谵妄的预防r谵妄预防的集束化方案-ABCDE方案r谵妄治疗预防谵妄-ABCDE Approach rDelirium in the ICU is frequent
26、ly multifactorial,so it is unlikely that a single intervention can prevent or reduce delirium with regularity(规则性)rTherefore,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
27、 ABCDE approach,has been proposed to improve multiple outcomes,including preventing and reducing the duration of delirium in the ICUWhat Is the ABCDE Bundle?rThe ABCDE bundle is multicomponent approach designed to improve patient outcome by facilitating clinical team collaboration,standardizing care
28、 processes,and breaking the cycle of oversedation and prolonged ventilation.With many demands on critical care staff there is a great need to align and support the people,processes,and technology focused on improving the comfort and outcome of patients who require admission to an ICU.The ABCDE bundl
29、e promotes patient wakefulness through sedation down-titration and optimal sedative and analgesic choice that facilitates early mobilization,delirium recognition,and extubation.谵妄监测与评估rRecent expert guidelines advocate（提倡）the use of the Confusion Assessment Method for the ICU(CAM-ICU)or the Intensive Care Unit Delirium Screening Checklist(ICDSC)
