ICU谵妄及ABCDE集束化预防方案

南华大学附属第一医院ICU王桥生Delirium-谵妄内容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谵妄治疗流行病学Deliriumoccursinupto80%ofpatientsadmittedtointensivecareunits.Althoughunder-diagnosed,deliriumisassociatedwithasignificantincreaseinmorbidityandmortalityincriticalpatients.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流行病学DeliriumiscommonintheICU,affecting60%to80%ofmechanicallyventilatedpatientsand20%to50%ofnonmechanicallyventilatedpatients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谵妄治疗概念Deliriumintheintensivecareunit(ICU)representsanacuteformoforgandysfunction,whichmanifestsasarapidlydevelopingdisturbanceofbothconsciousnessandcognitionthattendstofluctuatethroughoutthecourseofaday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、迅速发展的意识和认知紊乱。谵妄的主要特征TheAmericanPsychiatricAssociation(APA)DiagnosticandStatisticalManualofMentalDisorders,fourthedition,textrevision(DSM-IV)defines4keyfeaturesofdelirium:(1)disturbanceofconsciousnesswithreducedawarenessoftheenvironmentandimpairedabilitytofocus,sustain,orshiftattention;(2)alteredcognition(eg,impairedmemory,languagedisturbance,ordisorientation)orthedevelopmentofaperceptual（知觉）disturbance(eg,hallucinations（幻觉）,delusions（妄想）,orillusions（错觉）)thatisnotbetteraccountedforbypreexistingorevolvingdementia（痴呆）;谵妄的主要特征(3)disturbancethatdevelopsoverashortperiodoftime(hourstodays)andtendstofluctuateduringthecourseoftheday;(4)evidenceofanetiologicfactor(ie,deliriumduetogeneralmedicalcondition,substance-induceddelirium,deliriumduetomultiplecauses,ordeliriumnototherwisespecified)谵妄分类--发病时间Theclassificationofdeliriumcanbesubdividedbycourseovertimeandmotorsubtypes.1.Theterminology,accordingtothecourseovertime,includesa)prevalent(ifitisdetectedatthetimeofadmission);b)incident(ifitemergesduringthehospitallengthofstay);andc)persistent(ifthesymptomspersistovertime)谵妄分类--运动亚型2.Theterminologyaccordingtomotorsubtypesincludesa)hyperactivedelirium(inwhichthereisanincreaseinthepsychomotoractivityandagitation,withattemptstoremoveinvasivedevices);b)hypoactivedelirium(characterizedbypsychomotorslowing,apathy(淡漠),lethargy（昏睡）andadecreaseinresponsetoexternalstimuli);andc)mixeddelirium(withunpredictablefluctuationofsymptomsbetweenthefirsttwosubtypes)谵妄分类3.Additionaldefinitionsaredescribed,whichincludesubsyndromaldelirium（亚临床谵妄）anddeliriumsuperimposedondementia（谵妄叠加痴呆）谵妄分类--根据ICDSC评分工具4.defineditspresence,usingtheIntensiveCareDeliriumScreeningChecklist(ICDSC),inapopulationfromanICU.TheICDSCassignsascorefrom0to8points,delirium:ascore≥4subsyndromaldelirium:ascorebetween1and3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谵妄治疗目前ICU谵妄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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谵妄治疗谵妄的危害increasedriskforprolongedmechanicalventilation,catheterremoval,self-extubation,andtheneedforphysicalrestraints.Inaddition,deliriumpredisposespatients（有谵妄倾向患者）tolongerhospitalstays,withgreaterhealthcarecosts,increasedriskofdeathduringthehospitalization,andincreasedoddsofinstitutionalizationfollowingdischarge.Evenafterhospitaldischarge,theamountoftimeapatienthasbeendeliriousintheICUpredictslong-termcognitiveimpairment,physicaldisability,anddeathuptoayearlater.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ICU谵妄的风险因素TheaveragemedicalICUpatienthas11ormoreriskfactorsfordevelopingdelirium,11whichcanbedividedintobaseline(predisposing)andhospital-related(precipitating)factors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谵妄治疗谵妄评估ICU理想的谵妄评估工具thescaleusedinthisenvironmentmusta)havethecapacitytoevaluatetheprimarycomponentsofdelirium(forexample,awareness,inattention,disorganizedthoughtandfluctuationcourse);b)musthaveprovenvalidityandreliabilityinICUpopulations;c)mustinvolveafastandeasyevaluation;andd)shouldnotnecessitatethepresenceofpsychiatricprofessionalsICU谵妄评估工具1.theConfusionAssessmentMethod-ICU(CAM-ICU)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2.theIntensiveCareDeliriumScreeningChecklist(ICDSC)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）？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，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ICU谵妄诊断DSM-Ⅳ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%，特异性100%。葡萄牙版本ofCAM-ICUEnglishversionsofC