重症醫學-PADIS

在加護病房、重症的病人上，常常會有PADIS的問題什麼是PADIS？ = 疼痛(Pain) = 躁動(Agitation) = 譫妄(Delirium) = 不動(Immobility) = 睡眠. ~Teachingcenter的醫學筆記~ 跳到主文 如有錯誤歡迎各方專家指正謝謝 部落格全站分類：醫療保健 相簿 部落格 留言 名片 圖片太大，可以右鍵或長按後在新分頁開啟 ***更多討論***痞客邦--醫學邦***點我前往*** ~~~MAX台灣唯一信託加密貨幣交易所~~~ 有幫助的文章，可以給個推或讚，讓我知道哪些是對大家有益的 Apr19Sun202020:32 重症醫學-PADIS 在加護病房、重症的病人上，常常會有PADIS的問題 什麼是PADIS？ =疼痛(Pain) =躁動(Agitation) =譫妄(Delirium) =不動(Immobility) =睡眠中斷(Sleepdisruption)   重點： •嗎啡是很好的止痛藥物 (Morphinesulfateisthepreferredanalgesicagentforcriticallyillpatients.) •對於血行動力學不穩定的病人，芬太尼是很好的選擇，相比於嗎啡，也比較少見組織胺的釋放或過敏反應 (Fentanylisthepreferredanalgesicagentforcriticallyillpatientswithhemodynamicinstability,forpatientsmanifestingsymptomsofhistaminereleasewithmorphineormorphineallergy.) •二氫嗎啡酮是嗎啡的另外一個選擇 (Hydromorphonecanserveasanacceptablealternativetomorphine.) •咪達唑侖和異丙酚建議用於重症病人短期的焦慮處理 (Midazolamorpropofolarethepreferredagentsonlyforpreferredagentsonlyfortheshort-term(lessthan24)treatmentofanxietyinthecriticallyilladult.) •蘿拉西泮建議用於需要長期治療的焦慮 (Lorazepamisthepreferredagentforprolongedtreatmentofanxietyinthecritically.) •氟哌啶醇建議用於瞻望治療 (Haloperidolisthepreferredagentfortreatmentofdeliriuminthecriticallyilladult.) ShapiroPA,etal.CritCarMed.1995;23(9):1596-1600.   Pain(Assessment) 1.Whatarethemostvalidandreliablemeasuresofpainincriticallyilladultpatientsregardlessofwhetherthepatientisundermechanicalventilation? -Forpatientswhocanself-report,eithertheNumericRatingScale(NRS)ortheVisualAnalogueScale(VAS)isrecommended,targetscoreforpainalleviationisNRS<4orVAS<3. -Forpatientswhocannotself-report,BehavioralPainScale(BPS)ortheCritical-CarePainObservationTool(CPOT)isrecommended,targetscoreforpainalleviationisBPS<5orCPOT<3. “Caution:ThevalidityandreliabilityshouldbereassessedafterChinesetranslationofthesetools. 2.ShouldvitalsignsbeusedtoassesspaininadultICUpatients? -Wedonotsuggestthatvitalsigns(orobservationalpainscalesthatincludevitalsigns)beusedaloneforpainassessmentinadultICUpatients. -Wesuggestthatvitalsignsmaybeusedasacuetobeginfurtherassessmentofpaininthesepatients. 疼痛評分量表(ScreeningToolsforPainAssessment) 疼痛 Pain 量表 評估方法 Self-reportScales 數字計算型量表(NumericalRating.Scale,NRS) -Referencestandard -VerballyorVisually -0~10numericratingscale Behavioralpainassessmenttools 疼痛行為計分量表(BehavioralPainScale,BPS) 非插管病患BPS(BPSinnon-intubated,BPS-NI) 重症照護疼痛觀察工具(Critical-CarePainObservationTool,CPOT) -Criticallyilladultsunabletoself-reportpain -Greatestvalidityandreliability 一般的生理監測(如心跳、血壓、呼吸速率、氧合濃度或呼吸末二氧化碳)，在重症病患不能單獨作為疼痛評估的工具，但可以做為一個啟動完整疼痛評估的觸發點 BPS BPS-NI CPOT Pain(Treatment) 1.Shouldprocedure-relatedpainbetreatedpre-emptivelyinadultICUpatients? -WerecommendthatforallpotentiallypainfulproceduresinadultICUpatients,pre-emptiveanalgesictherapyand/ornon-pharmacologicinterventionsmayalsobeadministeredtoalleviatepain. 2.WhattypesofmedicationsshouldbeadministeredforpainreliefinadultICUpatients? -AllavailableIVopioidscouldbeconsideredasthefirst-linedrugclassofchoicetotreatnon-neuropathicpainincriticallyillpatients. -Eitherenterallyadministeredgabapentinorcarbamazepine,inadditiontoIVopioids,couldbeconsideredforthetreatmentofneuropathicpain. “Caution:UseHLA-B1502genescreeningbeforeadministrationofcarbamazepinetoavoidSteven-Johnsonsyndromeortoxicepidermalnecrolysis. -Non-opioidanalgesicscouldbeconsideredtodecreasetheamountofopioidsadministered(ortoeliminatetheneedforIVopioidsaltogether)andtodecreaseopioid-relatedsideeffects. 3.Whatmodeofanalgesicdeliveryisrecommendedforpainreliefincriticallyilladultswhohaveundergoneeitherabdominalaorticsurgeryortraumaticribfractures? -Thoracicepiduralanesthesiacouldbeconsideredforpost-operativeanalgesiaforabdominalaorticsurgeryortraumaticribfracture.   Agitation(Assessment) 1.ShouldadultICUpatientsbemaintainedatalightlevelofsedation? -Thepatient'soutcome(suchasshorteningventilatordaysandICUstay)canbeimprovedbymaintaininglightsedationunlesscontraindicated. -Thestressresponseofthepatientmaybeincreasedbymaintaininglightsedation,butthefrequencyofmyocardialischemiaisnotaffected. 2.WhichsubjectivesedationscalesarethemostvalidandreliableintheassessmentofdepthandqualityofsedationinmechanicallyventilatedadultICUpatients? -TheRichmondAgitation-SedationScale(RASS)andtheSedation-AgitationScale(SAS)arethemostusefulscalesforassessingsedationdepthandqualityinadultpatients. -Othersedationscales(suchasRamsayscale)canbeusedaccordingtothehospitalpolicy. 3.Shouldobjectivemeasuresofbrainfunction(e.g.,auditoryevokedpotentials(AEPs),bispectralindex(BIS),Narcotrendindex(NI),patientstateindex(PSI),orstateentropy(SE))beusedtoassessdepthofsedationinnon-comatose,adultICUpatientswhoarenotreceivingneuromuscularblockingagents? -Wedonotrecommendthatobjectivemeasuresofbrainfunction(e.g.AEPs,BIS,NI,PSI,orSE)beusedastheprimarymeasuretomonitorthedepthofsedationinnon-comatose,non-paralyzedcriticallyilladultpatients,asthesemonitorsareinadequatesubstitutesforsubjectivesedationscoringsystems. 4.Shouldobjectivemeasuresofbrainfunction(e.g.AEPs,BIS,NI,PSI,orSE)beusedtomeasuredepthofsedationinadultICUpatientswhoarereceivingneuromuscularblockingagents? -Whentheneuromuscularblockingagentsisusedandthesubjectiveassessmentofapatientisdifficult,theuseofanobjectiveindexsuchastheauxillarysedationdepthassessmentissuggested. 5.ShouldEEGmonitoringbeusedtodetectnon-convulsiveseizureactivityandtotitrateelectrosuppressivemedicationtoobtainburstsuppressioninadultICUpatientswitheitherknownorsuspectedseizures? -TheEEG(30minutesorcontinuous)monitoringcouldbeconsiderintheICUpatientswithsuspectedorknownriskfactorsofnon-convulsiveseizures. “Riskfactorsofagitation” ......a.Comaofunknowncauses ......b.Inadequatetreatmentofgeneralizedstatusepilepticus ......c.Historyofepilepsy ......d.Encephalopathic ......e.Electrolyteabnormality ......f.Infectionsstate ......g.Glucosedysregulation RamsaySedationScale RikerSedation-AgitationScale(SAS) RichmondAgitationSedationScale(RASS) Agitation(Treatment) 1.Shouldnon-benzodiazepine(BZD)-basedsedation,insteadofsedationwithbenzodiazepines,beusedinmechanicallyventilatedadultICUpatients? -Wesuggestthatsedationstrategiesusingnon-BZDsedativescouldbechosentoimproveclinicaloutcomesinmechanicallyventilatedadultICUpatients. -Triglycerideconcentrationsshouldbemonitoredafter>2daysofpropofolinfusion,andtotalcaloricintakeformlipidsshouldbeincludedinthenutritionsupportprescription. -Thepotentialforopioid,BZDandpropofolwithdrawalshouldbeconsideredafterhighdosesormorethan7daysofcontinuoustherapy. -Dosesshouldbetaperedsystematicallytopreventwithdrawalsymptoms. 2.Whichsedativeismoreeffectiveforadultpatientsunderartificialrespiration,dexmedetomidineorpropofol? -Asofnow,therelativesuperiorityofdexmedetomidineorpropofolasasedativeforadultpatientsundermechanicalventilationcannotbedeterminedduetolackofevidence. 3.ShouldaprotocolthatincludeseitherdailysedativeinterruptionoralighttargetlevelofsedationbeusedinmechanicallyventilatedadultICUpatients? -Unlesshavingobviouscontra-indications,werecommendeitherdailysedationinterruptionoralighttargetlevelofsedationberoutinelyusedinmechanicallyventilatedadultICUpatients. 4.Shouldanalgesia-firstsedation(i.e.,analgosedation)orsedative-hypnotic-basedsedationbeusedinmechanicallyventilatedICUpatients? -WesuggestthatanalgosedationbeusedinmechanicallyventilatedadultICUpatients.   Sleepdisorder =Shouldnon-pharmacologicinterventionsbeusedtopromotesleepinadultICUpatients? -Werecommendmulti-facetedmeasurestoimprovesleepqualityinadultICUpatientsbyoptimizingpatients'environments,usingstrategiestocontrollightandnoise,clusteringpatientcareactivities,anddecreasingstimuliatnighttoprotectpatients'sleepcycles.   Delirium(Assessment) 1.WhatoutcomesareassociatedwithdeliriuminadultICUpatients? -DeliriumworsenstheprognosisofpatientsinICUs. -DeliriumprolongsthedurationofstayinICUs. -DeliriuminfluencessubsequentcognitivedysfunctionoutsidetheICU. 2.ShouldICUpatientsbemonitoredroutinelyfordeliriumwithanobjectivebedsidedeliriuminstrument? -WeencourageroutinemonitoringofadultICUpatientsforthesymptomsofdeliriumwithanobjectiveinstrument. 3.Whichinstrumentsavailablefordeliriummonitoringhavethestrongestevidenceforvalidityandreliabilityinventilatedandnon-ventilatedmedicalandsurgicalICUpatients? -TheConfusionAssessmentMethodforIntensiveCareUnit(CAM-ICU)andtheIntensiveCareDeliriumScreeningChecklist(ICDSC)arethemostvalidandreliabledeliriummonitoringtoolsforICUpatients. 4.Isimplementationofroutinedeliriummonitoringfeasibleinclinicalpractice? -ThedeliriummonitoringofadultICUpatientscanbepracticedroutinely. “Riskfactorsofdelirium” ……a.pre-existingdementia ……b.historyofhypertension ……c.alcoholism ……d.highseverityofillnessatadmission ……e.coma ……f.opioiduse ……g.benzodiazepineuse   Delirium(Prevention) 1.ShouldearlymobilizationbeusedintheICUtoreducetheincidenceordurationofdelirium? -WerecommendperformingearlymobilizationofadultICUpatientswheneverfeasibletoreducetheincidenceanddurationofdelirium. 2.ShouldhaloperidoloratypicalantipsychoticsbeusedprophylacticallytopreventdeliriuminICUpatients? -WedonotsuggestthateitherhaloperidoloratypicalantipsychoticsbeadministeredtopreventdeliriuminadultICUpatients. 3.ShoulddexmedetomidinebeusedprophylacticallytopreventdeliriuminICUpatients? -WeprovidenorecommendationfortheuseofdexmedetomidinetopreventdeliriuminadultICUpatients,asthereisnoevidenceregardingitseffectivenessinthesepatients. 4.Istherenon-pharmacologicpreventionforhighriskpatient? -Reduceorshortendelirium:Re-orientation,cognitivestimulation,useofclocks -Improvesleep:Minimizinglightandnoise -Improvewakefulness:Reducesedation -Reduceimmobility:Earlyrehabilitation/mobilization -Reducehearingandvisualimpairment:Enableuseofdevicessuchashearingaidsoreyeglasses   Delirium(Treatment) 1.WhatbaselineriskfactorsareassociatedwiththedevelopmentofdeliriumintheICU? -Baselineriskfactorsareasfollowing:age;ahighseverityofillness;infection(septicemia);pre-existingdementia;andhistoryofalcoholism. 2.WhichICUtreatment-related(acquired)riskfactor(I.e.,opioids,benzodiazepines,propofol,anddexmedetomidine)areassociatedwiththedevelopmentofdeliriuminadultICUpatients? -Benzodiazepine(BZD)usemaybeariskfactorforthedevelopmentofdelirium. -Conflictingdatatsurroundtherelationshipbetweenopioiduseanddelirium. -DexmedetomidineinfusionmaybeassociatedwithalowerprevalenceofdeliriumcomparedtoBZDinfusionsinmechanicallyventilatedadultICUpatientsatriskfordevelopingdelirium. 3.DoestreatmentwithhaloperidolreducethedurationofdeliriuminadultICUpatients? -Thereisnopublishedevidencethattreatmentwithhaloperidolreducesthedurationofdelirium. 4.DoestreatmentwithatypicalantipsychoticsreducethedurationofdeliriuminadultICUpatients? -Atypicalantipsychoticsmayreducethedurationofdelirium. 5.Shouldtreatmentwithcholinesteraseinhibitors(rivastigmine)beusedtoreducethedurationofdeliriuminICUpatients? -WedonotrecommendadministeringrivastigminetoreducethedurationofdeliriuminICUpatients. 6.Shouldhaloperidolandatypicalantipsychoticsbewithheldinpatientsathighriskfortorsadesdepointes? -Wedonotsuggestusingantipsychoticsinpatientsatsignificantriskoftorsadesdepointes(i.e.,prolongofQTinterval,receivingconcomitantmedicationknowntoprolongtheQTinterval,orpatientswithahistoryofthisarrhythmia). 7.Formechanicallyventilated,adultICUpatientswithdeliriumwhorequirecontinuousIVinfusionsofsedativemedications,isdexmedetomidinepreferredoverBZDtoreducethedurationofdelirium? -WesuggestthatinadultICUpatientswithdeliriumunrelatedtoalcoholorBZDwithdrawal,continuousIVinfusionsofdexmedetomidinemaybebetterthanBZDinfusionstoreducethedurationofdelirium. 8.Whatispropofolrelatedinfusionsyndrome(PRIS)? -Rarecomplication(<1%),highmortality(33~66%) -Highdoses(>4mg/kg/hr),prolongeduse(>48hrs) -Riskfactors:youngage,criticalillness,highfatandlowcarbohydrateintake,inborneroorsofmitochondrialfattyacidoxidation,concomitantcatecholamineinfusionorsteroidtherapy -CharacteristicsofPRIS:acuterefractorybradycardia,severemetabolicacidosis,cardiovascularcollapse,rhabdomyolysis,hyperlipidemia,renalfailure,hepatomegaly     文章標籤 PADIS pain agitation delirium immobility sleepdisruption 加護病房 ICU 重症 醫學 醫療 建議 治療 診斷 監測 藥物 嗎啡 止痛 瞻望 評估 全站熱搜 創作者介紹 TeachingCenter. ~Teachingcenter的醫學筆記~ TeachingCenter.發表在痞客邦留言(3)人氣() E-mail轉寄 全站分類：醫療保健個人分類：內科此分類上一篇：血中乳酸(Lactate) 此分類下一篇：林格氏液(Ringer’sSolution) 上一篇：主動脈剝離、皮瓣手術 下一篇：林格氏液(Ringer’sSolution) 歷史上的今天 2019:解毒劑Antidotesinpoisoning健保給付規範 2019:抗微生物劑Antimicrobialagents健保給付規範 ▲top 留言列表 發表留言 來訪人數 本日人氣： 累積人氣： 熱門文章 最新文章 文章分類 醫學筆記-小兒外科(3) 小兒外科(10)小兒科(63)胚胎學、發育(24) 醫學筆記-外科(2) 外科(198)外科營養(15) 醫學筆記-內科(3) 內科(311)住院醫師生存守則(10)ACLS急救(12) 醫學筆記-其他科(5) 婦產科(28)精神科(5)皮膚科(3)急診(12)中英對照(8) 全民健保(1) 健保給付(17) 輕鬆一下(4) 笑話(9)優惠活動(3)敲獎券、經驗值(6)資源(4) 生命(2) 想法(41)藥物使用心得(個人經驗)(3) 國中(2) 數學(8)理化(2) 高中(4) 數學(36)物理(21)生物(5)地球科學(2) 未分類文章(1) 我的好友 最新留言 ***更多討論***痞客邦--醫學邦***~~Freebitco.in水龍頭~~ ~~MAX台灣唯一信託加密貨幣交易所~~ BitcoinDonation:1FWWCw3fbGfD3sNGQHsebK9Z3oi1MYx2hu 回到頁首 回到主文 免費註冊 客服中心 痞客邦首頁 ©2003-2021PIXNET 關閉視窗 PIXNET Facebook Yahoo! 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