【正文】 . Routine nursing care and prolonged immobility,后果(h242。,第四十九頁，共八十七頁。,Opioid Administration Techniques.,Bolus doses Intravenous administration intramuscular administration. a transdermal patch(on the permeability, temperature, perfusion, and thickness of the skin). Intramuscular administration is not recommended in hemodynamically unstable patients because of altered perfusion and variable absorption. Daily awakening,第五十四頁，共八十七頁。,SEDATION,anxiety and agitation原因(yu225。,recall their ICU stay report unpleasant or frightening memories, which may contribute to posttraumatic stress disorder (PTSD) symptoms。,Sedation Therapy,第七十二頁，共八十七頁。,Prolonged use (48 hours) of high doses of propofol (66 g/kg/min infusion) has been associated with lactic acidosis. bradycardia,and lipidemia in pediatric patients anddoses 83 g/kg/min have been associated with an increased risk of cardiac arrest in adults. The adults athighest risk for cardiac complications received 100 g/kg/min infusion of a 2%propofol solution to achieve deep sedation after neurologic injury. against the use of propofol for the prolonged sedation of pediatric patients. monitor metabolic acidosis or arrhythmias.,第八十頁，共八十七頁。ir243。ng)才能保持藥效不減。耐藥性：隨時間的延長藥效降低，或需加大劑量(j236。,Withdral syndrome,第八十六頁，共八十七頁。,Benzodiazepine antagonist, such as flumazenil, is not recommended. inducing withdrawal symptoms and increasing myocardial oxygen consumption with as little as 0.5 mg of flumazenil. a single low dose is recommended.,第七十八頁，共八十七頁。,Objective Assessment of Sedation.,Include heart rate variability and loweresophageal contractility the bispectral index (BIS)uses a digital scale from 100 (completely awake) to 0 (isoelectric EEG) BIS Limitations in the ICU environment Musclebased electrical activity may artificially elevate BIS scores if the patient has not received neuromuscular blockade,第七十頁，共八十七頁。,Sedatives reduce the stress response and improve the tolerance of routine ICU procedures maintain patient safety and comfort of restraint and are not to be “used as a means of coercion, discipline,convenience, or retaliation by staff”。,第六十頁，共八十七頁。 Be useful for requiring interruptions for neurologic examination,第五十二頁，共八十七頁。,2.Pharmacologic therapies：include opioids,nonsteroidal antiinflammatory drugs(NSAIDs), and acetaminophen.,第四十七頁，共八十七頁。,ICU疼痛(t233。n t242。n t242。 hu224。 3. 心血管 體位性低血壓：同嗎啡 腦血管擴張：抑制呼吸使CO2積蓄。ng)器官的敏感性,第三十三頁，共八十七頁。芬太尼的代謝產(chǎn)物雖可發(fā)生蓄積，但大多(d224。2. 耐受性和依賴性戒斷癥狀：興奮、失眠、腺體分泌增加、震顫，嘔吐、腹瀉焦慮、瞳孔散大,嗎啡(ma fēi),第三十一頁，共八十七頁。 代謝：大部分在肝，與葡萄糖醛酸結(jié)合，10%成為去甲嗎啡 排泄(p225。其主要不良反應為易于造成(z224。nj236。,異丙酚(propofol) 常作為icu連續(xù)靜脈用藥(y242。,右美托咪啶,第二十四頁，共八十七頁。,右美托咪陡為一種a2激動劑型新鎮(zhèn)靜藥，正推薦用于ICU。對于急性激動的患者(hu224。它也可引起注射時疼痛及代謝性酸中毒、橫紋肌溶解及循環(huán)性虛脫。,第二十一頁，共八十七頁。為此它與丙泊酚被推薦用于短期( 24 h )治療危重患者的焦慮。由于勞拉西浮是在丙二醇中稀釋的，故在溶液中不穩(wěn)定，并在靜脈導管中可發(fā)生沉淀。地西浮由肝微粒體系統(tǒng)的酶代謝為兩種活性產(chǎn)物去甲地西洋和奧沙西泮。ng)藥物應用的適應癥,第十八頁，共八十七頁。,第十六頁，共八十七頁。,小劑量：鎮(zhèn)靜作用，用于治療(zh236。o)性操作 Ramsay評分6級,第十一頁，共八十七頁。nj236。,對于疼痛和焦慮(jiāolǜ)的評價,第八頁，共八十七頁。VAS簡便易行并有較高的可靠性和確實性，但卻忽略了其他的量綱，例如疼痛的性質(zhì)等。,重癥病人獲得充分的鎮(zhèn)靜和鎮(zhèn)痛(zh232。ng)與鎮(zhèn)痛 （sedation and analgesia in ICU）,第一頁，共八十七頁。i sh249。nzhě)的晝夜生理節(jié)律,第四頁，共八十七頁。Elderly patients may have difficulty with VAS,第五頁，共八十七頁。最近有些學者(xu233。n)焦慮、煩躁不安 2級 病人合作、清醒入睡 3級 病人僅對指令有反應 4級 病人入睡、輕叩眉間反應敏捷 5級 病人入睡、輕叩眉間反應遲鈍 6級 深睡或麻醉狀態(tài) (British Journal of Intensive Care. 1992,516),第十頁，共八十七頁。ng)藥物,第十二頁，共八十七頁。nj236。nɡ)的鎮(zhèn)靜藥和鎮(zhèn)痛藥,第十七頁，共八十七頁。長期攝人能因活性產(chǎn)物而使鎮(zhèn)靜作用延長，故不宜于TCU中的鎮(zhèn)靜使用。,勞拉西泮 勞拉西浮比地西伴的藥效高5一10倍，優(yōu)選用于長期治療成人危重患者的焦慮。勞拉西浮在肝中被葡糖醛酸化為無活性產(chǎn)物。持久滴注有時導致較長時間的作用，特別是在危重患者(由于活性代謝產(chǎn)物蓄積所致)。n)作用，但不止痛，其作用機制可能涉及中樞神經(jīng)系統(tǒng)中的GABA受體。,氟派啶醇,氟派啶醇為丁酰苯型抗精神病藥，已用于治療危重患者(hu224。氟娠嚨醇有一些重要的不良反應:降低癲痛發(fā)作闡、突發(fā)錐體外系反應、使QT間期延長等。插管和除管時減少(jiǎnshǎo)血液動力學反應，減輕對外科手術(shù)的應激反應，加強止痛藥的作用。ng)、抗驚厥 地西潘（diapezam)：起效時間35min，半衰期2036hrs。nj236。nj236。嗎啡的排除半衰期為2一4 h.其活性代謝產(chǎn)物嗎啡6葡糖醛酸可發(fā)生蓄積而導致腎衰患者發(fā)生鎮(zhèn)靜過度。ixi232。它只引起較輕的血液動力學改變，但不影響心肌收縮力的狀態(tài)。,芬太尼,第三十二頁，共八十七頁。也無止瀉作用。u)痙攣、驚厥：與其代謝產(chǎn)物去甲哌替啶有關(guān)。,美沙酮,第三十七頁，共八十七頁。高度脂溶性，作用迅速。ng),耐藥性：隨時間的延長藥效降低，或需加大劑量(j236。uguǒ)： inadequate sleep, exhaustion and disorientation. evokes a stress response cha