【文章內(nèi)容簡介】 isorientation. evokes a stress response characterized by tachycardia, increased myocardial oxygen consumption, hypercoagulability, immunosuppression,and persistent catabolism.pulmonary dysfunction,第四十三頁，共八十七頁。,Recommendation: All critically ill patients have the right to adequate analgesia and management of their pain. (Grade of recommendation C),第四十四頁，共八十七頁。,Pain Assessment,The most reliable and valid indicator of pain is the patient’s selfreport。,第四十五頁，共八十七頁。,Analgesia Therapy,1.Nonpharmacologic：proper positioning of patients, stabilization of fractures, and elimination of irritating physical stimulation；Application of heat or cold therapy,第四十六頁，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。,第四十八頁，共八十七頁。,第四十九頁，共八十七頁。,理想(lǐxiǎng)：Desirable attributes of an opioid include rapid onset, ease of titration, lack of accumulation of the parent drug or its metabolites, and low cost. Fentanyl has the most rapid onset and shortest duration, but repeated dosing may cause accumulation and prolonged effects. Morphine has a longer duration of action。hypotension may result from vasodilation and an active metabolite may cause prolonged sedation in the presence of renal insufficiency.,第五十頁，共八十七頁。,hydromorphone lacks a clinically significant active metabolite or histamine release. Meperidine has an active metabolite that causes neuroexcitation (apprehension, tremors, delirium,and seizures) and may interact with antidepressants (contraindicated with monoamine oxidase inhibitors and best avoided with selective serotonin reuptake inhibitors), so it is not recommended for repetitive use。,第五十一頁，共八十七頁。,Remifentanil has not been widely studied in ICU patients and requires the use of a continuous infusion because of its very short duration of action。 Be useful for requiring interruptions for neurologic examination,第五十二頁，共八十七頁。,Adverse effects,patients. Of greatest concern are respiratory, hemodynamic, central nervous system, and gastrointestinal effects. hypotension :the combination of sympatholysis,vagally mediated bradycardia,and histamine release(when using codeine,morphine, or meperidine) central nervous system :hallucinations may increase agitation insome patients. gastrointestinal effects :Routine prophylactic use of a stimulant laxative may minimize constipation.Smallbowel intubation may be needed for enteral nutrition because of gastric hypomotility (45).,第五十三頁，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。,The use of a reversal agent,Naloxone , is not recommended because it can induce withdrawal and may cause nausea, cardiac stress, and arrhythmias.,第五十五頁，共八十七頁。,Recommendations:,1.A therapeutic plan and goal of analges(c) 2.intravenous doses of an opioid analgesic are required, fentanyl, hydromorphone,and morphine are the recommended agents. (c) 3. Scheduled opioid doses or a continuous infusion is preferred over an “as needed” regimen to ensure consistent analgesia.A PCA device may be utilized to deliver opioids if the patient is able to understand and operate the device. (b),第五十六頁，共八十七頁。,4.Fentanyl is preferred for a rapid onset of analgesia in acutely distressed patients. (C) 5. Fentanyl or hydromorphone are preferred for patients with hemodynamic instability or renal insufficiency.(C) 6. Morphine and hydromorphone are preferred for intermittent therapy because of their longer duration of effect.(C),第五十七頁，共八十七頁。,NSAIDs,adverse effects, including gastrointestinal bleeding,bleeding secondary to platelet inhibition, and the development of renal insufficiency. NSAIDs should not be admini