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危重患者中镇静-镇痛药物：选择、开始、维持和停药

Authors
Barry Fuchs, MD
Cassandra Bellamy, PharmD, BCPS
Section Editor
Polly E Parsons, MD
Deputy Editor
Geraldine Finlay, MD
Translators
刘晔, 主治医师

引言

劣性应激通常表现为激越状态。这在危重患者(尤其是插管患者或与其照料者沟通困难的患者)中很常见[1]。为了使患者感到舒适，需要治疗劣性应激，因为劣性应激会增加交感紧张，可能会造成不良的生理效应[2]。除了少数例外(如神经肌肉麻痹和手术)，镇静-镇痛药物的使用应当基于所观察到的而不是基于预期的劣性应激；否则，将有过度镇静增加的风险，过度镇静已经显示会使患者的临床结局恶化。

对危重患者激越状态的治疗将总结在此，包括药物镇静的开始、维持及停止。危重患者常见的镇静-镇痛药物、疼痛的治疗以及神经肌肉阻断药的使用将在别处讨论。 (参见“用于危重病成人患者的镇静-镇痛药：药物特性、剂量方案和不良反应”和“危重成人患者的疼痛控制”和“神经肌肉阻断药在危重患者中的应用”)

药物治疗开始前

在开始使用镇静-镇痛药物处理激越状态之前，应明确和处理劣性应激的原因。非药物策略应优先考虑，且应在使用药物治疗前进行。

明确劣性应激的原因 — 引起危重患者劣性应激的常见原因包括：焦虑、疼痛、谵妄、呼吸困难以及神经肌肉麻痹。这些病因可能单独或共同存在。

●焦虑–焦虑定义为对真实或感知威胁的反应，是一种恐惧和自主性觉醒的持续状态[1]。对痛苦和死亡的恐惧、丧失控制和无法有效沟通所致的挫折是危重患者焦虑的典型原因。症状和体征包括：头痛、恶心、失眠、厌食、呼吸困难、心悸、眩晕、口干、胸痛、发汗、过度通气、皮肤苍白、心动过速、发抖和/或过度警觉。

明确和治疗焦虑的近因总是最理想的，因为这样可能改善两方面的问题。例如，呼吸困难是危重患者焦虑常见的基础原因。因此，如果是因为呼吸机流量设置不当引起患者呼吸困难从而造成焦虑，那么焦虑(和潜在的呼吸困难)的最终治疗可能是调整呼吸机设置。或者，焦虑的突然发作可能提示应对心肺方面作进一步诊断性检查。

                  

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Literature review current through: 2017-07 . | This topic last updated: 2016-04-15.
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