重症病患鎮靜止痛簡介

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贮劳梨乔
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1 外科重症患者 Dexmedetomidine 使用經驗分享陳威豪嘉義基督教醫院外科部重症醫療科

2 重症病患鎮靜止痛簡介

3 鎮靜止痛在 ICU 目標患者的舒適度和疼痛控制抗焦慮和失憶鈍化自主神經和血流動力學反應減少機械通氣時患者不適感減少耗氧量避免自拔管代價譫妄影響血流動力學呼吸器使用時間延長其他 : 腸蠕動減緩最少的代價 ( in hemodynamics / Ventilation) 達到最大的目標 (Analgesia / Sedation)

4 目前 ICU 常用鎮靜止痛藥物 Midazolam Propofol Opioid Sedation v v Analgesia v Sympatholytic v v v Lack of cooperation v v Delirium v v v Hypotension v v Respiratory depression v v v Ileus v Cumulative effects v v v Cocktail, not single agent Coma, not conscious sedation Long-term, not short-term

5 Ø Cocktail Ø Long-term Ø Not consc. sedation 找病因, 根本解除原因非藥物性治療, 改善環境 Pain scale Sedation scale Delirium scale 是止痛目標鎮靜目標控制譫妄目標病人焦躁痛苦否每日重新評估治療目標 Titrate 及 Taper 劑量 Daily wake-up 持續高劑量超過 7 天則減量血流動力不穩定 Fentanyl: ug, q 5-15 血流動力穩定 Morphine: 2-5mg, q 5-15 Acute agitation Midazolam: 2-5mg, q 5-15 Ongoing sedation (1)Propofol: 5µg/kg/min 起始, q 5 調劑量 (2)Lorazepam: 1-4mg, q (3) 超過 3 天 Propofol 則改為 (2) Haloperidol: 2-10mg, q Score Protocol Assessment 若每次給藥間隔小於 2 小時持續給藥, 選擇 Benzodiazepine 或 opioid 戒斷每日減少 10-25% 劑量評分方案評估 Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002; 30:

6 Visual Analogue Scale 彰基何明霖醫師

7 Richmond Agitation-Sedation Scale 調整劑量理想狀況調整劑量 (but no eye contact) Sessler CN et al, Am J Respir Crit Care Med 2002;166:

8 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit Juliana Barr, MD, FCCM1; Gilles L. Fraser, PharmD, FCCM2; Kathleen Puntillo, RN, PhD, FAAN, FCCM3; E. Wesley Ely, MD, MPH, FACP, FCCM4; Céline Gélinas, RN, PhD5; Joseph F. Dasta, MSc, FCCM, FCCP6;Judy E. Davidson, DNP, RN7; John W. Devlin, PharmD, FCCM, FCCP8; John P. Kress, MD9;Aaron M. Joffe, DO10; Douglas B. Coursin, MD11; Daniel L. Herr, MD, MS, FCCM12; Avery Tung, MD ; Bryce R. H. Robinson, MD, FACS ; Dorrie K. Fontaine, PhD, RN, FAAN ; Michael A. Ramsay, MD ; Richard R. Riker, MD, FCCM ; Curtis N. Sessler, MD, FCCP, FCCM18;Brenda Pun, MSN, RN, ACNP ; Yoanna Skrobik, MD, FRCP ; Roman Jaeschke, MD Crit Care Med; 2013;

9 用於鎮靜給藥準則的建議 Maintaining light levels of sedation in adult ICU patients is associated with improved clinical outcomes (e.g., shorter duration of mechanical ventilation and a shorter ICU length of stay [LOS]) (B) The Richmond Agitation-Sedation Scale (RASS) and Sedation-Agitation Scale (SAS) are the most valid and reliable sedation assessment tools for measuring quality and depth of sedation in adult ICU patients (B). Crit Care Med; 2013;

10 Dexmedetomidine 作用簡介

11 Adrenoceptors Alpha-1 Beta-1, Beta-2, Beta-3 Alpha-2a, Alpha-2b, Alpha-2c Central v.s. Peripheral Presynaptic v.s. Postsynaptic Extrasynaptic (Vascular)

12 Mechanism of Action-α 2 Agonist α2-receptor( 特別集中於大腦藍斑核神經元上 ) 受到刺激後, 產生回饋抑制的效用 ü 降低正腎上腺素的釋放 ü 降低腦部正腎上腺體的活性 ü 臨床表現產生鎮靜的效果抑制交感神經活性減緩血壓及心跳減少止痛劑的追加 Precedex

13 Dexmedetomidine 主要作用部位作用部位 Brain (Locus coeruleus) 第 4 腦室底上角藍斑核 Spinal cord 脊髓交感神經 CEREBRUM 中樞神經之作用 Sedation 鎮靜 Anxiolysis 抗焦 Analgesia 止痛 PONS Dexmedetomidine CEREBELLUM FOURTH VENTRICLE LOCUS COERULEUS Spinal Cord 交感神經之作用 ê Sympathetic activity ê BP, ê HR

14 鎮靜 α 2A 心跳抑制顫抖 α 2A (lower dose) α 2B (higher dose) α 2A (lower dose) 血管利尿止痛 Anesthesiology 2000;93: α 2A

15 Precedex 臨床特性 Cooperative sedation 1 合作式的鎮靜 Analgesia 2,3 止痛 Organ Protection (ie, neural, renal, cardiac) 1 保護器官 Anxiolysis 2,3 去除焦慮 Controls hyperadrenergic response to stress 1-3 控制壓力 Reduces shivering 3 減少顫抖 Diuretic action 4 利尿作用 Mimics Natural Sleep 1 正常睡眠 1 Aantaa R, et al. Drugs of the Future. 1993;18: Kamibayashi T, et al. Anesthesiology. 2000;93: Wagner BK J, et al. Clin Pharmacokinet. 1997;33: Goodman LS, et al. The Pharmacological Basis of Therapeutics. New York, NY: McGraw-Hill;2004:

目前 ICU 常用鎮靜止痛藥物 Midazolam Propofol Opioid Dexmedetomidine Sedation v v v Analgesia v v Sympatholytic v v v v Lack of cooperation v v Delirium v v

16 目前 ICU 常用鎮靜止痛藥物 Midazolam Propofol Opioid Dexmedetomidine Sedation v v v Analgesia v v Sympatholytic v v v v Lack of cooperation v v Delirium v v v Hypotension v v v Respiratory depression v v v Ileus v Cumulative effects v v v Cocktail Coma Long-term Single agent Conscious sedation Short-term

17 Dexmedetomidine 臨床使用注意事項

18 Precedex Dexmedetomidine Hydrochloride Injection Precedex 快速分佈半衰期為 6min, 末端排除半衰期為 2 hr 臨床研究中, 於輸注 Precedex 8-12min, 評估病患之鎮靜分數老年患者 (>65 歲 ) 或患有肝或腎功能不全, 劑量減少 200 mcg/2ml /vial

19 劑量準則用於已在使用其他鎮靜, 麻醉, 安眠藥或鴉片類止痛藥之病人時 Precedex: mcg/kg/hr 不建議從 Loading 1 mcg/kg/10min 開始若要給予 Loading, 可考慮 0.4 mcg/kg/10min 1 mcg/kg/20min

20 Precedex 200mcg/2ml 注射劑量 ( 每瓶請稀釋成 50mL:2ml Precedex + 48ml N/S)

21 治療準則 Clinical effective sedation Primary Dexmedetomidine Adjuvant Propofol Midazolam Fentanyl / Morphine Tramadol NSAIDs 何時用 Adjuvant? 止痛程度評估鎮靜程度評估血流動力學評估

22 Q1: 止痛程度評估 Midazolam Propofol Opioid Dexmedetomidine Sedation v v v Analgesia v v Sympatholytic v v v v Lack of cooperation v v Delirium v v v Hypotension v v v Respiratory depression v v v Ileus Cumulative effects v v v Analgesia-first sedation should be used in mechanically ventilated adult ICU patients. (+2B) v Crit Care Med; 2013;

23 Q2: 鎮靜程度評估考慮止痛理想狀況狀況有變 (but no eye contact) Sessler CN et al, Am J Respir Crit Care Med 2002;166:

24 是病人焦躁痛苦否找病因, 根本解除原因非藥物性治療, 改善環境 Pain scale Sedation scale Delirium scale 止痛目標鎮靜目標控制譫妄目標每日重新評估治療目標 Titrate 及 Taper 劑量 Daily wake-up 持續高劑量超過 7 天則減量血流動力不穩定 Fentanyl: ug, q 5-15 血流動力穩定 Morphine: 2-5mg, q 5-15 Acute agitation Midazolam: 2-5mg, q 5-15 Ongoing sedation (1)Propofol: 5µg/kg/min 起始, q 5 調劑量 (2)Lorazepam: 1-4mg, q (3) 超過 3 天 Propofol 則改為 (2) Haloperidol: 2-10mg, q 若每次給藥間隔小於 2 小時持續給藥, 選擇 Benzodiazepine 或 opioid 戒斷每日減少 10-25% 劑量 Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002; 30:

25 血流動力學變化之處理增加靜脈注射液少量血管收縮劑減少 Precedex 劑量 Atropine 心跳 α 2A (lower dose) α 2B (higher dose) α 2A (lower dose) 血管 Anesthesiology 2000;93:

26 感謝聆聽

Q3: 血流動力學評估 (1) Echocardiographic Evaluation of the Effects of Dexmedetomidine on Cardiac Function during Total Intravenous Anesthesia Induction Propofol +

27 Q3: 血流動力學評估 (1) Echocardiographic Evaluation of the Effects of Dexmedetomidine on Cardiac Function during Total Intravenous Anesthesia Induction Propofol + Remifentanil + Rocuronium Maintain (BIS 40 50) Propofol+ Remifentanil Study (Dexmedetomidine) Loading: 1ug/kg, over 10min Maintain: 0.5ug/kg/h Anesthesia 2015; 70:

28 Q3: 血流動力學評估 (2) T0: baseline T1: 20min T2: 40min T3: 60min BIS HR l Dexmedetomidine Saline SBP MBP DBP *p < 0.05 compared with T0; p < 0.05 compared with saline. Anesthesia 2015; 70:

29 Q3: 血流動力學評估 (3) l Dexmedetomidine Saline T0: baseline T1: 20min T2: 40min T3: 60min LV FAC MV E/e C.O. LV afterload Anesthesia 2015; 70:

ICU病人镇痛镇静治疗指南（初稿）

ICU病人镇痛镇静治疗指南（初稿） ICU 病人镇痛镇静治疗指南 ( 初稿 ) 目录第一节. 引言第二节. ICU 病人镇痛与镇静治疗指征第三节. ICU 病人疼痛与意识状态及镇痛镇静疗效的观察与评价第四节. ICU 病人镇痛镇静治疗的方法与药物选择第五节. 镇痛镇静治疗中器