1,2 1,3 1,4,5 analgesic agentsedative agent Anti-psychotic Agent neuromuscular blockade, NMB 2008 Surviving Sepsis Campaign 1 Grade 1B 2 Grade 1B 3 train-of-four measurement TOF Grade 1B analgesic agent sedative agent Anti-psychotic Agent neuromuscular blockade, NMB 2008 Surviving Sepsis Campaign 1 Grade 1B 701 901 06-281-2811 5736006-282-8928 E-mail r1210415@ms11.hinet.net 2 4 3 5 36
2 Grade 1B 3 Train of Four Grade 1B 1 severe sepsis acute lung injury acute respiratory distress syndrome, ARDS 18%~46% ARDS 2-4 catecholamine cortisol glucagon 5 6-9 Analgesic Agent 1 10 11 1 visual analogue scale VAS 37
Adjective Rating Scale (ARS) No Mild Moderate Severe Very Severe Worst Possible Numerical Rating Scale (NRS) 0 1 2 3 4 5 6 7 8 9 10 Visual Analog Scale (VAS) No Worst Possible 1 11, 26 12 2 Benzodiazepine NSAID non-steroidal anti-inflammatory drug, NSAID Meperidine Demerol, Pethidine Meperidine normeperidine 15-40 13 normeperidine myoclonus morphine fentanyl hydromorphone Morphine fentanyl 2 4 morphine-6-glucuronide 38
10, 45 Morphine Hydromorphone Fentanyl 2 5mg 0.2 1.5mg 25 100 g 30 20 4 2 4 2 3 30 60 3 7 2 3 1.5 6 1 10 mg/hr 0.2 2 mg/hr 25 350 g/hr PCA Bolus 0.5 3 mg 0.1 0.5 mg 10 75 g Lockout interval 10 20 5 15 3 10 Potency 1x 5 10x 80 100x 1x 0.2x 600x 0 50% 14 Morphine euphoria Oddi 15 Morphine morphine morphine Hydromorphone morphine morphine 5-10 morphine hydromorphone 16 Fentanyl morphine 80-100 morphine fentanyl fentanyl morphine fentanyl 3 morphine hydromorphone intermittent fentanyl continuous infusion Fentanyl hydromorphone acetaminophen 39
17 18 p.r.n p.r.n 11 16 patient-controlled analgesia, PCA PCA epidural epidural 19 Sedative Agent 1 85% anxiety agitation delirium 20 21,22 23,24 Ramsay scale Sedation-Agitation Scale SAS Motor Activity Assessment Scale MAAS Ramsay scale Ramsay scale 1974 25 Ramsay scale 2-3 4-5 2 benzodiazepine propofol Benzodiazepine diazepam valium GABA midazolam Dormicum lorazepam Ativan propofol Dexmedetomidine diazepam Midazolam midazolam benzodiazepine 26 Midazolam hydroxymidazolam cytochrome P450 midazolam Midazolam 48-72 Lorazepam midazolam 40
Ramsay 10, 45 1 2 3 4 5 6 benzodiazepine 10, 45 Midazolam Lorazepam Diazepam 0.02 0.1mg/kg 0.02 0.06mg/kg 0.05 0.2mg/kg 1 5 5 20 2 5 1 2 2 6 2 4 3 11 8 15 20 120 0.04 0.2mg/kg/hr 0.01 0.1 mg/kg/hr Potency 3x 6x 1x 1.5x 0.5x 1x 0 50% 10, 45 Propofol Dexmedetomidine 0.25 1mg/kg 1 g/kg in 10min < 1 1 3 10 15 6 10 25 75 g/kg/min 0.2 0.7 g/kg/min Sympathetic rebound Propofol infusion syndrome 41
Lorazepam lorazepam lorazepam propylene glycol lorazepam propylene glycol 27 propylene glycol midazolam propofol Diazepam lorazepam propylene glycol diazepam 28 Propofol GABA Propofol 29 propofol status epilepticus delirium tremens Propofol 7 0.5 1 mg/kg 0.5 6 mg/ kg/hr Propofol propofol propofol 1.1 kcal/ml propofol infusion syndrome 30 propofol > 4 6mg/kg/hr 24 48 > 80% propofol 29 Dexmedetomidine 2 clonidine 8 1999 24 Dexmedetomidine 6 10 24 sympathetic rebound 3 midazolam propofol Lorazepam propofol lorazepam 42
26 benzodiazepine propofol 2 agonist Dexmedetomidine 2008 Surviving Sepsis Campaign Grade 1B 1 Grade 1B 23,31 Anti-psychotic Agent 1 87% 20 ICU psychosis haloperidol benzodiazepine benzodiazepine haloperidol 32 2 Haloperidol dopamine Haloperidol QT Torsades de pointes amiodarone 33 neuroleptic malignant syndrome 34 haloperidol 3 0.5 10mg 15-20 35 22 Neuromuscular Blockade, NMB 1 ARDS 43
compliance 36 37 2 Succinylcholine Pacuronium Vecuronium Atracurium Pancuronium aminosteroid 60-180 Pancuronium vagal blockade 36 Vecuronium aminosteroid 40-60 Vecuronium vecuronium 50-80% Atracurium benzylquinolinium Hoffman degradation 30 Atracurium 3 prolonged weakness postparalytic syndrome 120 CPK pancuronium vecuronium 10, 45 Pancuronium Vecuronium Atracurium 0.1mg/kg 0.1mg/kg 0.4 0.5mg/kg 1 2 g/kg/min 1 2 g/kg/min 4 12 g/kg/min 3 5 2 3 2 5 45 60 20 35 20 35 60 180 40 60 40 60 44
atracurium 38 critical illness myopathy polyneuropathy 39 pancuronium Atracurium adductor pollicis muscle train-of-four measurement TOF 40,41 TOF TOF Radius TOF Strange vecuronium vs. atracurium 40,41 2008 Surviving Sepsis Campaign TOF Grade 1B 1 42 Kress daily interruption 43 43 44 protocol 23,25 2008 Surviving Sepsis Campaign Grade 1B daily interruption Grade 1B TOF Grade 1B 1 2 45
杜漢祥等 Taiwan Crit. Care Med.2009;10:36-49 圖 2 奇美醫院之止痛 鎮靜 譫妄臨床指引 46
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THE APPLICATION OF ANALGESIA, SEDATION, ANTI-PSY- CHOTIC AGENT AND NEUROMUSCULAR BLOCKADE IN SE- VERE-SEPSIS PATIENTS Doh Han Siang 1,2, Chin-Ming Chen 1,3, Kuo-Chen Cheng 1,4,5 Abstract It is very important to appropriately use analgesia, sedation, anti-psychotic agent and neuromuscular blockade in the care of critically ill patients. According to revised Surviving Sepsis Campaign in 2008, the effective application of sedation, analgesia, and neuromuscular blockade takes an important role in the care of severe-sepsis patients, especially those with ventilator use. Thus, we will introduce the principles and guidelines of analgesia, sedation, anti-psychotic agent and neuromuscular blockade in severesepsis patients, including: (1) use sedation protocols with a sedation goal for critically ill mechanically ventilated patients (Grade 1B); (2) use either intermittent bolus sedation or continuous infusion sedation to predetermined end points (sedation scales), with daily interruption/lightening to produce awakening; re-titrate if necessary (Grade 1B); avoid neuromuscular blockade where possible; monitor depth of block with train of four when using continuous infusions (Grade 1B). We wish to improve the high mortality rate and expenditure in severe-sepsis patients under these guidelines. Key words: Analgesia, Sedation, Anti-psychotic agent, Neuromuscular blockade and severe sepsis Correspondence: Dr. Chin-Ming Chen Department of Intensive Care Medicine, Chi-Mei Medical Center, 901 Chung Hwa Road, Yang Kang City, Tainan, Taiwan, 71044 Phone: 886-6-281-2811 ext 57360; Fax: 886-6-282-8928; E-mail: r1210415@ms11.hinet.net Section of Infection, 2 Section of Respiratory Care, 4 Department of Internal Medicine, Chi Mei Medical Center, Tainan Department of Medicine, 3 Department of Respiratory Therapy, 5 Taipei Medical University, Taipei, Taiwan 49