每日一题_2022.5.25

A 64-year-old woman with chronic, severe back pain has been mechanically ventilated for five days secondary to hypoxemic respiratory failure. She is receiving appropriate antibiotics for Staphylococcus aureus pneumonia. Her past medical history is significant for anxiety and hypertension. She has been positive on the Confusion Assessment Method for the ICU for the past three days. At times she appears to have hyperactive agitation and has remained in upper-extremity restraints for her own safety. Her current sedation regimen is a continuous infusion of propofol, 0.05 mg/kg/min, that is being titrated to a Richmond Agitation-Sedation Scale goal of -1.

Which of the following should be the next step in sedation management?

A. Start continuous infusion of fentanyl.

B. Start continuous infusion of midazolam.

C. Start continuous infusion of haloperidol.

D. Start continuous infusion of dexmedetomidine. 

E. Increase continuous infusion dose of propofol.

答案解析：

最近的重症监护医学学会指南检查了需要机械通气患者的适当连续输注策略。这些建议是基于疼痛、激越和谵妄指南。一旦确定了适当的镇静策略目标（例如，基于患者特征、疾病状态、危重疾病等的Richmond躁动-镇静量表目标），可以选择适当的药物。持续输注的第一个目标应该是使用短效麻醉剂（如芬太尼）充分控制疼痛。一旦疼痛得到充分解决，提供镇静是下一步。理想情况下，应首先使用间歇性剂量的镇静剂。如果无法控制激越，则应开始连续输注镇静剂。研究显示谵妄与连续输注苯二氮卓类药物之间的相关性增加。此时，连续输注苯二氮卓类药物将被认为是二线镇静剂。潜在的一线药物包括右美托咪定和丙泊酚。这两种药物在减少谵妄方面均未显示出优越的效应特征。抗精神病药物，包括氟哌啶醇，也被研究作为限制ICU谵妄的潜在药物。研究表明，氟哌啶醇对急性激越有有利影响，但对总体谵妄无显著降低作用。一旦疼痛和激越得到控制，临床医生应继续使用ICU的意识模糊评估方法等工具筛查谵妄，因为发病率和死亡率与未识别的谵妄相关。

正确答案：A