背景 缺乏一个完整的、系统的评估工具是当今重症监护室(ICU)疼痛评估的一大障碍.免于疼痛是病患的权力,是基本的人权,也是家属极为关心的事项之一.评估疼痛、管理疼痛和及时缓解疼痛是提供优质护理服务必需做到的,然而国际上目前尚无一种受到普遍认可的适用于存在交流障碍的患者的疼痛评估工具. 目的 分析总结目前能评估交流障碍的危重症患者疼痛的评估工具. 内容 危重症患者疼痛评估的重要性;危重症患者疼痛评估工具:疼痛行为量表(the behavior pain scale,BPS)、伤害性昏迷量表(nociception coma scale,NCS)、疼痛评估量表(face,legs,activity,cry,consolability behavioural tool,FLACC)、非语言的疼痛的量表(non-verbal pain scale,NVPS)、危重症患者疼痛观察工具(the critical-care pain observation tool,CPOT)、晚期老年痴呆症疼痛评估量表(the pain assessment In advanced dementia scale,PAINAD);危重症患者疼痛评估工具的局限性. 趋向 国内的重症患者疼痛评估尚处起步之中,规律地使用疼痛评估工具可避免患者处于镇静过度而镇痛不足的痛苦状态,提高患者的依从性,使其积极地配合治疗.

目的：探讨神经外科ICU躁动患者的干预评估方法。方法采用随机数字表法将106例躁动患者分成观察组51例和对照组55例，对照组实施常规护理，观察组采用Riker 镇静躁动评分（ SAS）进行干预护理。比较两组患者非计划性拔管、坠床、皮肤受损及动脉瘤体破裂等并发症的发生率。结果观察组患者发生非计划性拔管1例，坠床0例，皮肤受损1例，再次出血0例，动脉瘤体破裂0例；对照组患者发生非计划性拔管8例，坠床6例，皮肤受损7例，再次出血5例，动脉瘤体破裂4例，两组患者并发症发生情况比较，差异均有统计学意义（χ2值为5．39，5．90，4．40，4．87，3．85；P ＜0．05）。结论使用SAS评分系统评估干预神经外科ICU躁动患者，可以降低并发症的发生率。

目的探讨多发伤镇静镇痛治疗患者实施每日唤醒计划及护理的策略。方法对78例ICU多发伤患者给予丙泊酚或咪达唑仑镇静、芬太尼镇痛治疗;同时实施每日唤醒计划和相应护理。结果实施镇静镇痛3～6d,Riker镇静和躁动评分从+1～+2分降至-2～-3分。机械通气时间、入住ICU时间显著短于上年同期65例未实施每日唤醒计划的患者(均P<0.01)。结论多发伤镇静镇痛治疗患者实施每日唤醒计划及相应护理有利于其病情的改善。

BACKGROUND: The authors conducted a patient-based survey of practices to fully describe the assessment and the management of pain and sedation of a large cohort of mechanically ventilated patients during their first week of intensive care unit (ICU) stay. METHODS: A total of 1,381 adult patients were included in a prospective, observational study in 44 ICUs in France. Pain and sedation assessment, analgesic and sedative use, and analgesic management during procedural pain were collected on days 2, 4, and 6 of the ICU stay. RESULTS: The observed rates of assessment on day 2 for sedation (43%) and analgesia (42%) were significantly smaller than that of use of sedatives (72%) and opioids (90%), also noted on days 4 and 6. The use of protocols/guidelines for sedation/analgesia in the ICU reduced the proportion of patients who were treated, although not evaluated. A large proportion of assessed patients were in a deep state of sedation (40-50%). Minor changes in the dosages of the main prescribed agents for sedation (midazolam, propofol) and analgesia (sufentanil, fentanyl, morphine, remifentanil) were found across 6 days of the patient's ICU stay. Procedural pain was specifically managed for less than 25% of patients; during those procedures, the proportion of patients with pain significantly increased from the baseline pain evaluation. CONCLUSIONS: Excessively deep states of sedation and a lack of analgesia during painful procedures must be prevented. To facilitate systematic pain and sedation assessment and to adjust daily drug dosages accordingly, it seems crucial to promote educational programs and elaboration of protocols/guidelines in the ICU.

Objective: To revise the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically III Adult" published in Critical Care Medicine in 2002.Methods: The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over 6 yr in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (http://www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks(R) database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (http://www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (-) an intervention. A strong recommendation (either for or against) indicated that the intervention's desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase "We recommend ..." is used throughout. A weak recommendation, either for or against an intervention, indicated that the tradeoff between desirable and undesirable effects was less clear. For all weak recommendations, the phrase "We suggest ..." is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflict of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding.Conclusion: These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients. (Crit Care Med 2013; 41:263-306)

毋庸置疑,镇痛镇静治疗是重症患者临床处理的重要组成部分,重症脑损伤患者也不例外.然而,现实情况却表 现为镇痛镇静在重症脑损伤患者中的应用存在争议,在不同单位中的实施也存在很大差异.造成这种现状的原因主要有两点:首先,镇痛镇静药物对意识评估的影 响,是临床医师在对脑损伤患者实施镇痛镇静治疗时的主要担心;其次,对于脑损伤患者的镇痛镇静治疗缺乏高级别的循证医学证据,尤其是对远期神经系统转归的 影响.在2012年7月召开的中国神经重症学术会议上,镇痛镇静论坛共收集到了超过400个相关提问,说明临床医师对该问题的重视.

This review covers the main principles of the Lund concept for treatment of severe traumatic brain injury. This is followed by a description of results of clinical studies in which this therapy or a modified version of the therapy has been used. Unlike other guidelines, which are based on meta-analytical approaches, important components of the Lund concept are based on physiological mechanisms for regulation of brain volume and brain perfusion and to reduce transcapillary plasma leakage and the need for plasma volume expanders. There have been nine non-randomized and two randomized outcome studies with the Lund concept or modified versions of the concept. The non-randomized studies indicated that the Lund concept is beneficial for outcome. The two randomized studies were small but showed better outcome in the groups of patients treated according to the modified principles of the Lund concept than in the groups given a more conventional treatment.

We propose an integrated and adaptable approach to improve patient care and clinical outcomes through analgesia and light sedation, initiated early during an episode of critical illness and as a priority of care. This strategy, which may be regarded as an evolution of the Pain, Agitation and Delirium guidelines, is conveyed in the mnemonic eCASH arly Comfort using Analgesia, minimal Sedatives and maximal Humane care. eCASH aims to establish optimal patient comfort with minimal sedation as the default presumption for intensive care unit (ICU) patients in the absence of recognised medical requirements for deeper sedation. Effective pain relief is the first priority for implementation of eCASH: we advocate flexible multimodal analgesia designed to minimise use of opioids. Sedation is secondary to pain relief and where possible should be based on agents that can be titrated to a prespecified target level that is subject to regular review and adjustment; routine use of benzodiazepines should be minimised. From the outset, the objective of sedation strategy is to eliminate the use of sedatives at the earliest medically justifiable opportunity. Effective analgesia and minimal sedation contribute to the larger aims of eCASH by facilitating promotion of sleep, early mobilization strategies and improved communication of patients with staff and relatives, all of which may be expected to assist rehabilitation and avoid isolation, confusion and possible long-term psychological complications of an ICU stay. eCASH represents a new paradigm for patient-centred care in the ICU. Some organizational challenges to the implementation of eCASH are identified.