Piva Simone, McCreadie Victoria A, Latronico Nicola
Division of Neuroanesthesia and Neurointensive Care, Department of Anesthesia, Intensive Care & Perioperative Medicine, University of Brescia at Spedali Civili, Piazzale Ospedali Civili, 1, 25123 Brescia Italy.
Cardiovasc Hematol Disord Drug Targets. 2015;15(1):10-8. doi: 10.2174/1871529x15666150108112452.
Sepsis-associated delirium (SAD) is a clinical manifestation of the involvement of the central nervous system (CNS) during sepsis. The purpose of this review is to provide a concise overview of SAD including the epidemiology and current diagnostic criteria for SAD. We present in detail the pathophysiology with regards to blood-brain-barrier breakdown, cytokine activation and neurotransmitter deregulation. Treatment and prognosis for SAD are also briefly discussed. SAD is the most common form of delirium acquired in the ICU (Intensive Care Unit), and is described in about 50% of septic patients. Clinical features include altered level of consciousness, reduced attention, change in cognition and perceptual disturbances. Symptoms can reversible, but prolonged deficits can be observed in older patients. Pathophysiology of SAD is poorly understood, but involves microvascular, metabolic and, not least, inflammatory mechanisms leading to CNS dysfunction. These mechanisms can be different in SAD compared to ICU delirium associated with other conditions. SAD is diagnosed clinically using validated tools such as CAM-ICU (Confusion Assessment Method for the Intensive Care Medicine) or ICDSC (The Intensive Care Delirium Screening Checklist), which have good specificity but low sensitivity. Neuroimaging studies and EEG (Electroencephalography) can be useful complement to clinical evaluation to define the severity of the condition. Prompt diagnosis and eradication of septic foci whenever possible is vital. Preventive measures for SAD in the critically ill patient requiring long-term sedation include maintaining light levels of sedation using non-benzodiazepine sedatives (either propofol or dexmedetomidine). Early mobilization of patients in the ICU is also recommended. Antipsychotic drugs (haloperidol and atypical antipsychotics) are widely used to treat SAD, but firm evidence of their efficacy is lacking.
脓毒症相关性谵妄（SAD）是脓毒症期间中枢神经系统（CNS）受累的一种临床表现。本综述的目的是简要概述SAD，包括其流行病学及当前的诊断标准。我们详细阐述了与血脑屏障破坏、细胞因子激活和神经递质失调相关的病理生理学。还简要讨论了SAD的治疗和预后。SAD是重症监护病房（ICU）中最常见的获得性谵妄形式，约50%的脓毒症患者会出现。其临床特征包括意识水平改变、注意力下降、认知改变和感知障碍。症状可能可逆，但老年患者可能会出现长期缺陷。SAD的病理生理学尚不清楚，但涉及微血管、代谢机制，尤其是炎症机制，这些机制会导致中枢神经系统功能障碍。与其他情况相关联的ICU谵妄相比，SAD中的这些机制可能有所不同。临床上使用经过验证的工具，如重症监护医学谵妄评估方法（CAM-ICU）或重症监护谵妄筛查清单（ICDSC）来诊断SAD，这些工具具有良好的特异性，但敏感性较低。神经影像学研究和脑电图（EEG）有助于补充临床评估以确定病情严重程度。尽可能及时诊断并根除脓毒症病灶至关重要。对于需要长期镇静的重症患者，预防SAD的措施包括使用非苯二氮䓬类镇静剂（丙泊酚或右美托咪定）维持轻度镇静水平。还建议在ICU中尽早让患者活动。抗精神病药物（氟哌啶醇和非典型抗精神病药物）广泛用于治疗SAD，但缺乏其疗效的确切证据。
