Durbin C G
Department of Anesthesiology, University of Virginia Health Sciences Center, Charlottesville, USA.
Crit Care Clin. 1995 Oct;11(4):913-36.
One of the most demanding and stressful situations is management of the agitated, unintubated, critically ill patient. Sedation often must be provided without a specific diagnosis, and the need for rapid airway control must be anticipated. No predictably safe and effective techniques are proven. The experience and skill of the physician managing the patient during sedation are the predictive factors for the best outcome. Even in expert hands, airway compromise and cardiovascular decompensation often occur in these very ill patients. Many techniques for sedation have been described. Treatment of pain followed by small boluses of intravenous sedative agents is a reasonable initial approach. Benzodiazepines have a good safety record and provide good amnesia. Other agents have been used, by themselves or in combination. Haloperidol may have a therapeutic advantage in the disoriented, agitated patient. Prolonged need for significant sedative medication usually mandates a secure airway. Once this is accomplished, the requirement for a continuously present airway expert at the bedside is removed. The standard for sedating a patient without an artificial airway requires a higher level of expertise than sedating a critically ill patient with an artificial airway.
最具挑战性和压力的情况之一是对烦躁不安、未插管的危重症患者进行管理。通常必须在没有明确诊断的情况下给予镇静，而且必须预见到快速气道控制的必要性。目前尚无经证实的可预测的安全有效技术。在镇静过程中管理患者的医生的经验和技能是取得最佳结果的预测因素。即使在专家手中，这些重症患者也经常出现气道受损和心血管代偿失调的情况。已经描述了许多镇静技术。先处理疼痛，然后小剂量静脉注射镇静剂是一种合理的初始方法。苯二氮䓬类药物有良好的安全记录，并能提供良好的遗忘效果。其他药物也已单独或联合使用。氟哌啶醇对定向障碍、烦躁不安的患者可能具有治疗优势。长期需要大量镇静药物通常需要建立安全的气道。一旦完成这一步，就不再需要床边始终有气道专家在场。为没有人工气道的患者进行镇静的标准要求的专业水平高于为有人工气道的危重症患者进行镇静。
