背景:镇静的最佳管理,镇痛和谵妄为重症监护患者提供舒适和安全,允许更容易地应用支持措施,并实现医疗保健的整体方法,同时降低并发症的发生率,这意味着更好的患者结果。
目的:为了更新2007年在MedicinaIntensiva杂志上发表的《Puíaprcínicabasadaenlaevidenciaparaelmanejodelasedoadienteenfermo》,并为镇静管理提供建议,镇痛,和谵妄.
方法:一组来自9个泛美联邦国家的21名强化者,其中3人也是临床流行病学和方法学专家,为制定指导方针而聚集。根据建议评估的分级,对证据质量和建议进行评估。开发和评估系统。建议的强度被分类为1=强,或2=弱,证据质量A=高,B=中等,或C=低。两位作者搜索了以下数据库:MEDLINE至PUBMED,Cochrane图书馆和LiteraturaLatinoamericanaydelCaribeenCienciasdelaSalud并检索了相关信息。分配到准则的11个部分的成员,在文献综述的基础上,制定了建议,在全体会议上讨论过。只有达成共识80%以上的建议才获得最后文件的批准。哥伦比亚重症医学和重症监护协会(AMCI)支持制定本指南。
结果:纳入了467篇文章进行审查。观察到出版物的数量和质量都有所增加。与上一版的28项建议相比,这允许生成64项具有高和中等证据质量的强有力建议。
结论:本指南包含基于可用于镇静管理的最佳证据的建议和建议,危重病人的镇痛和谵妄,包括一系列服务于此目的的策略。我们通过经过验证的量表强调疼痛和激动/镇静的评估,最初使用阿片类药物来抑制镇痛控制,与多模式策略相关,以减少阿片类药物的消耗;促进最低程度的镇静必要避免过度镇静。此外,如果需要镇静剂,选择最适合患者需求的,避免使用苯二氮卓类药物并确定谵妄的危险因素,为了防止它的发生,诊断谵妄并用最合适的药物治疗,不管是氟哌啶醇,非典型抗精神病药或右美托咪定,再一次,避免使用苯二氮卓类药物和减少阿片类药物的使用。
BACKGROUND: Optimal management of sedation, analgesia and delirium offers comfort and security for the critical care patient, allows support measures to be applied more easily and enables an integral approach of medical care, at the same time that lowers the incidence of complications, wich translates in better patient outcomes.
OBJECTIVE: To update the Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo published in Medicina Intensiva in 2007, and give recommendations for the management of sedation, analgesia, and delirium.
METHODS: A group of 21 intensivists from 9 countries of the Federación Panamericana e Ibérica de Sociedades de Medicina Crítica y Terapia Intensiva, 3 of them also specialists in clinical epidemiology and methodology, gathered for the development of
guidelines. Assessment of evidence quality and recommendations were made based on the Grading of Recommendations Assessment, Development and Evaluation system. Strength of recommendations was classified as 1=strong, or 2=weak, and quality of evidence as A=high, B=moderate, or C=low. Two authors searched the following databases: MEDLINE through PUBMED, The Cochrane Library and Literatura Latinoamericana y del Caribe en Ciencias de la Salud and retrieved pertinent information. Members assigned to the 11 sections of the
guidelines, based on the literature review, formulated the recommendations, that were discussed in plenary sessions. Only those recommendations that achieved more than 80% of
consensus were approved for the final document. The Colombian Association of Critical Medicine and Intensive Care (AMCI) supported the elaboration of this guidelines.
RESULTS: Four hundred sixty-seven articles were included for review. An increase in number and quality of publications was observed. This allowed to generate 64 strong recommendations with high and moderate quality of evidence in contrast to the 28 recommendations of the previous edition.
CONCLUSIONS: This
Guidelines contains recommendations and suggestions based on the best evidence available for the management of sedation, analgesia and delirium of the critically ill patient, including a bundle of strategies that serves this purpose. We highlight the assessment of pain and
agitation/sedation through validated scales, the use of opioids initially to apropiate analgesic control, associated with multimodal strategies in order to reduce opioide consumption; to promote the lowest level of sedation necessary avoiding over-sedation. Also, in case of the need of sedatives, choose the most appropiate for the patient needs, avoiding the use of benzodiazepines and identify risk factors for delirium, in order to prevent its occurrence, diagnose delirium and treat it with the most suitable pharmacological agent, whether it is haloperidol, atypical antipsychotics or dexmedetomidine, once again, avoiding the use of benzodiazepines and decreasing the use of opioids.