摘要
重症患者的治疗过程可分为抢救、优化、稳定、撤离四个阶段,各阶段的治疗核心和目标不尽相同,但均可能影响重症患者的预后。随着治疗理念的进步和技术的革新,重症患者抢救阶段的救治成功率大大提高,但重症后稳定、撤离阶段的诊疗仍未引起足够重视。为改进重症后恢复阶段的管理,由冷静治疗研究组、重症超声研究组根据国内外最新文献资料及多年来的临床实践经验,组织重症医学专家在充分讨论和沟通的基础上制定了本共识,旨在提高重症患者的诊疗水平,缩短住ICU时间,促进重症后患者的全面康复。
We wished to establish an expert consensus on late stage of critical care(CC)management.The panel comprised 13 experts in CC medicine.Each statement was assessed based on the Grading of Recommendations Assessment,Development,and Evaluation(GRADE)principle.Then,the Delphi method was adopted by 17 experts to reassess the following 28 statements.(1)ESCAPE has evolved from a strategy of delirium management to a strategy of late stage of CC management.(2)The new version of ESCAPE is a strategy for optimizing treatment and comprehensive care of critically ill patients(CIPs)after the rescue period,including early mobilization,early rehabilitation,nutritional support,sleep management,mental assessment,cognitive-function training,emotional support,and optimizing sedation and analgesia.(3)Disease assessment to determine the starting point of early mobilization,early rehabilitation,and early enteral nutrition.(4)Early mobilization has synergistic effects upon the recovery of organ function.(5)Early functional exercise and rehabilitation are important means to promote CIP recovery,and gives them a sense of future prospects.(6)Timely start of enteral nutrition is conducive to early mobilization and early rehabilitation.(7)The spontaneous breathing test should be started as soon as possible,and a weaning plan should be selected step-by-step.(8)The waking process of CIPs should be realized in a planned and purposeful way.(9)Establishment of a sleep-wake rhythm is the key to sleep management in post-CC management.(10)The spontaneous awakening trial,spontaneous breathing trial,and sleep management should be carried out together.(11)The depth of sedation should be adjusted dynamically in the late stage of CC period.(12)Standardized sedation assessment is the premise of rational sedation.(13)Appropriate sedative drugs should be selected according to the objectives of sedation and drug characteristics.(14)A goal-directed minimization strategy for sedation should be implemented.(15)The principle of analgesia must be mastered first.(16)Subjective assessment is preferred for analgesia assessment.(17)Opioid-based analgesic strategies should be selected step-by-step according to the characteristics of different drugs.(18)There must be rational use of non-opioid analgesics and non-drug-based analgesic measures.(19)Pay attention to evaluation of the psychological status of CIPs.(20)Cognitive function in CIPs cannot be ignored.(21)Delirium management should be based on non-drug-based measures and rational use of drugs.(22)Reset treatment can be considered for severe delirium.(23)Psychological assessment should be conducted as early as possible to screen-out high-risk groups with post-traumatic stress disorder.(24)Emotional support,flexible visiting,and environment management are important components of humanistic management in the intensive care unit(ICU).(25)Emotional support from medical teams and families should be promoted through“ICU diaries”and other forms.(26)Environmental management should be carried out by enriching environmental content,limiting environmental interference,and optimizing the environmental atmosphere.(27)Reasonable promotion of flexible visitation should be done on the basis of prevention of nosocomial infection.(28)ESCAPE is an excellent project for late stage of CC management.
作者
汤铂
陈文劲
蒋丽丹
朱世宏
宋斌
晁彦公
宋天娇
何伟
刘杨
张宏民
柴文昭
尹万红
朱然
刘丽霞
武钧
丁欣
尚秀玲
段军
许强宏
张恒
王晓猛
黄齐兵
龚瑞琛
李尊柱
鲁梅珊
王小亭
Tang Bo;Chen Wenjin;Jiang Lidan;Zhu Shihong;Song Bin;Chao Yangong;Song Tianjiao;He Wei;Liu Yang;Zhang Hongmin;Chai Wenzhao;Yin Wanhong;Zhu Ran;Liu Lixia;Wu Jun;Ding Xin;Shang Xiuling;Duan Jun;Xu Qianghong;Zhang Heng;Wang Xiaomeng;Huang Qibing;Gong Ruichen;Li Zunzhu;Lu Meishan;Wang Xiaoting(Department of Critical Care Medicine,Peking Union Medical College Hospital,Peking Union Medical College,Chinese Academy of Medical Sciences,Beijing 100730,China;Department of Neurosurgery ICU,Xuanwu Hospital,Capital Medical University,Beijing 100053,China;Department of Critical Care Medicine,the Seventh Medical Center of PLA General Hospital,Beijing 100700,China;Department of Critical Care Medicine,the First Affiliated Hospital of Tsinghua University,Beijing 100016,China;Department of Critical Care Medicine,Beijing Tongren Hospital,Capital Medical University,Beijing 100730,China;Department of Critical Care Medicine,West China Hospital,Sichuan University,Chengdu 610041,China;Department of Critical Care Medicine,the First Hospital of China Medical Uinversity,Shenyang 110001,China;Department of Critical Care Medicine,the Fourth Hospital of Hebei Medical University,Shijiazhuang 050011,China;Department of Critical Care Medicine,Ruijin Hospital Affiliated to Shanghai Jiao Tong University,Shanghai 200025,China;Department of Critical Care Medicine,Fujian Provincial Hospital,Fuzhou 350001,China;Department of Critical Care Medicine,China-Japan Friendship Hospital,Beijing 100029,China;Department of Critical Care Medicine,Zhejiang Hospital,Hangzhou 310013,China;Department of Neurosurgery,the First Hospital of China Medical University,Shenyang 110001,China;Department of Critical Care Medicine,Xuzhou Central Hospital,Xuzhou 221009,China;Department of Neurosurgery,Qilu Hospital of Shandong University,Jinan 250012,China;Department of Critical Care Medicine,Affiliated Hospital of Taiwan Kaohsiung University,China;Department of Health Care and Medical,Peking Union Medical College Hospital,Peking Union Medical College,Chinese Academy of Medical Sciences,Beijing 100730,China)
出处
《中华内科杂志》
CAS
CSCD
北大核心
2023年第5期480-493,共14页
Chinese Journal of Internal Medicine
基金
中央高水平医院临床科研业务费资助(2022-PUMCH-B-026)。
关键词
重症后管理
镇痛
镇静
康复
Late stage of critical care management
Analgesia
Sedation
Rehabilitation
