2012SCCM镇静镇痛指南评分概要

2012年

SCCMICU镇静镇痛指南

评分系统概要

广西医科大学第一附属医院

林松

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内容

2012年SCCM镇静镇痛指南概要3

一、二、疼痛评估三、镇静评估四、谵妄评估

STATEMENTS AND RECOMMENDATIONS

1、疼痛与镇痛2、躁动与镇静3、谵妄

4、改善ICU预后的疼痛、

躁动及谵妄管理策略

Barr J, Fraser G L, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit[J]. Critical care medicine, 2013, 41(1): 263-306.

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内容

2012年SCCM镇静镇痛指南概要5

一、二、疼痛评估三、镇静评估四、谵妄评估

疼痛评估与预后

评估组(n=513)；不评估组(n=631)

呼吸机相关肺炎16% vs 24% P<0.01 机械通气时间8 vs 11 Days P<0.01ICU住院时间13 vs 18 Days P<0.01

Payen J F, Bosson J L, Chanques G, et al. Pain assessment is associated with decreased duration of

mechanical ventilation in the intensive care unit: a post Hoc analysis of the DOLOREA study[J]. Anesthesiology,

62009, 111(6): 1308-1316.

常用疼痛评估系统

Self report patient

Unable to self report patient

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常用疼痛评估系统

Numerical Rating Scale (NRS) (1 to 10 )（疼痛数字评估量表）

Visual Analog Scale (VAS) (1 to 100 mm)视觉评价量表语言评价量表(VRS) (0 to 4)

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1. Pain and Analgesiaa. Incidence of pain

i. Adult medical, surgical, and trauma ICU patients routinely experience pain, both at rest and with routine ICU care (B).

ii. Pain in adult cardiac surgery patients is common and poorly treated; women experience more pain than men after cardiac surgery (B).iii. Procedural pain is common in adult ICU patients (B).b. Pain assessment

i. We recommend that pain be routinely monitored in all adult ICU patients (+1B).

ii. The Behavioral Pain Scale (BPS)and the Critical-Care Pain

Observation Tool (CPOT)are the most valid and reliable behavioral pain scales for monitoring pain in medical, postoperative, or trauma (except for brain injury) adult ICU patients who are unable to self-report and in whom motor function is intact and behaviors are bservable. Using these scales in other ICU patient populations and translating them into foreign

languages other than French or English require further validation testing (B).

Barr J, Fraser G L, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adultpatients in the intensive care unit[J]. Critical care medicine, 2013, 41(1): 263-306.

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The Behavioral Pain Scale行为疼痛分评分(BPS)Item Facial expression Description Relaxed Partially tightened Fully tightened Grimacing Upper limbs No movement Partially bent Fully bent with finger flexion Permanently retracted Compliance with ventilation Tolerating movement Coughing but tolerating ventilation for most of the time Fighting ventilator Unable to control ventilationPay

en J F, et al. Assessing pain in critically ill sedated patients by using a behavioral pain scale[J]. Critical care medicine, 2001, 29(12): 2258-2263.

Score 1 2 3 4 1 2 3 4 1 2 3 4

The Behavioral Pain Scale行为疼痛分评分(BPS)项目面部表情描述放松局部紧张完全紧张扭曲上肢运动无动作局部弯曲弯曲以及手指屈曲持续收缩呼吸机依从性顺从咳嗽但基本耐受对抗机械通气不能控制通气Payen J F, et al. Assessing pain in critically ill sedated patients by using a behavioral pain scale[J]. Critical care medicine, 2001, 29(12): 2258-2263.

分值 1 2 3 4 1 2 3 4 1 2 3 411

The Behavioral Pain Scale行为疼痛分评分（BPS）

BPS总分3~12分面部表情上肢运动

机械通气依从性分值越高疼痛越严重BPS≦5认为疼痛可耐受*

* Chanques G, Jaber S, Barbotte E, Violet S, Sebbane M, Perrigault PF, Mann C, Lefrant JY, Eledjam JJ: Impact of systematic evaluation of pain and agitation in an intensive care unit. Crit Care Med 2006, 34:1691-169912

Payen J F, et al. Assessing pain in critically ill sedated patients by using a behavioral pain scale[J]. Critical care medicine,2001, 29(12): 2258-2263.

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Payen J F, et al. Assessing pain in critically ill sedated patients by using a behavioral pain scale[J]. Critical care medicine,2001, 29(12): 2258-2263.

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Payen J F, et al. Assessing pain in critically ill sedated patients by using a behavioral pain scale[J]. Critical care medicine,2001, 29(12): 2258-2263.

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We have shown

that responsesto nonnoxious

and noxious stimuli can bedifferentiated accurately in

sedated, mechanically ventilatedpatients by using behavioralindicators.

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重症监护疼痛观察工具

care Pain Observation Tool, CPOT

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Critical -

Indicator Facial expression

Description No muscular tension observed Presence of frowning, brow lowering, orbit tightening,and levator contraction All of the above facial movements plus eyelid tightly closed

Score Relaxed, neutral Tense Grimacing Absence of movements Protection 0 1 2 0 1

Body movements

Does not move at all (does not necessarily mean absence of pain) Slow, cautious movements, touching or rubbing the pain site, seeking attention through movements Pulling tube, attempting to sit up, moving limbs/thrashing, not following commands, striking at staff,trying to climb out of bed

Restlessness Relaxed Tense, rigid Very tense or rigid Tolerating ventilator or movement Coughing but tolerating Fighting ventilator Talking in normal tone or no sound Sighing, moaning Crying out, sobbing

2 0 1 2 0 1 2 0 1

Muscle tension Evaluation by passive flexion and extension of upper extremities Compliance with the ventilator (intubated patients) OR Vocalization (extubated patients)

No resistance to passive movements Resistance to passive movements Strong resistance to passive movements, inability to complete them Alarms not activated, easy ventilation Ala

rms stop spontaneously Asynchrony: blocking ventilation, alarms frequently activated Talking in normal tone or no sound Sighing, moaning Crying out, sobbing

18 20-8

Total, range

重症监护疼痛观察工具(Critical - care pain observation tool, CPOT)指标面部表情描述未观察到肌肉紧张皱眉、皱额，眼眶紧绷上述表情加眼睑紧闭躯体活动无运动缓慢小心运动，触碰或摩擦疼痛部位，通过运动寻求关注企图拔管，坐起，不听指令，攻击，试图翻越下床肌张力被动弯曲和伸展上肢不抵抗被动运动抵抗被动运动强烈抵抗被动运动，不能完成机械通气依从性 (插管病人)或发声(拔管病人)无报警，人机协调可自动停止的报警不同步：对抗呼吸机，反复报警交谈正常或无声音叹气呻吟哭泣或呜咽合计放松紧张扭表情曲无运动防护动作多动放松紧张，僵硬非常紧张，非常僵硬耐受机械通气咳嗽但可忍耐机械通气人机对抗交谈正常或不发声叹气呻吟哭泣呜咽分值 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0-8

重症监护疼痛观察工具

Critical -care pain observation tool, CPOT

面部表情0-2肢体运动0-2肌肉张力0-2机械通气依从性或0-2发声语言情况

总分0-8分，分值越高表示疼痛越严重

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感受伤害性操作时CPOT>2，

操作后CPOT>1，

判定是否存在疼痛的特异性及敏感性最高

Gélinas C, Harel F, Fillion L, et al: Sensitivity and specificity of the Critical-Care Pain Observation Tool for the detection of pain in intubated adults after cardiac surgery. J Pain Symptom Manage 2009; 37:58–67

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