鎮靜劑和肌肉鬆弛劑2
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麻醉止痛 /鎮靜安眠 /肌肉鬆弛劑簡介 -2
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什麼時候要用上鎮靜藥物 ?
焦慮
希望病人失憶
↑O2 消耗 ↑CO2 產生
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誰好 ?
可能延長呼吸器使用時間文獻 : Chest. 1998;114(2):541.
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目前準則建議 :
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• 間歇性一次給予或每日暫停或劑量慢慢降低維持輕度鎮靜 (RASS -2 to 0)
• 但也有些情況需較深的鎮靜,須依病人情況和主治醫師判定
文獻 : Crit Care Med. 2013;41(1):263.
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RASS鎮靜程度評估表
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Ramsay鎮靜程度評估表
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有那些鎮靜藥物呢 ?
Dormicum Ativan Propofol
Benzodiazepines(BZD)
其它
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BZD脂溶性高,易分布到組織
擔心藥物蓄積於體內
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BZD作用與毒性
呼吸抑制
低血壓
讓人想睡 抗癲癇
無止痛作用
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Dormicum
作用快 (0.5-5 分鐘 )作用時間短 (< 2 小時 )
肥胖、老人、肝腎功能不好者容易蓄積體內
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Midazolam (Dormicum/Midatin) 5 mg/1 ml/amp
11Ref: Midazolam: Drug information Copyright 1978-2006 Lexi-Comp, Inc. All rights reserved.
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Ativan較不受年齡和肝功能影響
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Lorazepam (Ativan/Anxicam) 2 mg/1 ml/amp
13Ref: Midazolam: Drug information Copyright 1978-2006 Lexi-Comp, Inc. All rights reserved.
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Propylene glycol toxicity
• Lorazepam針劑中一種溶質• 症狀 :
– 高滲透壓, anion gap 代謝酸中毒,通常伴隨急性腎衰竭和多重器官衰竭• 劑量大於 0.1 mg/kg/hr (10 mg/hr)容易發生• Midazolam沒有此溶質,所以不會發生
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Propofol (Fresofol) 200 mg/20 ml/amp
15Ref: Propofol: Drug information Copyright 1978-2006 Lexi-Comp, Inc. All rights reserved.
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Propofol
高脂溶性,可快速進入 CNS再分布快,作用快速
呼吸抑制讓人想睡
抗癲癇
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Propofol副作用
低血壓
綠色尿
監測 TG
計算熱量 Propofol infusion syndrome
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Propofol Infusion Syndrome
• 心律不整• 心衰竭• 代謝性酸中毒• 高血鉀• 橫紋肌溶解症• 與劑量或濃度相關 Propofol infusion syndrome
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Propofol infusion syndrome
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< 1% >4 mg/kg/hr >48 hrs
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鎮靜的時間
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穩定後停藥
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戒斷症候群
焦慮不安 混亂 焦慮
心跳快 高血壓 發燒
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慢慢停藥避免戒斷症候群先停鎮靜劑 再停鴉片類止痛藥
停藥速度因人而異 短期使用可直接停長期使用 (>7days)要分幾天慢慢停
要注意病人有可能停藥後不會馬上醒
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病人可能不會馬上醒過來 ?
• 因為脂溶性藥物可能蓄積• 此外
– 小心鴉片類止痛藥物戒斷症狀•激動,混亂,拉肚子,噁心嘔吐,發燒
– 小心鎮靜藥物戒斷症狀•激動,緊張,發抖,心跳快,血壓高
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