29. 鎮静薬の比較
Polderman KH, Herold I: Therapeutic hypothermia and cotrolled normothermia in the intensive care
unit: Practical considerations, side effects, and cooling methods. Crit Care Med 37: 1101-20, 2009
35. 鎮痛薬の比較
Polderman KH, Herold I: Therapeutic hypothermia and cotrolled normothermia in the intensive care
unit: Practical considerations, side effects, and cooling methods. Crit Care Med 37: 1101-20, 2009
36. 鎮痛薬の比較
Polderman KH, Herold I: Therapeutic hypothermia and cotrolled normothermia in the intensive care
unit: Practical considerations, side effects, and cooling methods. Crit Care Med 37: 1101-20, 2009
心筋収縮力抑制作用や血管拡張作用が少ないため、
循環状態が不安定な場合はmorphineよりfentanylの
使用が推奨される
38. 筋弛緩薬
Polderman KH, Herold I: Therapeutic hypothermia and cotrolled normothermia in the intensive care
unit: Practical considerations, side effects, and cooling methods. Crit Care Med 37: 1101-20, 2009
利点: 100% 効果有り.
欠点:
抗シバリング作用は無い
むしろ不十分な鎮静,てんかん発作を隠してしまう
長期使用によりcritical illness neuropathy, myopathyなどの副作用
39. 筋弛緩薬の特徴
利点
酸素消費量を減らす
胸郭のコンプライアンスの改善
ファイティングの防止
炎症性サイトカインの減少
シバリングのコントロール
When Should Sedation or Neuromuscular Blockade
Be Used During Mechanical Ventilation?
Suzanne Bennett MD and William E Hurford MD
Introduction
The Triad of Agitation
Pain
Anxiety
Delirium
Deep Sedation and Anesthesia
Neuromuscular Blocking Agents
Summary
Sedation has become an important part of critical care practice in minimizing patient discomfort
and agitation during mechanical ventilation. Pain, anxiety, and delirium form a triad of factors that
can lead to agitation. Achieving and maintaining an optimal level of comfort and safety in the
intensive care unit plays an essential part in caring for critically ill patients. Sedatives, opioids, and
neuromuscular blocking agents are commonly used in the intensive care unit. The goal of therapy
should be directed toward a specific indication, not simply to provide restraint. Standard rating
Respir Care 2011;56(2):168 –176.
欠点
無気肺の出現
横隔膜の挙上
肺胞の虚脱
40. Chamorro C; Anesth Analg 2010;110:1328-35
低体温療法導入の例
導入はNMBA使用
モニタリングとして
BIS
TOF: train of four
EEG
を推奨
42. SCCMにおける筋弛緩薬の位置付け
These agents control the muscular symptoms of
shivering, but their use normally is reserved as a
last therapeutic option.
Society of Critical Care Medicine; Aug 2008
43. SCCMにおける筋弛緩薬の位置付け
These agents control the muscular symptoms of
shivering, but their use normally is reserved as a
last therapeutic option.
Society of Critical Care Medicine; Aug 2008
54. Bedside Shivering Assessment Scale
Score
0 シバリングとして咬筋(そしゃく筋),頸部,胸部に筋収縮が見られず,
かつ電気生理学的にシバリングを認めない(心電図を使用)
1 電気生理学的にシバリングを認めるが(心電図を使用),臨床的な
シバリングの所見を認めない
2 頸部および/または胸部に限局したシバリング
3 上肢(頸部や胸部も含む)の激しい活動を伴うシバリング
4 体幹・上下肢の激しい活動を伴うシバリング
Badjatia N, Strongilis E, Gordon E, et al. Metabolic impact of shivering during therapeutic temperature modulation: the
Bedside Shivering Assessment Scale. Stroke. 2008;39(12): 3242-3247. doi:10.1161/STROKEAHA .108.523-654.