ส่วนที่ 1 ข้อมูลเอกสาร
| ชื่อ CNPG | การพยาบาลผู้ป่วย ICU Delirium & Sedation Management |
|---|
| วัตถุประสงค์ | ป้องกันและจัดการ ICU delirium ลด cognitive impairment ระยะยาว |
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| มาตรฐานอ้างอิง | SCCM PADIS Guidelines 2018, ABCDEF Bundle, ICU Liberation Campaign |
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ส่วนที่ 2 Assessment Tools
2.1 RASS (Richmond Agitation-Sedation Scale)
| Score | Description |
|---|
| +4 | Combative |
| +3 | Very agitated |
| +2 | Agitated |
| +1 | Restless |
| 0 | Alert & calm (target) |
| -1 | Drowsy (light sedation) |
| -2 | Light sedation |
| -3 | Moderate sedation |
| -4 | Deep sedation |
| -5 | Unarousable |
2.2 CAM-ICU (Confusion Assessment Method)
Delirium = Feature 1 + 2 + (3 or 4)
- Acute onset / Fluctuating course
- Inattention (ASE letters test — score > 2 errors)
- Altered consciousness (RASS other than 0)
- Disorganized thinking (yes/no questions, commands)
Assess ทุกเวร (q 8-12h)
2.3 CPOT (Critical-Care Pain Observation Tool)
- Facial expression (0-2)
- Body movements (0-2)
- Muscle tension (0-2)
- Ventilator compliance / vocalization (0-2)
- Score ≥ 3 = pain
ส่วนที่ 3 ABCDEF Bundle (ICU Liberation)
| Letter | Intervention |
|---|
| A | Assess, Prevent, Manage Pain |
| B | Both SAT (Spontaneous Awakening Trial) + SBT (Spontaneous Breathing Trial) |
| C | Choice of analgesia and sedation |
| D | Delirium: Assess, Prevent, Manage |
| E | Early mobility and Exercise |
| F | Family engagement and empowerment |
3.1 Daily SAT/SBT
- SAT: Hold sedation each morning → Assess RASS, CAM-ICU
- SBT readiness: FiO₂ ≤ 0.5, PEEP ≤ 8, hemodynamically stable
- SBT: 30-120 นาที spontaneous breathing → assess tolerance
- Passed SBT → consider extubation
ส่วนที่ 4 Pain Management
4.1 Analgesia Ladder
- Non-opioid: Acetaminophen, Ketorolac (caution in AKI)
- Opioid: Fentanyl 25-50 mcg q 1-2h IV PRN, infusion 25-100 mcg/hr
- Regional: Epidural, nerve blocks (post-op)
- Adjuncts: Gabapentin, Ketamine (sub-anesthetic)
4.2 Analgesia First (Analgo-sedation)
ให้ analgesia ก่อน sedation — ลด benzodiazepine use
ส่วนที่ 5 Sedation
5.1 Target
- Light sedation (RASS 0 to -2) preferred — unless specific need for deep
- Deep sedation (RASS -3 to -5): refractory ICH, NMB, status epilepticus
5.2 Sedatives
| Drug | Dose | Pros/Cons |
|---|
| Propofol | 5-50 mcg/kg/min | Quick on/off, BP drop, propofol infusion syndrome > 48h |
| Dexmedetomidine | 0.2-1.5 mcg/kg/hr | Arousable sedation, less delirium, bradycardia/hypotension |
| Midazolam | 1-10 mg/hr | Avoid — associated with delirium |
ส่วนที่ 6 Delirium Prevention
6.1 Non-pharmacological
- Sleep hygiene: reduce noise, lights at night, earplugs/eye mask
- Orientation: clock, calendar, family photos, day/night cycle
- Early mobilization: out of bed day 1 if possible, PT/OT
- Sensory: Glasses, hearing aids, dentures
- Family involvement: Visits, participation in care
- Minimize restraints: Only if absolutely necessary
- Nutrition + hydration
- Bowel/bladder function
6.2 Pharmacological (Treatment of Agitation)
- Dexmedetomidine — first choice for hyperactive delirium with agitation
- Haloperidol 1-5 mg IV PRN (monitor QTc)
- Atypical antipsychotics: Quetiapine 50 mg BID
- ⚠️ Benzodiazepines increase delirium — avoid unless EtOH withdrawal
KPIs
| KPI | Target |
|---|
| RASS assessment per shift | 100% |
| CAM-ICU assessment per shift | 100% |
| Pain assessment per shift | 100% |
| Delirium prevalence | < 40% |
| ABCDEF Bundle compliance | ≥ 70% |
| Average RASS (ventilated) | 0 to -2 |
| Mechanical ventilation days | ↓ 25% from baseline |
References
- Devlin, J.W., et al. (2018). Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS). Critical Care Medicine, 46(9).
- Ely, E.W., et al. (2017). The ABCDEF Bundle: Science and Philosophy of How ICU Liberation Serves Patients and Families. Critical Care Medicine.
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