吸入麻醉与术后躁动

全麻术后苏醒期患者躁动的危害性极大,其诱发因素很多,其中吸入麻醉可能是主要原因。中枢局灶敏感化是吸入麻醉诱发躁动的可能机制,这种功能完整性的缺失影响患者对感觉的反应和处理能力,在某些有害刺激的作用下,中枢神经系统表现为过度兴奋而诱发躁动。预防和治疗术后躁动的方法包括药物性和非药物性处理措施。     

Assessing Alzheimer's disease patients with the Cohen-Mansfield Agitation Inventory: scoring and clinical implications.

We explored the applicability of the standard scoring of the Cohen-Mansfield Agitation Inventory (CMAI), a widely used nursing-home derived instrument, to community-dwelling persons with Alzheimer's disease (AD). Item responses to the CMAI were gathered from participants in two large clinical studies, one of which specifically included patients with behavioral disturbances. Confirmatory factor analysis in these two groups of well-characterized AD patients suggested that conventional CMAI subscoring did not adequately describe the responses of these two groups. Exploratory factor analysis indicated that the four CMAI subscores, based on a verbal-physical and aggressive-non-aggressive conceptualization of behavioral disturbance, did not fit community dwelling persons with AD. Based on cross-sectional and longitudinal analyses, there was suggestive evidence for three behavioral clusters, but these clusters did not achieve statistical significance Overall, the CMAI seemed best suited to describe the overall level rather than the specific subtypes of behavioral dyscontrol in community-dwelling persons with AD.     

现代电休克治疗激越行为对照研究

目的：比较现代电休克治疗(MECT)和氟哌啶醇注射治疗对急性激越患者的疗效以及对血清催乳素(PRL)水平的影响。方法：60例伴有激越行为的急性期精神疾病患者，随机分成两组，MECT组28例，氟哌啶醇组32例，分别在入组前、治疗第4天和第7天采用阳性与阴性症状量表(PANSS)的激越因子分以及临床总体印象量表(CGI)评定疗效，副反应量表(TESS)评定不良反应。使用酶联免疫吸附法测定血清PRL水平。结果：两组治疗后第4天和第7天的PANSS激越因子分、CGI总分均较疗前显著下降，第7天时以MECT组显著较好。氟哌啶醇组在第7天TESS总分显著高于MECT组，治疗第7天比治疗前催乳素水平有显著提高。结论：MECT和氟哌啶醇注射治疗急性期兴奋患者的激越症状均有很好疗效。MECT的疗效、依从性、疗效指数更有优势，对PRL的影响是短暂的。     

阿立哌唑合用氯硝西泮治疗精神分裂症兴奋症状疗效分析

目的：以氯氮平为对照组，探讨阿立哌唑合用氯硝西泮治疗精神分裂症兴奋症状的疗效及不良反应。方法：对62例精神分裂症兴奋症状患者，随机分为阿立哌唑合用氯硝西泮组（31例）和氯氮平组（3l例）进行治疗，疗程1周。治疗前及治疗1周末，分别以阳性与阴性症状量表兴奋因子（PANSS—EC）和TESS量表评定疗效及不良反应。结果：阿立哌唑合用氯硝西泮组和氯氮平组均获得明显疗效（P〈0．01），两组间差异无显著性（P〉0．05）。氯氮平组嗜睡、便秘、流涎和心动过速的发生率高于阿立哌唑合用氯硝西泮组（P〈0．05）。结论：阿立哌唑合用氯硝西泮可有效治疗精神分裂症兴奋症状，不良反应较少。     

布托啡诺对全麻术后躁动的防治作用

目的评价布托啡诺用于预防和治疗全麻患者术后躁动的有效性与安全性。方法ASAⅠ～Ⅱ级上腹部择期手术患者40例,随机分为对照(C)组与布托啡诺(B)组,每组20例。在术毕停用麻醉药即刻,C组经静脉注射生理盐水2ml;B组静脉注射布托啡诺0.02mg/kg。记录停用麻醉药前、拔管即刻、拔管后5min时的心率、血压,并对循环稳定程度、躁动程度、镇静状态进行评分。结果与麻醉前相比,拔管时、拔管后5min对照组患者血压明显升高(P<0.05)、心率加快(P<0.05),而布托啡诺组血压、心率相对平稳,两组比较有显著性差异(P<0.05)。与C组比较布托啡诺组躁动发生率更低(P<0.05),患者安静(P<0.05)。C组有6例患者术后持续躁动,经静脉注射布托啡诺0.02mg/kg,症状控制率达83.33%。结论布托啡诺是全麻术后躁动预防与治疗理想的选择药物。     

Pain,agitation and delirium in the intensive care unit

Pain, agitation and delirium are common during critical illness and are associated with many adverse consequences. A key aim of critical care is the facilitation of a calm, comfortable patient who can interact with their family and staff. Intensive care unit (ICU) patients frequently have pain from a variety of sources, many of which are not readily appreciated or actively managed. This article explores the challenges of assessing pain in the ICU and outlines methods that can be used to better identify and manage pain in this patient group. Agitation in ICU is often multifactorial, with many of its sources under-recognized. We will discuss the potential reasons that ICU patients become agitated, methods for measuring agitation and the actions that can be taken to alleviate it. Although the use of sedative and anxiolytic drugs is common in ICU, their use is not without risks. This article will outline these risks, the variety of drugs available and how to use these drugs to a targeted effect. We will also explore delirium, its risk factors, precipitants and associated morbidity and mortality. This article will discuss how to diagnose delirium and the methods used to prevent and manage it.     

Insomnia brings soldiers into mental health treatment,predicts treatment engagement,and outperforms other suicide-related symptoms as a predictor of major depressive episodes

Given the high rates of suicide among military personnel and the need to characterize suicide risk factors associated with mental health service use, this study aimed to identify suicide-relevant factors that predict: (1) treatment engagement and treatment adherence, and (2) suicide attempts, suicidal ideation, and major depressive episodes in a military sample. Army recruiters (N = 2596) completed a battery of self-report measures upon study enrollment. Eighteen months later, information regarding suicide attempts, suicidal ideation, major depressive episodes, and mental health visits were obtained from participants’ military medical records. Suicide attempts and suicidal ideation were very rare in this sample; negative binomial regression analyses with robust estimation were used to assess correlates and predictors of mental health treatment visits and major depressive episodes. More severe insomnia and agitation were significantly associated with mental health visits at baseline and over the 18-month study period. In contrast, suicide-specific hopelessness was significantly associated with fewer mental health visits. Insomnia severity was the only significant predictor of major depressive episodes. Findings suggest that assessment of sleep problems might be useful in identifying at-risk military service members who may engage in mental health treatment. Additional research is warranted to examine the predictive validity of these suicide-related symptom measures in a more representative, higher suicide risk military sample.     

利培酮合并氯硝西泮口服与氟哌啶醇肌注后换利培酮口服治疗精神分裂症兴奋激越症状的随机对照研究

目的比较利培酮口服液合并氯硝西泮片与氟哌啶醇肌注控制精神分裂症兴奋激越症状的疗效和安全性,以及在兴奋激越控制后以利培酮口服液替换氟哌啶醇肌注的疗效及安全性。方法纳入33例兴奋激越的精神分裂症患者：18例随机分入利培酮组,利培酮口服液（2～6ml/d）合并氯硝西泮（4～8mg/d）,第6天起氯硝西泮逐渐减量,共观察47d;15例分入氟哌啶醇组,前5天氟哌啶醇肌注（10～20mg/d）,第6天起逐渐替换为利培酮口服液（2～6ml/d）,共观察47d。以阳性与阴性综合征量表（PANSS）、Barnes静坐不能量表（BAS）,类帕金森综合征量表（SAS）评定疗效和不良反应。结果第5天末利培酮组和氟哌啶醇组PANSS兴奋激越因子分的平均（标准差）减分值分别为6.9（3.8）分,8.2（4.7）分,t=0.85,P=0.403,PANSS总分平均减分值分别为41.1（13.5）分,47.7（14.2）分,t=1.31,P=0.199。第5天末利培酮组的SAS评分低于氟哌啶醇肌注组[分别为0（0）分,2（9）分,Z=2.72,P=0.006]。结论利培酮口服液合并氯硝西泮片剂可有效安全地治疗精神分裂症急性兴奋激越。用氟哌啶醇肌注控制兴奋激越后直接换利培酮口服液,也能保持疗效。     

Répercussions psychocomportementales en périopératoire chez l’enfant

The relevant literature since the 1940s has been collected from the Medline database, using the keywords: child, operation, anxiety, distress, postoperative complications, preparation, premedication, parental presence, prevention. Preoperative anxiety, emergence delirium, and postoperative behavior changes are all manifestations of psychological distress in children undergoing surgery. Preoperative anxiety is most prominent during anaesthesia induction. Emergence delirium is frequent and somewhat independent of pain levels. Postoperative behavior changes most often include separation anxiety, tantrums, fear of strangers, eating problems, nightmares, night terrors and bedwetting. These difficulties tend to resolve themselves with time but can last up to one year in some children. The major risk factors for postoperative behavior problems are young age, prior negative experience with hospitals or medical care, certain kinds of hospitalization, postoperative pain, parental anxiety, and certain personality traits of the child. Currently, tools exist for quantifying anxiety (m-YPAS) and postoperative behavior (PHBQ). It is possible to identify those children who are at risk for postoperative complications during the preanaesthesia consultation by paying close attention to children under six years with higher levels of emotionality and impulsivity and poorer socialization skills with anxious parents. Suggested strategies for reducing child distress include preoperative preparation, premedication, parental presence during anaesthesia induction, and interventions affecting the child's environment, such as hypnosis. There are numerous ways to provide preoperative preparation (information, modeling, role playing, encouraging effective coping) and their effectiveness is proven in the preoperative setting but not during anaesthesia induction or in the operating room. Midazolam has been shown to be an effective preoperative sedative for reducing anxiety. Parental presence during induction has been shown to effectively reduce preoperative anxiety in children in certain contexts (when the parent is calm and the child is anxious). It is worthwhile if it is integrated into a family-centered anxiety management program and remains one of several options offered to families. Overall, taking into account the child's psychological needs should be considered an essential part of paediatric anaesthesia. Tools and techniques are available for assessing and managing the perioperative distress experienced by children.