摘要
随着危重症救治水平不断提高,危重症幸存者日益增多,其将面临长期认知及功能障碍.已有研究表明,危重症患者住院治疗后1~5年内持续存在认知及功能障碍.认知功能障碍表现为记忆力减退,注意力下降和执行能力下降.功能障碍表现为肌无力,活动耐力下降和日常生活能力下降.多种危险因素与长期认知及功能障碍有关,包括疾病严重程度、重症脓毒症、长时间机械通气、谵妄和既往存在认知功能障碍.危重症幸存者发生长期认知及功能障碍病理生理机制复杂.神经系统炎症反应及血-脑屏障破坏可能与长期认知功能障碍有关.而ICU获得性肌无力及长期功能障碍可能与全身炎症反应损害肌肉结构及功能有关.目前,对于危重症幸存者的长期认知及功能障碍主要采取多种策略预防其发生,以及出院后康复治疗.谵妄是长期认知功能障碍的明确危险因素,预防谵妄措施对保护认知功能尤为重要,主要包括减少镇静药物使用量,合理选用镇静药物(避免使用苯二氮卓类药物),维持浅镇静,每日唤醒及早期活动等.多方面集束化预防措施能改善危重症幸存者远期预后,提高其生存质量.但关于认知及功能康复治疗研究资料少,结论尚不明确.
With the improvement of medical treatment,more and more critical illness survivors will face long-term cogmitive and functional impairment.Longitudinal studies have demonstrated impairments persisting at least 1-5 years after hospitalization for critical illness.Cognitive domains impacted include memory,attention,and processing speed.Functional impairments include physical weakness,reduced endurance,and dependence on others for basic tasks of daily living such as bathing or feeding.Multiple risk factors have been identified for subsequent impairment,including increased severity of illness and severe sepsis,prolonged mechanical ventilation,and delirium.Preadmission status including frailty,high level of preexisting comorbidities,and base-line cognitive dysfunction are also associated with impairment after critical illness.Development of cognitive and functional impairment is likely multifactorial,and multiple mechanistic theories have been proposed.Neuroinflammation,disruption of the blood-brain barrier,and structural alterations in the brain have all been observed in patients with long-term cognitive dysfunction.Systemic inflammation has also been associated with alterations in muscle integrity and function,which is associated with intensive care unit-acquired weakness and prolonged functional impairment.Efforts to ease the burden of long-term impairments include prevention strategies and rehabilitation interventions after discharge.Delirium is a well-established risk factor for long-term cognitive dysfunction,and using delirium-prevention strategies may be important for cognitive protection.Current evidence favors minimizing overall sedation exposure,careful selection of sedation agents including avoidance of benzodiazepines,and targeted sedation goals to avoid over-sedation.Daily awakening and spontaneous breathing trials and early mobilization have shown benefit in both cognitive and functional outcomes.Multifactorial prevention bundles are useful tools in improving care provided to patients in the intensive c
作者
胡悦育(综述)
王鹏飞(审校)
HU Yue-yu;WANG Peng-fei(Department of Neurology,Shanghai Fourth People's Hospital Afiliated to Tongji University School of Medicine,Shanghai 200081,China;Department of General Surgery,Shanghai Ninth People's Hospital,Shanghai Jiaotong University School of Medicine,Shanghai 200011,China)
出处
《加速康复外科杂志》
2019年第2期77-83,共7页
JOURNAL OF ENHANCED RECOVERY AFTER SURGERY
关键词
危重症幸存者
认知功能障碍
康复治疗
Critical illnsssurvivors
Cognitive dysfunction
Rehabilitation treatment
