Analgosedierung und Delir in der Intensivmedizin

Kernaussagen

Viele Patienten werden während der Behandlung auf der Intensivstation zumindest phasenweise analgosediert. Eine wichtige Maßnahme ist ein täglicher Aufwachversuch mit Spontanatmungsversuch, wodurch die Dauer der Beatmung verkürzt und das Outcome verbessert werden kann. Grundlage eines rationalen Einsatzes sedierender und analgetischer Substanzen ist die Überwachung von Schmerzen, Bewusstsein und Sedierungstiefe in regelmäßigen Abständen. Hiermit verbunden ist die individuelle Festlegung eines Sedierungsziels und die Verwendung eines strukturierten Sedierungsprotokolls.

Eine besondere Herausforderung stellt der Patient mit Intensivdelir dar. Diese häufige Komplikation ist mit hohen Kosten, einer erhöhten Mortalität und einer längerfristigen Beeinträchtigung der kognitiven Funktionen verbunden. Daher sollte man ein regelmäßiges Screening auf ein Delir unter Einsatz validierter Messverfahren vornehmen (z. B. CAM-ICU).

Zahlreiche Risikofaktoren für die Delirentwicklung sind nicht oder kaum zu beeinflussen (z. B. Alter, Vorerkrankungen). Trotzdem ist es möglich, Inzidenz und Verlauf eines Delirs günstig zu beeinflussen. Beispielsweise sollte man dem Patienten notwendige sensorische Hilfsmittel (Brille, Hörgerät) zur Verfügung stellen. Auch die Orientierung des Patienten muss aktiv unterstützt werden, hierbei können Angehörige und private Gegenstände hilfreich sein.

Es gibt keine gesicherten Erkenntnisse zur medikamentösen Prophylaxe des Intensivdelirs. Gleichwohl benötigen viele Patienten bei Auftreten des Delirs eine symptomorientierte medikamentöse Therapie. Hierzu sollte man bevorzugt Neuroleptika einsetzen. Benzodiazepine sollte man dagegen wegen ihrer potenziell delirogenen Eigenschaften zurückhaltend verwenden. Die derzeitigen Erkenntnisse über den Einfluss der Medikamente zur Analgosedierung auf die Entwicklung eines Delirs erlauben keine generelle Empfehlung bestimmter Substanzen.

• Literatur

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