Das Delir – Konsequenzen für die Analgosedierung kritisch kranker Patienten

Zusammenfassung

Das Monitoring von Analgesie, Sedierung und Delir mit validierten Messinstrumenten sowie die sich daraus ableitenden therapeutischen und diagnostischen Maßnahmen bilden die Basis für jede intensivmedizinische Behandlung von kritisch kranken Patienten. Nach Veröffentlichung der eigens für Deutschland entwickelten S2-Leitlinie (LL) zur Analgesie und Sedierung in der Intensivmedizin konnte bereits im Jahr 2006 eine Verbesserung des Monitorings von 8 auf 51% und eine Steigerung von protokollbasiertem Vorgehen von 21 auf 46% festgestellt werden. Von 2006–2009 wurde die bestehende S2-LL von der Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) und der Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI) auf eine S3-LL erweitert. In Zusammenarbeit mit weiteren 10 Fachgesellschaften wurde die Literatur nach Kriterien des Oxford Centre of Evidence Based Medicine bewertet. Unter Berücksichtigung von 671 Literaturstellen wurden Volltext, Schemata und Empfehlungen erstellt. Dabei ist ein erster Unterschied zwischen der S2-LL und der aktuelle S3-LL geradezu offensichtlich: der Titel der Leitlinie wurde um den Begriff ”Delirmanagement“ erweitert. Entsprechend finden sich in der aktuellen LL jetzt auch erstmals evidenz- und konsensbasierte Handlungsempfehlungen für das Monitoring und die Therapie des Delirs bei kritisch kranken Patienten. Der Beitrag skizziert die wesentlichen Inhalte der S3-LL zur Analgesie, Sedierung und Delirmanagement bei Erwachsenen.

Abstract

Monitoring and protocolized management for analgesia, sedation and delirium are key indicators for an evidence-based treatment of critically ill patients. Through the dissemination of these guidelines in 2006, use of monitoring was shown to have improved from 8 to 51% and the use of protocol-based approaches increased to 46% (from 21%). From 2006–2009, the existing guidelines from the DGAI (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin) and DIVI (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) were developed into 3rd Generation Guidelines for the securing and optimization of quality of analgesia, sedation and delirium management in the intensive care unit (ICU). In collaboration with another 10 professional societies, the literature has been reviewed using the criteria of the Oxford Center of Evidence Based Medicine. Using data from 671 reference works, text, diagrams and recommendations were drawn up. The new 3rd Generation Guideline now includes evidence and consensus-based recommendations for the management of delirium in the intensive care unit.

Kernaussagen

• Das Management von Schmerz, Sedierung und Delir bei kritisch kranken Patienten sollte immer als Gesamtaufgabe verstanden werden. Erst das Gesamtkonzept (”ABCDE-Bundle“ plus bedarfsadaptierte Analgesie) bedingt den signifikanten Outcome-Vorteil für den Patienten [5] [67].

• Das protokollbasierte Weaning sollte immer in Kombination mit einem Sedierungsprotokoll angewendet werden [3].

• Die Sedierungstiefe sollte mindestens alle 8 h mit Hilfe eines validen Messinstruments erfasst werden. Bei Sedierungsdauer bis zu 7 Tagen sollte bevorzugt Propofol als Sedativa eingesetzt werden.

• Die Analgesiequalität sollte alle 8 h evaluiert werden. Dafür stehen je nach Zustand des Patienten unterschiedliche validierte Schmerzscores zur Verfügung.

• Beim Delir sollte neben der Ursachendiagnostik so bald wie möglich eine symptomorientierten Therapie erfolgen.

Schlüsselwörter:

Delirium - Sedierung - Analgesie - Leitlinie - Intensivmedizin

Key words:

delirium - sedation - analgesia - guideline - intensive care

Im Nahmen aller Leitlinien-Miglieder:

Martin J, Heymann A, Bäsell K, Baron R, Biniek R, Bürkle H, Dall P, Dictus C, Eggers V, Eichler I, Engelmann L, Garten L, Hartl W, Haase U, Huth R, Kessler P, Kleinschmidt, S, Koppert W, Kretz FJ, Laubenthal H, Marggraf G, Meiser A, Neugebauer E, Neuhaus U, Putensen C, Quintel M, Reske A, Roth B, Scholz J, Schröder S, Schreiter D, Schüttler J, Schwarzmann G, Stingele R, Tonner P, Tränkle P, Treede RD, Trupkovic T, Tryba M, Wappler F, Waydhas C.

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