さまよう薬剤師のブログ

学位を持っても、センスのない、感染制御専門薬剤師のブログ.  I have Ph.D. but less sense ID pharmacist.

せん妄の治療

最近、せん妄の相談が多いです。
非常に難しく、悩ましいですね。

せん妄→「ハロペリドール」「クエチアピン」効果ない時はバタバタ…

鎮静薬をプレセデックス考慮などなどありますが、決定打ではないですよね。

エビデンスは薄いのですが、長く続くせん妄の予防として、「抑肝散」も選択肢に入れて主治医と協議してます。願いを込めた、ハイパープラセーボとして…



以下、UpToDate より

SUMMARY AND RECOMMENDATIONS — 

Delirium is an acute confusional state characterized by an alteration of consciousness with reduced ability to focus, sustain, or shift attention.

●Effective measures to prevent delirium include avoiding where possible, those factors known to cause or aggravate delirium, orientation protocols, environmental modification and nonpharmacologic sleep aids, early mobilization and minimizing use of physical restraints, and visual and hearing aids.

●Prophylactic medications (cholinesterase inhibitors, antipsychotic agents) have not been conclusively demonstrated to prevent delirium

●Thiamine supplementation should be considered in all patients with delirium.

●When the underlying acute illness responsible for delirium is identified, specific therapy is directed toward that condition as the most effective means of reversing the delirium.

●Physical restraints should be used only as a last resort, if at all, as they frequently increase agitation and create additional problems, such as loss of mobility, pressure ulcers, aspiration, and prolonged delirium.

●Frequent reassurance, touch, and verbal orientation from familiar persons can lessen disruptive behaviors.

●A cautious trial of psychotropic medication should be reserved for treatment of severe agitation or psychosis with the potential for harm. In this setting, we suggest using low-dose haloperidol (0.5 to 1.0 mg po or IM) (Grade 2C). 

Haloperidol is associated with a low frequency of sedation and hypotension.

-Haloperidol should be avoided in patients with underlying parkinsonism, for whom atypical antipsychotics (eg, quetiapine) are preferred.

-Short term use of antipsychotic agents is advised.

●Benzodiazepines should be avoided in patients with or at risk for delirium, except in cases of sedative drug and alcohol withdrawal or when neuroleptic medications are contraindicated.

Cholinesterase inhibitors are not effective in preventing or treating the symptoms of delirium, and often create undesirable side effects. 

Delirium may require weeks or months to fully resolve. Episodes of delirium may adversely affect the course of the disease in patients with Alzheimer disease. Delirium appears to be associated with increased short and long-term mortality.