Psychische Störungen in der Intensivmedizin – Teil 2: Prävention und Therapie

Zusammenfassung

Der zweiteilige Artikel ”Psychische Störungen in der Intensivmedizin“ stellt die häufigsten psychischen Störungen und Erkrankungen vor, mit denen der Intensivmediziner konfrontiert wird. Teil 1 befasst sich mit Grundlagen, Störungsbildern und der Diagnostik, Teil 2 mit der Prävention und Therapie dieser Erkrankungen.

Für die Therapie psychischer Störungen auf der Intensivstation liegen keine Empfehlungen vor, die höchsten Evidenzkriterien genügen. Dennoch gibt es eine Reihe von Therapieoptionen, die neben der Psychopharmakotherapie auch psycho-therapeutische Maßnahmen und die Gestaltung der Umgebungsbedingungen beinhalten. Prophylaktische und rationale therapeutische Maßnahmen können den Behandlungsverlauf ganz erheblich positiv beeinflussen.

Abstract

This two part article “Mental disorders in intensive care medicine” aims to give an understanding of the most frequent mental disorders in critical care medicine. Part 1 highlights the basics, disturbances and diagnostics, part 2 prevention and therapeutic approaches.

Kernaussagen

• Viele psychische Störungen auf der Intensivstation lassen sich durch die Gestaltung der Umgebungsbedingungen positiv beeinflussen.

• Die effektivste Therapie des Delirs ist die Prophylaxe.

• Die nicht pharmakologische Prophylaxe des Delirs ist zum Teil mit sehr einfachen Mitteln zu erreichen (z. B. Hör- und Sehhilfen).

• Die Dämpfung mit α₂-Agonisten und die niedrigdosierte Gabe eines Antipsychotikums (z. B. Haloperidol) sind sinnvolle pharmakologische Maßnahmen zur Delirprophylaxe.

• Für die Therapie des Delirs haben Antipsychotika die stärkste Evidenz.

• Bei Depression zeigt Methylphenidat – wenngleich für diese Indikation nicht zugelassen – einen schnellen Wirkeintritt mit Besserung des Affekts.

• Beim Einsatz von Antidepressiva sollten neuere Substanzen wie Citalopram oder Venlafaxin bevorzugt eingesetzt werden.

• Die Beherrschung einfacher Grundregeln der (Psycho-)Pharmakotherapie ist angesichts der Häufigkeit psychischer Störungen auf der Intensivstation unverzichtbar.

Schlüsselwörter:

psychische Störungen - IST - Intensivmedizin - Prävention - Therapie

Key words:

mental disorders - psychic disorders - icu - critical care - prevention - therapy

• Literatur

• 1 Wolf A, Pajonk FGB. Psychische Störungen in der Intensivmedizin. Teil 1: Grundlagen, Störungsbilder und Diagnostik. Anästhesiol Intensivmed Notfallmed Schmerzther 2012; 47: 150-157
• 2 Köllner V. Chirurgie, Intensiv- und Transplantationsmedizin. In: Köllner V, Broda M, Hrsg. Praktische Verhaltensmedizin. Stuttgart: Thieme; 2005
• 3 Bergner C, Brink A, Overkamp B et al. Psychisches Akuttrauma bei Unfallverletzten. Verhinderung der Chronifizierung durch Früherkennung. Trauma Berufskrankh 2008; 10: 228-234
• 4 Li SY, Wang TJ, Vivienne WuSF et al. Efficacy of controlling night-time noise and activities to improve patients' sleep quality in a surgical intensive care unit. J Clin Nurs 2011; 20: 396-407
• 5 Xie H, Kang J, Mills GH. Clinical review: The impact of noise on patients' sleep and the effectiveness of noise reduction strategies in intensive care units. Crit Care 2009; 13: 208-208
• 6 Tracy MF, Chlan L. Nonpharmacological interventions to manage common symptoms in patients receiving mechanical ventilation. Crit Care Nurse 2011; 31: 19-28
• 7 Szilagyi KA, Dioszeghy C, Varga K. Psychologists working as members of the intensive care team could reduce the length of stay. Orv Hetil 2008; 149: 2329-2333
• 8 Hwang SL, Chang Y, Ko WJ et al. Stress-reducing effect of physician's tape-recorded support on cardiac surgical patients in the intensive care unit. J Formos Med Assoc 1998; 97: 191-196
• 9 Hofhuis JG, Spronk PE, van Stel HF et al. Experiences of critically ill patients in the ICU. Intensive Crit Care Nurs 2008; 24: 300-313
• 10 Friesner SA, Curry DM, Moddeman GR. Comparison of two pain-management strategies during chest tube removal: relaxation exercise with opioids and opioids alone. Heart Lung 2006; 35: 269-276
• 11 Miller KM, Perry PA. Relaxation technique and postoperative pain in patients undergoing cardiac surgery. Heart Lung 1990; 19: 136-146
• 12 Richardson S. Effects of relaxation and imagery on the sleep of critically ill adults. Dimens Crit Care Nurs 2003; 22: 182-190
• 13 Deisch P, Soukup SM, Adams P et al. Guided imagery: replication study using coronary artery bypass graft patients. Nurs Clin North Am 2000; 35: 417-425
• 14 Halpin LS, Speir AM, CapoBianco P et al. Guided imagery in cardiac surgery. Outcomes Manag 2002; 6: 132-137
• 15 Tusek DL, Cwynar R, Cosgrove DM. Effect of guided imagery on length of stay, pain and anxiety in cardiac surgery patients. J Cardiovasc Manag 1999; 10: 22-28
• 16 Peris A, Bonizzoli M, Iozzelli D et al. Early intra-intensive care unit psychological intervention promotes recovery from post traumatic stress disorders, anxiety and depression symptoms in critically ill patients. Crit Care 2011; 15
• 17 Ely EW, Gautam S, Margolin R et al. The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med 2001; 27: 1892-1900
• 18 Ely EW, Shintani A, Truman B et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004; 291: 1753-1762
• 19 Lin SM, Liu CY, Wang CH et al. The impact of delirium on the survival of mechanically ventilated patients. Crit Care Med 2004; 32: 2254-2259
• 20 Milbrandt EB, Deppen S, Harrison PL et al. Costs associated with delirium in mechanically ventilated patients. Crit Care Med 2004; 32: 955-962
• 21 Pisani MA, Kong SY, Kasl SV et al. Days of delirium are associated with 1-year mortality in an older intensive care unit population. Am J Respir Crit Care Med 2009; 180: 1092-1097
• 22 Dasgupta M, Dumbrell AC. Preoperative risk assessment for delirium after noncardiac surgery: a systematic review. J Am Geriatr Soc 2006; 54: 1578-1589
• 23 Inouye SK, Bogardus Jr ST, Charpentier PA et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999; 340: 669-676
• 24 Leslie DL, Marcantonio ER, Zhang Y et al. One-year health care costs associated with delirium in the elderly population. Arch Intern Med 2008; 168: 27-32
• 25 Harari D, Hopper A, Dhesi J et al. Proactive care of older people undergoing surgery ('POPS'): designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients. Age Ageing 2007; 36: 190-196
• 26 Siddiqi N, Stockdale R, Britton AM et al. Interventions for preventing delirium in hospitalised patients. Cochrane Database Syst Rev CD 005563 2007;
• 27 Marcantonio ER, Flacker JM, Wright RJ et al. Reducing delirium after hip fracture a randomized trial. J Am Geriatr Soc 2001; 49: 516-522
• 28 Liptzin B, Laki A, Garb JL et al. Donepezil in the prevention and treatment of post-surgical delirium. Am J Geriatr Psychiatry 2005; 13: 1100-1106
• 29 Sampson EL, Raven PR, Ndhlovu PN et al. A randomized, double-blind, placebo-controlled trial of donepezil hydrochloride (Aricept) for reducing the incidence of postoperative delirium after elective total hip replacement. Int J Geriatr Psychiatry 2007; 22: 343-349
• 30 Gamberini M, Bolliger D, Lurati Buse GA et al. Rivastigmine for the prevention of postoperative delirium in elderly patients undergoing elective cardiac surgery – a randomized controlled trial. Crit Care Med 2009; 37: 1762-1768
• 31 Pandharipande PP, Pun BT, Herr DL et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA 2007; 298: 2644-2653
• 32 Riker RR, Shehabi Y, Bokesch PM et al. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA 2009; 301: 489-499
• 33 Pandharipande PP, Sanders RD, Girard TD et al. Effect of dexmedetomidine versus lorazepam on outcome in patients with sepsis: an a priori-designed analysis of the MENDS randomized controlled trial. Crit Care 2010; 14
• 34 Rubino AS, Onorati F, Caroleo S et al. Impact of clonidine administration on delirium and related respiratory weaning after surgical correction of acute type-A aortic dissection: results of a pilot study. Interact Cardiovasc Thorac Surg 2009; 10: 58-62
• 35 European Medicines Agency (EMA). Summary of opinion (initial authorisation) Dexdor dexmedetomidine. http://www.ema.europa.eu/docs/en_GB/document_library/Summary_of_opinion_-_Initial_authorisation/human/002268/WC500109198.pdf 2011
• 36 Hudetz JA, Patterson KM, Iqbal Z et al. Ketamine attenuates delirium after cardiac surgery with cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2009; 23: 651-657
• 37 Sultan SS. Assessment of role of perioperative melatonin in prevention and treatment of postoperative delirium after hip arthroplasty under spinal anesthesia in the elderly. Saudi J Anaesth 2010; 4: 169-173
• 38 Al-Aama T, Brymer C, Gutmanis I et al. Melatonin decreases delirium in elderly patients: a randomized, placebo-controlled trial. Int J Geriatr Psychiatry 2011; 26: 687-694
• 39 Kalisvaart KJ, de Jonghe JF, Bogaards MJ et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc 2005; 53: 1658-1666
• 40 Larsen KA, Kelly SE, Stern TA et al. Administration of olanzapine to prevent postoperative delirium in elderly joint-replacement patients: a randomized, controlled trial. Psychosomatics 51: 409-418
• 41 Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI). S3-Leitlinie: Analgesie, Sedierung und Delirmanagement in der Intensivmedizin – Langfassung. http://www.awmf.org/uploads/tx_szleitlinien/001-012l.pdf
• 42 Lonergan E, Britton AM, Luxenberg J. Antipsychotics for delirium. Cochrane Database Syst Rev CD 005594 2007;
• 43 Gilchrist NA, Asoh I, Greenberg B. Analytic reviews: atypical antipsychotics for the treatment of ICU delirium. J Intensive Care Med 2011;
• 44 Overshott R, Karim S, Burns A. Cholinesterase inhibitors for delirium. Cochrane Database Syst Rev CD 005317 2008;
• 45 van Eijk MM, Roes KC, Honing ML et al. Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre, double-blind, placebo-controlled randomised trial. Lancet 2010; 376: 1829-1837
• 46 Reade MC, O'Sullivan K, Bates S et al. Dexmedetomidine vs. haloperidol in delirious, agitated, intubated patients: a randomised open-label trial. Crit Care 2009; 13
• 47 Hanania M, Kitain E. Melatonin for treatment and prevention of postoperative delirium. Anesth Analg 2002; 94: 338-339
• 48 Furuse T, Hashimoto K. Sigma-1 receptor agonist fluvoxamine for delirium in intensive care units: report of five cases. Ann Gen Psychiatry 2010; 9: 18-18
• 49 Haase U, Rundshagen I. Pharmakotherapie – Physostigmin post OP. Anasthesiol Intensivmed Notfallmed Schmerzther 2007; 42: 188-189
• 50 DiMartini A, Crone C, Fireman M et al. Psychiatric aspects of organ transplantation in critical care. Crit Care Clin 2008; 24: 949-981
• 51 Johnson CJ, Auger WR, Fedullo PF et al. Methylphenidate in the 'hard to wean' patient. J Psychosom Res 1995; 39: 63-68
• 52 Candy M, Jones L, Williams R et al. Psychostimulants for depression. Cochrane Database Syst Rev CD 006722 2008;
• 53 Hardy SE. Methylphenidate for the treatment of depressive symptoms, including fatigue and apathy, in medically ill older adults and terminally ill adults. Am J Geriatr Pharmacother 2009; 7: 34-59
• 54 Chlan L. Effectiveness of a music therapy intervention on relaxation and anxiety for patients receiving ventilatory assistance. Heart Lung 1998; 27: 169-176
• 55 Chlan LL. Psychophysiologic responses of mechanically ventilated patients to music: a pilot study. Am J Crit Care 1995; 4: 233-238
• 56 Dijkstra BM, Gamel C, van der Bijl JJ et al. The effects of music on physiological responses and sedation scores in sedated, mechanically ventilated patients. J Clin Nurs 2010; 19: 1030-1039
• 57 Wong HL, Lopez-Nahas V, Molassiotis A. Effects of music therapy on anxiety in ventilator-dependent patients. Heart Lung 2001; 30: 376-387
• 58 Fleischer S, Berg A, Neubert TR et al. Structured information during the ICU stay to reduce anxiety: study protocol of a multicenter randomized controlled trial. Trials 2009; 10: 84-84
• 59 Rincon HG, Granados M, Unutzer J et al. Prevalence, detection and treatment of anxiety, depression, and delirium in the adult critical care unit. Psychosomatics 2001; 42: 391-396