基于循证的ICU成人患者疼痛管理证据总结

doi:10.3969/j.issn.1004-583X.2026.04.009

摘要/Abstract

摘要：

目的检索、评价并总结ICU成人患者疼痛管理的最新证据,为临床管理与实践提供参考。方法按照“6S”证据金字塔模型自上而下检索相关数据库及网站中与ICU成人患者疼痛管理相关的文献,检索时限为 2015年1月1日-2025年8月11日。接受过循证护理培训的研究者对纳入文献进行了质量评价,并完成证据的提取与汇总。结果共纳入13篇文献,包括临床决策4篇、指南4篇、系统评价1篇、专家共识4篇,从镇痛管理的基本原则、疼痛评估、药物镇痛管理、非药物镇痛措施、操作性相关疼痛、特殊人群疼痛管理、疼痛管理的培训与质量改进7个方面总结了32条证据,核心更新证据包括:强调镇痛优先原则;明确护士在疼痛评估与非药物镇痛中的主导作用;细化阿片类药物的最小化使用策略;明确提出对接受多种镇静镇痛药物患者的撤药顺序指导;系统提出对操作性疼痛实施预防性镇痛;将疼痛管理培训与质量指标纳入建议。结论该研究总结的ICU成人患者疼痛管理的循证证据具有一定的科学性和实用性,可为优化ICU成人患者疼痛管理、提升护理质量提供参考依据。

关键词: 疼痛管理, ICU, 成人, 证据总结, 循证护理

Abstract:

Objective To retrieve, appraise, and summarize the latest evidence on pain management in adult patients in the intensive care unit (ICU), providing a reference for clinical management and practice. Methods Following the top-down “6S” evidence pyramid model, relevant databases and websites were searched for literature related to pain management in adult ICU patients. The search period was from January 1, 2015 to August 11, 2025. Researchers who had received evidence-based nursing training appraised the quality of the included literature and completed evidence extraction and synthesis. Results A total of 13 articles were included, comprising 4 clinical decisions, 4 guidelines, 1 systematic review, and 4 expert consensuses. Thirty-two evidence statements were summarized across 7 aspects: basic principles of analgesic management, pain assessment, pharmacological pain management, non-pharmacological pain relief measures, procedure-related pain, pain management in special populations, and training and quality improvement in pain management. The core updated evidence included: emphasizing the principle of analgesia first; clarifying the leading role of nurses in pain assessment and non-pharmacological analgesia; refining strategies for minimizing opioid use; explicitly proposing guidance on the sequence of withdrawal for patients receiving multiple sedative-analgesic drugs; systematically recommending preventive analgesia for procedure-related pain; and incorporating pain management training and quality indicators into the recommendations. Conclusion The evidence-based findings summarized in this study regarding pain management in adult ICU patients are scientifically sound and practically applicable, and may serve as a reference for optimizing pain management and improving nursing quality in adult ICU patients.

Key words: pain management, intensive care units, adults, evidence summary, evidence-based nursing

中图分类号:

R619

金俊豪, 王永华, 王佳羲, 高曹吉, 蒋玲俐, 陈娟. 基于循证的ICU成人患者疼痛管理证据总结[J]. 临床荟萃, 2026, 41(4): 341-347.

Jin Junhao, Wang Yonghua, Wang Jiaxi, Gao Caoji, Jiang Lingli, Chen Juan. Evidence-based summary of pain management in adult ICU patients[J]. Clinical Focus, 2026, 41(4): 341-347.

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链接本文: https://www.lchc.cn/CN/10.3969/j.issn.1004-583X.2026.04.009

https://www.lchc.cn/CN/Y2026/V41/I4/341

图/表 5

参考文献 32

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纳入文献	发表年份	文献来源	文献类型	文献主题
Boncyk等^[14]	2024	BMJ	临床决策	重症监护室疼痛管理与镇静管理
Pandharipande等^[15]	2025	Uptodate	临床决策	成人危重症患者的疼痛控制
Fuchs等^[16]	2025	Uptodate	临床决策	通气成人的镇静镇痛的管理策略和药物选择
Fuchs等^[17]	2025	Uptodate	临床决策	通气成人的镇静镇痛的药物特性和给药方案
Wyler等^[18]	2018	Cochrane	系统评价	神经重症患者镇痛镇静
Bhadade等^[19]	2023	Pubmed	指南	重症监护室疼痛、躁动、谵妄、活动受限及睡眠障碍管理临床实践指南
Celis-Rodríguez等^[20]	2020	Pubmed	指南	重症成人患者镇静镇痛及谵妄的管理
Gélinas等^[21]	2025	RNAO	指南	疼痛预防、评估和管理
韩国重症医学会^[22]	2022	医脉通	指南	重症监护室内患者疼痛、躁动、谵妄、固定和睡眠障碍
中华医学会呼吸病学会^[23]	2023	医脉通	专家共识	成人呼吸危重症患者镇痛镇静管理及相关问题专家共识
神经重症专家共识工作组^[24]	2023	医脉通	专家共识	神经重症患者镇痛镇静治疗中国专家共识(2023)
中华医学会重症医学分会^[25]	2023	医脉通	专家共识	中国成人重症患者镇痛管理专家共识
汤铂等^[26]	2023	中华医学期刊	专家共识	重症后专家管理共识

纳入文献	发表年份	文献来源	文献类型	文献主题
Boncyk等^[14]	2024	BMJ	临床决策	重症监护室疼痛管理与镇静管理
Pandharipande等^[15]	2025	Uptodate	临床决策	成人危重症患者的疼痛控制
Fuchs等^[16]	2025	Uptodate	临床决策	通气成人的镇静镇痛的管理策略和药物选择
Fuchs等^[17]	2025	Uptodate	临床决策	通气成人的镇静镇痛的药物特性和给药方案
Wyler等^[18]	2018	Cochrane	系统评价	神经重症患者镇痛镇静
Bhadade等^[19]	2023	Pubmed	指南	重症监护室疼痛、躁动、谵妄、活动受限及睡眠障碍管理临床实践指南
Celis-Rodríguez等^[20]	2020	Pubmed	指南	重症成人患者镇静镇痛及谵妄的管理
Gélinas等^[21]	2025	RNAO	指南	疼痛预防、评估和管理
韩国重症医学会^[22]	2022	医脉通	指南	重症监护室内患者疼痛、躁动、谵妄、固定和睡眠障碍
中华医学会呼吸病学会^[23]	2023	医脉通	专家共识	成人呼吸危重症患者镇痛镇静管理及相关问题专家共识
神经重症专家共识工作组^[24]	2023	医脉通	专家共识	神经重症患者镇痛镇静治疗中国专家共识(2023)
中华医学会重症医学分会^[25]	2023	医脉通	专家共识	中国成人重症患者镇痛管理专家共识
汤铂等^[26]	2023	中华医学期刊	专家共识	重症后专家管理共识

纳入文献	各领域标准化百分比(%)						≥60%领域数 (个)	≥30%领域数 (个)	推荐级别 (级)
纳入文献	范围和目的	参与人员	严谨性	清晰性	应用性	独立性	≥60%领域数 (个)	≥30%领域数 (个)	推荐级别 (级)
Bhadade等^[19]	90%	88%	93%	78%	92%	85%	6	6	A
Celis-Rodríguez等^[20]	88%	80%	92%	76%	75%	85%	6	6	A
Gélinas等^[21]	100%	94%	85%	100%	92%	100%	6	6	A
韩国重症医学会^[22]	88%	79%	68%	83%	78%	100%	6	6	A

纳入文献	各领域标准化百分比(%)						≥60%领域数 (个)	≥30%领域数 (个)	推荐级别 (级)
纳入文献	范围和目的	参与人员	严谨性	清晰性	应用性	独立性	≥60%领域数 (个)	≥30%领域数 (个)	推荐级别 (级)
Bhadade等^[19]	90%	88%	93%	78%	92%	85%	6	6	A
Celis-Rodríguez等^[20]	88%	80%	92%	76%	75%	85%	6	6	A
Gélinas等^[21]	100%	94%	85%	100%	92%	100%	6	6	A
韩国重症医学会^[22]	88%	79%	68%	83%	78%	100%	6	6	A

类别	证据内容	证据等级
镇痛管理的基本原则	1.坚持镇痛为先的基本原则和治疗策略^{[14-15,19 -20,26]}	1a
	2.多模式镇痛有助于减少阿片类药物用量及其不良反应^{[14,16,19,21]}	1a
	3.镇痛管理应根据持续疼痛评估结果进行动态调整^[15,21,25]	4a
疼痛评估	4.ICU成人患者应常规、系统地进行疼痛评估,疼痛应作为常规监测指标之一^{[14-15,18 -19,21 -22,24 -25]}	4a
	5.镇痛评估时首选患者对疼痛的主观感受^{[15,17,21,25 -26]}	5b
	6.对意识清醒能够自述疼痛程度的患者,推荐采用数字评分量表(Numeric Rating Scale, NRS)或者视觉模拟评分法(Visual Analog Scale, VAS)进行评估^{[14,16,19,22,26]}	1a
	7.对无法进行口头和非语言交流的患者,推荐使用已存在经过验证的工具,采用CPOT或疼痛行为评分量表进行评估,如重症监护疼痛观察工具(CPOT)或疼痛行为量表(BPS)^{[14,16,19,22,26]}	1a
	8.疼痛评估应在镇痛前后、操作前后以及病情变化时重复进行^{[15,19,21,25]}	4a
	9.护士在ICU疼痛评估中承担主要实施与持续监测责任^{[15,21,25 -26]}	5b
	10.不推荐单独以生命体征变化作为疼痛的评估方法,但可作为辅助手段,用于发现潜在疼痛^{[15,17,21,25 -26]}	4a
药物镇痛管理	11.阿片类药物是ICU中重度疼痛管理的主要药物^{[14-15,19 -20,22,26]}	1a
	12.常用阿片类药物包括芬太尼、吗啡、瑞芬太尼和氢吗啡酮^{[14-15,21,25]}	1b
	13.使用阿片类药物时应严密监测呼吸抑制、低血压、肠蠕动减弱等不良反应^{[15,19,21,25]}	1a
	14.尽可能使用最低阿片类药物剂量以确保达到治疗目标,且仅在尽可能短的时间内使用,长期或大剂量使用阿片类药物可能导致耐受、依赖及戒断反应^{[15-16,19,21]}	1a
	15.非阿片类镇痛药如非甾体抗炎药(NSAIDs)、对乙酰氨基酚或氯胺酮应作为辅助镇痛手段,以减少阿片类药物的使用需求和不良反应^{[14,19,21,23,25 -26]}	1a
	16.非甾体抗炎药(NSAIDs)在ICU中使用需谨慎,特别是存在肾功能不全或出血风险的患者^[15-16,19]	1a
	17.辅助镇痛药物(如氯胺酮、加巴喷丁类)可在特定情况下用于镇痛^[15-16,19]	1a
非药物镇痛措施	18.非药物镇痛措施可作为药物镇痛的辅助手段^{[15,17,21,24]}	1a
	19.常用非药物镇痛措施包括体位调整、环境优化、音乐疗法、放松训练、按摩、冷热疗法、安抚性接触、宠物疗法^{[14,16,19,21,25 -26]}	2b
	20.护士在非药物镇痛措施实施中起主导作用^[17,25,26]	5b
操作相关疼痛管理	21. ICU常见护理及诊疗操作(如吸痰、翻身、导管置入)可引起显著疼痛^{[15,19,21,25]}	4a
	22.在可能引起疼痛的操作前应进行预防性镇痛^{[15,19,21,25]}	1a
特殊人群疼痛管理	23.机械通气患者更容易出现疼痛评估不足,应加强评估,建议采用目标导向的流程化镇痛策略^{[15,19,21,25]}	1a
	24.肾和(或)肝功能不全的危重症患者,通常选择静脉给予芬太尼或氢吗啡酮,不应使用吗啡^[16-17,19]	1a
	25.老年ICU患者镇痛管理应关注药物不良反应和谵妄风险^[15,19,21]	3b
	26.对心肌梗死患者采用吗啡以外的镇痛策略,包括使用硝酸酯类药物和β受体阻滞剂^[20]	1a
	27.对于接受1种以上镇静镇痛药物且不能评估疼痛的患者,例如丙泊酚+阿片类药物,应最后减停阿片类,这样患者不会在疼痛中苏醒。若能够评估患者的疼痛,可同时减停这些药物并治疗疼痛^[16]	5b
	28.对确诊或有活动性支气管痉挛的患者,首选芬太尼或氢吗啡酮,而非吗啡^[15]	1a
	29.神经重症患者应谨慎使用氯胺酮^[24]	5b
疼痛管理的培训与质量改进	30.实施标准化疼痛评估与管理流程可提高镇痛效果^{[14-15,17,21]}	2b
	31.对ICU护士进行疼痛评估与镇痛管理培训可改善患者疼痛控制^{[17,21,25 -26]}	1a
	32.疼痛管理质量指标应纳入ICU护理质量评价体系^[17,21,25]	5b