重症监护室患者不适体验及其与事实记忆的关系

目的探讨重症监护室（intensivecareunit，ICU）患者不适体验及其与事实记忆（factual recollection，FR）的相关性。方法对55例ICU患者及63例普通病房患者进行标准化FR问卷调查，并对结果进行分析。结果64％的ICU转出患者有ICU不适体验，其中以气管内导管、疼痛及幻觉所引起的不适较为常见；ICU患者FR评分平均为7．25分，普通病房患者FR评分平均为13．50分，二者比较差异有统计学意义（t=3．34，P〈0．01）；Logistic回归分析表明，FR评分与ICU患者不适体验，尤其是与气管内导管、疼痛及幻觉所引起的不适的发生显著相关，0R95％CI（1．2～2．1），P〈0．01。结论ICU患者的不适体验主要来自于气管内导管、疼痛和幻觉等；ICU患者相对于普通病房患者可能存在记忆减退；FR可能与ICU不适体验的发生具有相关性。     

重症监护室患者的不适体验对患者健康相关生存质量的影晌

重症监护室(intensive care unit,ICU)患者因病情危重,患者的日常活动受到很大的限制,患者在ICU期间仍可能伴有明显的不适体验,且大多为不愉快的负性体验.主要来自于焦虑、疼痛、口唇发干、失眠、失定向、呼吸困难、丧失活动能力、医疗行为及气管内导管等[1].有研究[2]提示,气管内吸引术所产生的不适对患者影响尤为明显.本研究旨在通过随访调查,阐述ICU患者的不适体验对患者健康相关生存质量(healthrelated quality of life,HRQOL)的影响,现报道如下.     

重症监护室患者的不适体验对患者健康相关生存质量的影响

重症监护室（intensive care unit,ICU）患者因病情危重,患者的日常活动受到很大的限制,患者在ICU期间仍可能伴有明显的不适体验,且大多为不愉快的负性体验。主要来自于焦虑、疼痛、口唇发干、失眠：失定向、呼吸困难、丧失活动能力、医疗行为及气管内导管等。有研究提示,气管内吸引术所产生的不适对患者影响尤为明显。本研究旨在通过随访调查,阐述ICU患者的不适体验对患者健康相关生存质量（heahhrelated quality of life,HRQOL）的影响,现报道如下。     

ICU病人疼痛的护理

ICU与普通病房相比,收治的患者病情重、生命重危、身体衰弱,其环境特殊与外界隔绝,使患者产生极度的紧张与焦虑,此时,躯体的疼痛更增加患者的痛苦和不安,护士如何帮助患者解除疼痛,是危重病人抢救中一项不可忽视的工作. 1 ICU病人疼痛的原因及影响因素 造成ICU病人躯体疼痛的原因,可以是疾病本身如急性心肌梗死;也可能来自于医源性的,如气管切开.此外,因长期卧床引起的褥疮、便秘、体位不适,肌肉痛等均会引起疼痛.许多研究结果表明,ICU病人的痛感普遍增强,其主要原因是病人对死亡的恐惧,特殊环境造成的焦虑,对治疗效果不佳的失望,以及伴随疾病而来的“间接问题”如与家人的隔离,失去社会地位,经济负担加重等。     

ICU患者气管插管相关性压力性损伤的危险因素分析

目的调查重症监护病房(ICU)患者气管插管相关性压力性损伤(PI)的特征并分析危险因素,为ICU患者气管插管相关性PI的防治提供依据。方法采用回顾性病例对照研究设计,调查2018年1—12月入住我院ICU的156例气管插管患者,并对相关因素进行分析。结果患者气管插管相关性PI发生率为23.7%,唇部为PI的高发部位(76.7%);气管导管留置时间、使用声门下吸引导管、插管时Braden评分中潮湿分、移动力分、摩擦力剪切力分值均是导致气管插管相关性PI的危险因素(P0.05)。结论 ICU患者气管插管相关性PI发生率高,应重点关注高发部位,临床护理过程应早期识别相关危险因素,及时干预,预防气管插管相关性PI的发生。     

ICU术后患者真实操作性疼痛体验与护士认知差异的调查研究

目的 调查重症监护室(ICU)术后患者真实操作性疼痛体验与临床护士认知之间的差异,以调整操作性疼痛评估及管理行为,提高ICU患者的护理质量.方法 选取四川大学华西医院外科重症监护室(SICU)2020年1月-2021年3月收治的210例术后患者及采用整群抽样法抽取该科室的65名护士为研究对象,采用自行设计的ICU术后患者真实操作性疼痛体验问卷、疼痛数字评分法(NRS)和重症监护室疼痛观察工具法(CPOT)对术后患者操作性疼痛真实体验与护士对患者疼痛认知之间的差异进行调查.结果 32项操作中,除一般口腔护理、更换CVC敷料、更换胃管胶布、尿管护理、测量血压、床旁胸片检查和床旁B超检查7项操作护士与患者真实的操作性疼痛评分比较差异无统计学意义(P＞0.05),其余25项操作患者的真实疼痛评分均明显高于护士认为患者的疼痛得分(P＜0.05),护士低估患者操作性疼痛的发生率为78.13％,护士和患者真实操作性疼痛得分比较差异无统计学意义占21.88％.其中引起患者疼痛强度最高的5项操作依次为:动脉采血(7.73±2.24)、翻身(6.59±2.14)、吸痰(6.06±2.08)、皮试(5.70±2.21)和拔除气管插管(5.47±2.23).结论 与患者的真实操作性疼痛体验相比,护士普遍低估了 ICU术后患者的真实操作性疼痛,提示应加强护士操作性疼痛评估及管理培训,改善患者护理体验.     

疼痛观察工具应用于ICU非气管插管患者的信效度分析

目的:探讨重症监护病房(ICU)非气管插管患者采用中文版重症监护疼痛观察工具(CPOT)的信效度情况。方法:将CPOT量表进行中文翻译得到中文版CPOT,采用CPOT和疼痛程度数字评估量表(NRS)对2016年10月～2017年10月期间术后入住我院ICU的58例非气管插管患者进行疼痛评估,完成CPOT内部一致性、效标关联效度以及已知族群效度评价。再通过10名ICU护士对另外20例ICU患者进行评估,计算组内相关系数,以完成评定者间信效度的评价。结果:中文版CPOT的Cronbach'sα系数为0. 906。不考虑评定者间相互影响时,中文版CPOT评定者间信度为0. 852,有疼痛时CPOT评定间信度为0. 719,无疼痛时为0. 752。在假定评定者间完全无相互影响时,中文版CPOT评定者间信度为0. 968,有疼痛时CPOT评定者间信度为0. 936,无疼痛时为0. 967。中文版CPOT与NRS评分具有密切关系(r=0. 952),无疼痛和有疼痛刺激时中文版CPOT和NRS评分依然具有相关性(r=0. 751、0. 833)。研究中评价中文版CPOT已知族群效度时,对比无痛刺激测量体温和疼痛刺激翻身时的中文版CPOT各条目评分发现,疼痛刺激翻身时中文版CPOT各项评分均高于无疼痛刺激测量体温时评分(P 0. 05)。结论:中文版CPOT评分对ICU非气管插管患者评价具有良好的信效度,适用于ICU非气管插管患者对疼痛的评估。     

重型颅脑损伤患者医院感染危险因素的研究

目的分析重型颅脑损伤患者多种危险因素与医院感染的相关性,为预防和控制医院感染提供依据.方法前瞻性调查我院神经外科2001年4月1日～2001年9月30日入院的重型颅脑损伤患者82例,发生医院感染(病例组)20例,未发生医院感染(对照组)62例,进行成组不匹配病例对照研究.结果病例组与对照组在住院时间、住ICU、意识障碍、GCS评分、留置胃管、气管切开、深静脉置管、留置尿管≥3天,抗生素使用的种类及联合用药上均相差非常显著(P<0.01), OR值均大于5.结论重型颅脑损伤患者的GCS评分、意识障碍、住ICU、住院时间长、留置胃管、气管切开、深静脉置管、留置尿管≥3天及抗生素的不合理应用是造成医院感染的相关危险因素.     

MEWS 评分对急诊外科患者病情判断和预后评估的意义

目的:探讨改良早期预警评分(MEWS)对急诊外科患者病情判断和预后评估的临床意义。方法:选取2015年4月~2017年4月我院急诊外科收治的600例患者作为研究对象,所有患者均进行MEWS评分,将所有患者分为好转回家、门诊治疗、入住普通病房和入住ICU病房4种去向,追踪所有患者的最终转归(好转与死亡),比较4种不同去向患者的MEWS分值和死亡率,并对MEWS评分与死亡率进行Person相关性分析。结果:好转回家、门诊治疗、入住普通病房和入住ICU病房的患者的MEWS评分依次上升,且随着患者MEWS评分的增加,患者死亡率也在升高,差异有统计学意义,P<0.05;患者的MEWS评分与死亡率之间呈正相关性,相关系数为0.536,差异有统计学意义,P<0.05。结论:患者的MEWS评分与其病情呈正相关,该评分方法简便有效,对急诊外科患者的病情判断和预后评估具有重要的临床价值。     

手术患者麻醉后留置导尿效果观察

目的:探讨麻醉前后留置导尿对手术患者的影响。方法:将120例择期手术患者随机分为实验组和对照组各60例,对照组麻醉前由病房护士在病房留置导尿,实验组于硬膜外麻醉后留置导尿,观察并比较留置尿管时两组心率、血压、疼痛程度及一次置管成功率。结果:对照组患者留置尿管时血压、心率、疼痛程度均高于实验组(P<0.01),一次置管成功率低于实验组(P<0.01)。结论:麻醉后导尿可减轻患者的疼痛不适,适应患者生理、心理需求,值得推广应用。     

Discomfort and factual recollection in intensive care unit patients

Introduction

A stay in the intensive care unit (ICU), although potentially life-saving, may cause considerable discomfort to patients. However, retrospective assessment of discomfort is difficult because recollection of stressful events may be impaired by sedation and severe illness during the ICU stay. This study addresses the following questions. What is the incidence of discomfort reported by patients recently discharged from an ICU? What were the sources of discomfort reported? What was the degree of factual recollection during patients' stay in the ICU? Finally, was discomfort reported more often in patients with good factual recollection?

Methods

All ICU patients older than 18 years who had needed prolonged (>24 hour) admission with tracheal intubation and mechanical ventilation were consecutively included. Within three days after discharge from the ICU, a structured, in-person interview was conducted with each individual patient. All patients were asked to complete a questionnaire consisting of 14 questions specifically concerning the environment of the ICU they had stayed in. Furthermore, they were asked whether they remembered any discomfort during their stay; if they did then they were asked to specify which sources of discomfort they could recall. A reference group of surgical ward patients, matched by sex and age to the ICU group, was studied to validate the questionnaire.

Results

A total of 125 patients discharged from the ICU were included in this study. Data for 123 ICU patients and 48 surgical ward patients were analyzed. The prevalence of recollection of any type of discomfort in the ICU patients was 54% (n = 66). These 66 patients were asked to identify the sources of discomfort, and presence of an endotracheal tube, hallucinations and medical activities were identified as such sources. The median (min–max) score for factual recollection in the ICU patients was 15 (0–28). The median (min–max) score for factual recollection in the reference group was 25 (19–28). Analysis revealed that discomfort was positively related to factual recollection (odds ratio 1.1; P < 0.001), especially discomfort caused by the presence of an endotracheal tube, medical activities and noise. Hallucinations were reported more often with increasing age. Pain as a source of discomfort was predominantly reported by younger patients.

Conclusion

Among postdischarge ICU patients, 54% recalled discomfort. However, memory was often impaired: the median factual recollection score of ICU patients was significantly lower than that of matched control patients. The presence of an endotracheal tube, hallucinations and medical activities were most frequently reported as sources of discomfort. Patients with a higher factual recollection score were at greater risk for remembering the stressful presence of an endotracheal tube, medical activities and noise. Younger patients were more likely to report pain as a source of discomfort.

     

Patient recollection of airway suctioning in the ICU: routine versus a minimally invasive procedure

OBJECTIVE: Many patients have an unpleasant recollection of routine endotracheal suctioning after discharge from the Intensive Care Unit (ICU). We hypothesized that through minimally invasive airway suctioning discomfort and stress may be prevented, resulting in less recollection. DESIGN: A prospective randomized clinical trial. SETTING: Two ICUs at the University Hospital of Groningen, the Netherlands. PATIENTS AND PARTICIPANTS: Adult patients with an intubation period exceeding 24 h were included. INTERVENTIONS: Patients received either routine endotracheal suctioning (RES) or minimally invasive airway suctioning (MIAS) during the duration of intubation. MEASUREMENTS AND RESULTS: Within 3 days after ICU discharge all patients were interviewed, regarding recollection and discomfort of suctioning. The level of discomfort was quantified on a visual analogue scale (VAS). We analyzed data from 208 patients (RES: n=113, and MIAS: n=95). A significantly lower prevalence of recollection of airway suctioning was found in the MIAS group (20%) compared to the RES group (41%) (P-value =0.001). No significant difference in level of discomfort was found between the RES and the MIAS group (P-value =0.136). CONCLUSIONS: Minimally invasive airway suctioning results in a lower prevalence of recollection of airway suction than in RES, but not in discomfort.     

机械通气病人感受的研究

以应激与适应为概念框架 ,采用定势访谈法调查了 5 9例机械通气病人的感受。结果发现 ,气管插管是主要内在应激源 ,与气管插管有关的不适和疼痛、活动受限、睡眠障碍、体位不适等属于气管插管和机械通气的应激反应。吸痰、物理约束、ICU环境、抽血等是外在应激源。交流障碍、缺乏信息、医护人员及其医护活动等是人与人之间的应激源。还暴露了不被重视的适应性的行为。概括地描述了机械通气病人的感受 ,并根据病人的感受提出了一些建议 ;指出了改进研究的方法     

机械通气患者感受的研究

目的：研究机械通气患的感受。方法：以应激与适应为概念框架,采用定势访谈法调查了５９例机械通气患。结果：气管插管是主要内在应激源,与气管插管有关的不适和疼痛,活动受限,睡眠障碍,体位不适等属于气管插管和机械通气的应激反应。吸痰、物理约束、睡眠障碍、体位不适等属于气管插管和机械通气的应激反应,吸痰、物理约束,ＩＣＵ环境、抽血等是外在应激源,交流障碍、缺乏信息、医护人员及其医护活动等是人与人之间的     

肺部肿瘤术后患者ICU不适感与心理痛苦相关性研究

目的：了解肺部肿瘤术后患者ICU不适感与心理痛苦的相关性,从而为临床上采取相应措施降低ICU不适感与心理痛苦提供依据。 方法：采用方便抽样方法,于 2018年7月至12月选取182例天津市某三级甲等肿瘤专科医院肺部肿瘤术后患者,采用一般情况调查表、中文版ICU 患者不适评估量表、心理痛苦温度计量表进行调查。结果：肺部肿瘤术后患者ICU不适量表总分为（2.93±0.85）分,各条目中,得分最高的前5条,由高到低为疼痛不适（4.39±1.94）分、口渴的不适（4.27±1.94）分、焦虑（3.87±1.65）分、胸闷、呼吸困难（3.54±1.59）分、活动受限的不适（3.33±2.10）分。ICU不适总分在性别、年龄、婚姻、费用类型、术式、手术部位、是否吸烟上存在差异,具有统计学意义。心理痛苦得分为（4.74±1.63）分,心理痛苦程度在中度及以上144例,心理痛苦检出率为79.12%。相关分析结果显示,肿瘤术后患者ICU不适感与心理痛苦成正相关（r=0.62,P＜0.01）。结论：肺部肿瘤术后患者ICU不适感越高,心理痛苦程度越高。因此,在护理工作中,医护人员应当关注离异或丧偶的男性高龄患者,对于实施开胸的或者全肺切除的患者,加强患者术前戒烟的健康教育,以及术后疼痛的有效评估以及管理,适时与患者进行沟通,加强家属对患者积极的心理支持等,降低患者ICU不适感,从而降低患者心理痛苦程度,促进其更快的康复。     

A cross-sectional study of predictors of pain control during the transition from the surgical intensive care unit to surgical ward

Background

The transition of patients from the intensive care unit (ICU) to the ward is a complicated process and patients may be at risk of increased levels of pain.

Ward mortality in patients discharged from the ICU with tracheostomy may depend on patient’s vulnerability

Objective  To determine the effect of discharge from the ICU with a tracheostomy tube on ward mortality and its relation to patient vulnerability. Design and setting  Retrospective single-center cohort study. Methods  Database (2003–2006) review of patients undergoing mechanical ventilation (MV) > 24 h and discharged from the ICU with or without tracheostomy tube in place and followed up to hospital discharge or death. We recorded clinical characteristics, complications, major ICU procedures, subjective prognosis at ICU discharge (Sabadell score), and hospital outcome. Factors associated with ward mortality were analyzed by multiple logistic regression. Results  From 3,065 patients admitted to the ICU, 1,502 needed MV > 24 h. Only 936 patients (62%) survived the ICU and were transferred to the ward; of these, 130 (13.9%) had a tracheostomy tube in place. Ward mortality was higher in patients with a tracheostomy tube in place than in those without (26 vs. 7%, P < 0.001). Increased ward mortality among cannulated patients was seen only in those with intermediate Sabadell score (24 vs. 9% in score 1, P = 0.02, and 38 vs. 24% in score 2, P = 0.06), but not in the “good prognosis” (2 vs. 2%, score 0) and “expected to die in hospital” (80 vs. 75%, score 3) groups. Multivariate analysis found three factors associated with ward mortality: age, tracheostomy tube in place, and Sabadell score. Conclusion  Lack of tracheostomy decannulation in the ICU appears to be associated with ward mortality, but only in the group with a Sabadell score of 1. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Patterns and Clinical Correlates of Pain Among Brain Injury Patients in Critical Care Assessed with the Critical Care Pain Observation Tool

This study was conducted to assess the patterns and clinical correlates of acute pain in brain injury patients during the critical care period using the Critical Care Pain Observation Tool (CPOT). Data were collected from 31 brain-injury patients admitted to an intensive care unit (ICU) at a university hospital located in Incheon, Republic of Korea. Glasgow Coma Scale and CPOT scores were assessed on days 1, 3, 6, 9, and 14 after ICU admission. Results showed that temporal changes in pain intensity displayed a consistent pattern in critical care patients with a brain injury during the first 14 days of ICU admission. Mean pain score was highest on day 1, decreased rapidly to reach a minimum on day 3 or 6, and then increased on day 9. In most patients, pain reduced slightly on day 14. Mean CPOT scores were significantly higher in the nonsurgery group than in the surgery group. There was also a nonsignificant trend of higher pain intensity scores among patients with moderate brain injury compared with those with severe injury. CPOT scores immediately after endotracheal suctioning were significantly higher than before endotracheal suctioning, but CPOT scores 20 minutes after suctioning were similar to those before suctioning. The present study may be meaningful in terms of presenting valid clinical information regarding the patterns and characteristics of acute pain in brain injury patients who are often unable to self-report on the presence and intensity of pain.