氧合作用和血流灌注指标对ICU患者压疮发生的预警作用

目的 了解ICU压疮发病特征及氧合作用和血流灌注指标与压疮发生的相关性,为临床预防压疮提供依据.方法 采用自行设计问卷,通过皮肤检查和查阅病历,收集ICU患者的压疮发病情况及氧合作用和血流灌注指标等资料,将226例分为压疮组52例(为医院获得性压疮),非压疮组174例,并用SPSS15.0对各因素进行统计分析.结果 两组在年龄、动脉血酸碱度、动脉二氧化碳分压、收缩压、舒张压、平均动脉压及Braden评分等方面的差异有统计学意义(P<0.05);经多因素非条件Logistic回归分析,平均动脉压和Braden评分增加为ICU压疮的保护因素,呼吸系统疾病、外伤和其他类型疾病是ICU压疮的危险因素.结论 ICU患者是压疮的危险人群,平均动脉压和Braden评分高者发生压疮的危险较小,呼吸系统疾病、外伤和其他类型疾病的患者发生压疮的危险较大,年龄可能是压疮的间接危险因素.建议临床医护人员加强对ICU患者的血流动力学和动脉血气分析指标的监测,从中获取压疮预警信息,采取适当的预防措施,以降低压疮的发生率.     

Alternating pressure air mattresses as prevention for pressure ulcers: a literature review

OBJECTIVES: The purpose of this paper is to examine and synthesise the literature on alternating pressure air mattresses (APAMs) as a preventive measure for pressure ulcers. DESIGN: Literature review. DATA SOURCES: PubMed, Cinahl, Central, Embase, and Medline databases were searched to identify original and relevant articles. Additional publications were retrieved from the references cited in the publications identified during the electronic database search. RESULTS: Thirty-five studies were included. Effectiveness and comfort of APAMs were the main focuses of the studies evaluating APAMs. Pressure ulcer incidence, contact interface pressure, and blood perfusion were the most frequently used outcome measures to evaluate the effectiveness of APAMs. Fifteen randomised controlled trials (RCTs) analysed the pressure ulcer incidence. One RCT compared a standard hospital mattress with an APAM and found that the APAM was a more effective preventive measure. RCTs comparing APAMs with constant-low-air mattresses resulted in conflicting evidence. There was also no clear evidence as to which type of APAM performed better. All RCTs had methodological flaws. The use of contact interface pressure and blood perfusion measurements to evaluate the effectiveness of APAMs is questionable. Comfort of APAMs was the primary outcome measure in only four studies. Different methods for assessment were used and different types of APAMs were evaluated. Better measures for comfort are needed. A few studies discussed technical problems associated with APAMs. Educating nurses in the correct use of APAMs is advisable. CONCLUSION: Taking into account the methodological issues, we can conclude that APAMs are likely to be more effective than standard hospital mattresses. Contact interface pressure and blood perfusion give only a hypothetical conclusion about APAMs' effectiveness. Additional large, high-quality RCTs are needed. No conclusions can be drawn regarding the comfort of APAMs. A number of technical problems associated with APAMs are related to nurses' improper use of the devices.     

循证护理干预方案在ICU压疮高危患者中的应用

目的探讨循证护理干预方案在ICU压疮预防中的作用。方法将227例Braden评分≤12分的压疮高危患者按照入院的顺序分为对照组102例和观察组125例。对照组采用常规护理方法。观察组进行循证护理干预,予每2h翻身1次,左右30°侧卧位交替进行;平卧位时抬高患者床头不超过30°,足跟处垫软枕;对Braden评分〈7分、颈椎骨折及病情限制翻身的患者必须使用气垫床;在受压皮肤处及可能发生压疮的皮肤区域喷赛肤润;在皮肤受压部位应用康惠尔透明贴;根据患者营养状况给予肠内外营养;保持肛周皮肤干燥。比较2组的压疮发生情况。结果观察组的压疮发生率明显低于对照组,发生时间延迟,压疮严重程度轻。结论在ICU压疮高危患者中应用循证护理干预方案,能体现护理工作的科学性和艺术性,更有效地分配有限的护理资源,减少压疮的发生。     

Development of a new risk assessment scale for predicting pressure ulcers in an intensive care unit

Aims and objectives: The study aimed to evaluate the predictive validity and accuracy of a new pressure ulcer risk assessment scale in two Indonesia intensive care units (ICUs). Background: Several risk assessment scales have been designed to identify patients at risk of developing pressure ulcers in ICU. However, the relative weight of each variable that contributes to pressure ulcer development in these scales is not described to enable designing of a risk assessment scale. Currently, the risk factors contributing to pressure ulcer development include interface pressure, body temperature and cigarette smoking. Design: A prospective cohort study was conducted in two ICUs in Pontianak, Indonesia. Methods: A total of 253 patients were recruited to the study from both hospitals. Data collection included new risk assessment scale [i.e. the Suriadi and Sanada (S.S.) scale] scoring, demographic, pressure ulcer severity scores (based on the National Pressure Ulcer Advisory Panel) and skin condition measures. Using the S.S. scale, trained data collectors scored patients once and assessed the body temperature daily until patients were discharged. Additionally, daily data were also collected in relation to the patient‘s skin condition and stage of pressure ulcer. Results: Out of the 253 patients, 72 (28·4%) developed pressure ulcers. In ICU A, the incidence was 27%; pressure ulcers developed into stage I (41·7%), stage II (45·8%), stage III (10·4%) and stage IV (2·1%). In ICU B, the incidence was 31·6%; the development of pressure ulcers was 48% in stage I and 52% in stage II. Using the predictive validity test, the S.S. scale balanced sensitivity (81%) and specificity (83%) at a cut‐off score of 4. The area under the receiver‐operating characteristic curve was 0·888 (confidence interval: 0·84–0·93). Conclusion: The S.S. scale was found to be a valid risk assessment tool to identify the patients at risk of developing pressure ulcers in Indonesia ICU.     

Incidence and risk factors of pneumonia acquired in intensive care units

Objective To estimate the incidence of pneumonia acquired in the intensive care unit (ICU), and to define risk factors for developing such an event.Design European prospective survey, in which all patients admitted to the participating ICU from January, 17 to 23, 1990, were followed until ICU discharge.Setting 107 general ICUs from 18 countries.Patients Of 1078 admitted to the ICUs, 996 patients without pneumonia at admission were studied.Measurements Pneumonia was diagnosed by the staff physician on the basis of clinical, radiological and microbiological criteria, secondly validated by an expert committee who reviewed all the forms and even recontacted ICU physicians. Crude incidence and time to occurrence of pneumonia were estimated, then both used as endpoints for prognosis analysis.Results 89 pneumoniae were observed: crude incidence was estimated at 8.9%, 7-day and 14-day pneumonia rates at 15.8% and 23.4%, respectively. The risk of developing pneumonia increased when either coma, trauma, respiratory support, Apache II >16 and/or impaired airway reflexes were present at ICU admission. To predict time to occurrence of pneumonia, only two variables remained significant: the presence of impaired airway reflexes at admission and the use of mechanical ventilation during ICU course.Conclusion The role of the injury to the respiratory system — with the subsequent need for respiratory support-appears central in determining the risk to acquire pneumonia in ICU. In the future, the predictive value of severity scores during ICU course should be otherwise assessed.     

ICU患者压疮发生危险因素分析

目的：探讨导致ICU患者压疮发生的危险因素。方法：采用自行设计的“ICU患者压疮风险因素调查表”记录735例ICU患者的患病情况、主要治疗情况等资料。结果：性别、糖尿病、脑卒中、入ICU时间、是否持续进行动脉血压监测、水肿、平均动脉压、乳酸Lac、心率、Apachell评分是ICU患者发生压疮的影响因素。结论：ICU患者压疮发生是多因素共同参与的病理生理过程,护理人员应充分认识各种危险因素对ICU患者发生压疮的影响,对存在或可能存在危险因素的ICU患者实施重点防护以减少压疮的发生。     

支撑性工具在压疮防治中的循证评价

压疮是局部皮肤组织长期受压,导致缺血缺氧性损伤的病变,是长期住院、活动障碍及老年患者常见的并发症.选择合适支撑工具来减少局部长期压迫,是压疮防治的重要措施[1-2].     

Intervention studies for prevention of pressure ulcers in Turkey: a literature review

AIM: To examine critically the literature published in the Turkish language (1955-2004) related to risk assessment tool(s), their application to nursing care and prevention of pressure ulcers (PrUs). Specific objectives were to identify the advantages of risk assessment and prevention of PrUs in hospital; to establish the most valid and reliable methods available to evaluate the effectiveness of PrU prevention programmes; to determine methodological problems encountered by researchers and explore how these were overcome; and to present the findings so they could be used to develop a valid and reliable audit tool based upon the empirical evidence. METHODS: All journals and convention booklets published in Turkey related to nursing between the years 1955-2004 were examined. Because many journals in Turkey are not yet available by electronic means, the published Turkish articles were all examined by hand. A total of 3031 articles in 17 nursing journals and 36 congress books (convention booklets) were examined. Five articles were found to meet the study criteria and were taken into the study and evaluated. CONCLUSION: There is a need to determine valid and reliable assessment methods, and the results need to be recorded on standard forms. In addition, it is important to increase the motivation of nursing personnel who give direct patient care to use the tools available in order to prevent the development of PrUs. From the review findings it is apparent that in Turkey, there is a dearth of research evidence upon which to base practice in the sphere of PrU prevention, and further research is urgently required.     

Atrial fibrillation in trauma patients requiring intensive care

Objectives To evaluate the incidence and risk factors of atrial fibrillation (AF) in trauma patients. Design and setting Prospective observational study in a surgical intensive care unit (ICU). Patients All trauma patients admitted in the surgical ICU except those who had AF at admission. Measurements and results AF occurred in 16/293 patients (5.5%). AF patients were older, had a higher number of regions traumatized, and received more fluid therapy, transfusion products, and catecholamines. They more frequently experienced systemic inflammatory response syndrome, sepsis, shock, and acute renal failure and had higher scores of severity (Simplified Acute Physiology Score, SAPS II; Injury Severity Score). ICU length of stay and resources use were also increased. ICU and hospital mortality rates were twice higher in AF patients whereas standardized mortality ratio (observed/expected mortality by SAPS II) was similar in the two groups. We found five independent risk factors of developing AF: catecholamine use (OR = 5.7, 95% CI 1.7–19.1), SAPS II of 30 or higher (OR = 11.6, 95% CI 1.3–103.0), three or more regions traumatized (OR = 6.2, 95% CI 1.8–21.4), age 40 years or higher (OR = 6.3, CI 1.4–28.7), and systemic inflammatory response syndrome (OR = 4.4, 95% CI 1.2–16.1). Conclusions In addition to age and catecholamine use, inflammation and severity of injury may be involved in the development of AF in trauma patients. Our results suggest that AF could rather be a marker of a higher severity of illness without major effect on mortality. This article is discussed in the editorial available at: .     

Incidence,risk factors and microbiology of central vascular catheter-related bloodstream infection in an intensive care unit

Although there are many studies about catheter related infection in industrialized countries, very few have analyzed it in emerging countries. The aim of our study was to determine the incidence, microbiological profile and risk factors for catheter-related bloodstream infection (CRBSI) in a Tunisian medical intensive care unit. Over eight months (1 January 2012–30 August 2012) a prospective, observational study was performed in an 18-bed medical surgical intensive care unit at Tunis military hospital. Patients who required central venous catheter (CVC) placement for a duration greater than 48 h were included in the study. Two hundred sixty patients, with a total of 482 CVCs were enrolled. The mean duration of catheterization was 9.6 ± 6.2 days. The incidence for CRBSI and catheter colonization (CC) was 2.4 and 9.3 per 1000 catheter days, respectively. Risk factors independently associated with CRBSI were diabetes mellitus, long duration of catheterization, sepsis at insertion and administration of one or more antibiotics before insertion. The mortality rate among the CRBSI group was 21.8%. The predominant microorganisms isolated from CRBSI and CC episodes were Gram negative bacilli. All Gram negative organisms isolated among dead patients in CRBSI group were Extensive Drug Resistant (XDR). In our study the mortality rate among patients with CRBSI was high despite a low incidence of CRBSI. This high rate can be explained by the high-virulent status of Gram negative bacteria involved in CRBSI.     

Usefulness of intra-abdominal pressure in a predominantly medical intensive care unit

Background

The deleterious effects of elevated intra-abdominal pressure (IAP) have been known for more than a century. The proposed objectives were to measure changes in IAP and analyze increase-related factors and complications and whether high IAP and its persistence are related to complications and mortality in a predominantly medical intensive care unit.

Methods

Over a 1-year period, we conducted a prospective cohort study in which IAP was measured using the bladder method. Hospitalization time, demographic variables, diagnosis on admission, APACHE II score, and clinical complications were recorded.

Results

A total of 130 patients were studied. Overall mean IAP was 12.3 mm Hg (standard deviation [SD], 3.79; 95% confidence interval [CI], 11.7-13), and on the first day, 12.68 mm Hg (SD, 5.32; 95% CI, 11.8-13.6); maximum IAP was 16.4 mm Hg (SD, 4.6; 95% CI, 15.6-17.2). A positive correlation was found between IAP, APACHE (Acute Physiology And Chronic Health Evaluation) II, and age. Higher IAP values were independently associated with higher age, prolonged activated partial thromboplastin time, need for dialysis, and intolerance to enteral feeding. The value showing the best sensitivity and specificity in predicting mortality was persistence of IAP 20 mm Hg or greater for 4 days or more. The number of days with IAP 20 mm Hg or greater was a factor associated with a higher risk of death (odds ratio, 2.3). Patients who died showed a tendency to increased IAP.

Conclusion

In this study, a threshold IAP of 20 mm Hg and its permanence over time were the best predictive factors of complications and mortality. Among other relationships, we also observed that older patients had higher IAP. High IAP was a cause of intolerance to enteral nutrition.     

Pressure ulcer prevalence and incidence in intensive care patients: a literature review

Background: Pressure ulcers remain a common health problem worldwide within the different health‐care settings, especially in intensive care settings. Aims: The aims of this were to systematically assess the recent prevalence and incidence of pressure ulcers in intensive care patients (2000–2005), the factors related to pressure ulcer prevalence and incidence and the methodological rigour of studies about pressure ulcer prevalence and incidence in intensive care patients. Methods: The research design involved a review of literature for the period of 2000 to 2005, focused on the prevalence and incidence of pressure ulcers in intensive care patients. Results: The analysis of published papers revealed variations in pressure ulcer prevalence in intensive care settings ranging from 4% in Denmark to 49% in Germany, while incidence ranged from 38% to 124%. There was a wide variation in the prevalence and incidence of pressure ulcers in intensive care patients as evidenced in the studies examined. There is also a gap between theory and practice in the prevention and treatment of pressure ulcers which needs to be addressed. Conclusion: Further research is needed regarding the effectiveness of nursing care on pressure ulcer development and into treatments that may successfully prevent their occurrence in intensive care patients.     

Incidence of pressure ulcers in a neurologic intensive care unit

OBJECTIVES: To determine the risk factors for pressure ulceration in an intensive care setting, to evaluate the Braden scale as a predictor of pressure ulcer risk in critically ill patients, and to determine whether pressure ulcers are likely to occur early in the hospital stay. DESIGN: Cohort study of patients with no preexisting ulcers with a 3-month enrollment period. SETTING: The neurologic intensive care unit and the neurologic intermediate unit at a primary care/referral hospital with a level I trauma center. PATIENTS: A total of 186 patients entered the study. INTERVENTION: Within 12 hrs of admittance, initial assessment, photographs, and Braden score were completed. Patients were re-examined every 4 days or at discharge from the unit, whichever came first. MAIN OUTCOME MEASURES: Determining risk factors for pressure ulcers, performing detailed statistical analyses, and testing the usefulness of the Braden score as a predictor of pressure ulcer risk. RESULTS: Twenty-three of 186 patients developed at least one pressure ulcer (incidence = 12.4%) after an average stay of 6.4 days. The Braden scale, which measures six characteristics of skin condition and patient status, proved to be a primary predictor of ulcer development. No ulcers developed in the 69 patients whose Braden score was 16 or higher. The likelihood of developing a pressure sore was predicted mathematically from the Braden score. However, being underweight was a significant and distinct factor in pressure ulcer development. CONCLUSIONS: Pressure ulcers may develop within the first week of hospitalization in the intensive care unit. Patients at risk have Braden scores of < or = 16 and are more likely to be underweight. These results suggest that aggressive preventive care should be focused on those patients with Braden scores of < or = 13 and/or a low body mass index at admission.     

Colonization and infection in surgical intensive care patients —a prospective study

Nosocomial infections are a major problem in intensive care patients. Thirty-nine patients, requiring intensive care for 5 days or more (mean 15.8 days) were prospectively investigated, to determine the relation between colonisation and nosocomial infection. Thrice weekly, cultures from the oropharynx, respiratory and digestive tract were obtained. Colonization with aerobic gram-negative microorganisms of the oropharynx, respiratory and digestive tract significantly increased during the stay in the Intensive Care Unit. In 29 patients (74%) 78 nosocomial infections were diagnosed. The most frequent nosocomial infections were pneumonia (26 patients, 66.6%), catheterrelated bacteraemia (11 patients, 28.2%), and wound infections (7 patients, 17.9%). In 59 instances (75.6%), colonization with the same potential pathogenic microorganism preceeded the nosocomial infection. The overall mortality was 25.6% (10 patients), bacteraemia with aerobic gram-negative microorganisms being the cause of death in 7 patients.     

Nosocomial infections: prospective survey of incidence in five French intensive care units

Objective: To assess the incidence and to evaluate the feasibility of inter-unit continuous surveillance of intensive care unit (ICU)-acquired infections. Design: Prospective multicentre, longitudinal, incidence survey. Setting: Five ICUs in university hospitals in western France. Patients: All patients admitted to the ICU during two 3-month periods (1994–1995). Measurements and results: The main clinical characteristics of the patients, ICU-acquired infections, length of exposure to invasive devices and the micro-organisms isolated were analysed. The study included 1589 patients (16 970 patient-days) and the infection rate was 21.6 % (13.1 % of patients). The ventilator-associated pneumonia rate was 9.6 %, sinusitis 1.5 %, central venous catheter-associated infection 3.5 %, central venous catheter-associated bacteraemia 4.8 %, catheter-associated urinary tract infection 7.8 % and bacteraemia 4.5 %. The incidence density rate of ICU-acquired infections was 20.3 ‰ patient-days. Ventilator-associated pneumonia and sinusitis rates were 9.4 and 1.5 ‰ ventilation-days, respectively. Central venous catheter-associated infection and central venous catheter-associated bacteraemia rates were 2.8 and 3.8 ‰ catheter-days, respectively. The catheter-associated urinary tract infection rate was 8.5 ‰ urinary catheter-days and the bacteraemia rate 4.2 ‰ patient-days. Six independent risk factors for ICU-acquired infection were found by stepwise logistic regression analysis: absence of infection on admission, age > 60 years, length of stay, mechanical ventilation, central venous catheter and admission to one particular unit. A total of 410 strains of micro-organisms were isolated, 16.8 % of which were Staphylococcus aureus (58.0 % methicillin-resistant). Conclusion: This prospective study using standardised collection of data on the ICU-acquired infection rate in five ICUs identified six risk factors. It also emphasized the difficulty of achieving truly standardised definitions and methods of diagnosis of such infections. Received: 21 October 1997 Accepted: 4 June 1998     

Opening the doors of the intensive care unit to cancer patients: A current perspective

The introduction of new treatments for cancer and advances in the intensive care of critically ill cancer patients has improved the prognosis and survival. In recent years, the classical intensive care unit(ICU) admission comorbidity criteria used for this group of patients have been discouraged since the risk factors for death that have been studied, mainly the number and severity of organic failures, allow us to understand the determinants of the prognosis inside the ICU. However, the availability of intensive care resources is dissimilar by country, and these differences are known to alter the indications for admission to critical care setting. Three to five days of ICU management is warranted before making a final decision(ICU trial) to consider keep down intensive management of critically ill cancer patients. Nowadays, taking into account only the diagnosis of cancer to consider ICU admission of patients who need full-supporting management is no longer justified.