镇静镇痛集束化护理策略对脑创伤后机械通气患者谵妄的影响

 目的 评价镇静镇痛集束化护理对脑创伤后机械通气患者谵妄的影响。方法 便利抽样法选取2017-04至2018-04转入神经重症ICU行机械通气的脑创伤患者90例,常规护理的同时,行镇静镇痛集束化护理措施(干预组)。另选择90例机械通气的脑创伤患者,行常规护理,作为对照组。记录患者年龄、性别、ICU住院时间、APACHEⅡ评分、谵妄发生率、机械通气时间、谵妄类型及持续时间。结果 两组患者的年龄、性别、机械通气时间,以及APACHEⅡ评分差异无统计学意义,干预组在ICU的住院时间与对照组比较显著缩短[(12.86±3.24)d vs(16.24±2.63) d,P<0.05];与对照组相比,干预组谵妄发生率明显降低(52% vs 66%,P<0.05),谵妄持续时间显著缩短[(3.27±0.59)d vs (4.79±0.52) d,差异有统计学意义,(P<0.05)],谵妄构成类型无统计学差异(P＞0.05)。结论 应用镇静镇痛集束化护理可减少机械通气脑创伤患者的谵妄持续时间及ICU住院时间,并降低谵妄发生率。     

咪唑安定-异丙酚序贯给药对机械通气患者每日唤醒安全性的影响

目的 比较不同给药方案对机械通气患者镇静及每日唤醒过程中躁动与循环波动的影响,以寻找安全的镇静策略.方法 在5个临床中心选择ICU内接受机械通气时间超过24h的患者94例,在持续泵入芬太尼镇痛的基础上,随机给予咪唑安定(M组)、异丙酚(P组)或咪唑安定-异丙酚序贯用药(M P组)镇静,密切监测并维持躁动-镇静评分(SAS)在2～4分,每Et 9∶00时停止泵入所有镇静、镇痛药至完全唤醒.观察各组镇静及唤醒过程中血压及心率的波动、躁动情况、唤醒时间以及患者转出ICU后对镇静过程中与机械通气相关实际事件的记忆.结果 各组平均SAS评分无明显差异.M组唤醒时间较P组和M P组显著延长(P＜0.05).镇静过程中,3组患者血压、心率波动及躁动发生率均较低,但在唤醒过程中,各组血压、心率波动及躁动发生率均升高,与P组和M P组比较,M组升高更加显著(P＜0.05).与机械通气相关的翻身、吸痰、气管导管刺激等3项实际事件无记忆的发生率,P组、M组和M P组分别为16.7%、28.2%、36.7%.结论 咪唑安定、异丙酚及二者序贯用药均能达到良好镇静效果,序贯用药计划不仅能有效避免苏醒时间长、血压及心率波动、躁动等不安全因素,而且对机械通气相关实际事件的遗忘作用良好,是实施每日唤醒计划的一种较好的镇静策略.     

右美托咪啶联合布托啡诺对腹部外科术后机械通气患者镇静镇痛的效果

 目的 探讨右美托咪啶联合布托啡诺对腹部外科术后机械通气患者镇静镇痛的效果。方法 选取医院腹部外科术后机械通气患者60例,随机分为对照组和治疗组,各30例。对照组予咪达唑仑联合芬太尼进行镇静镇痛,治疗组予右美托咪啶联合布托啡诺镇静镇痛。比较两组患者用药前及用药后1 h的生命体征指标变化[心率(HR)、呼吸频率(RR)、平均动脉压(MAP)、血氧饱和度(SpO₂)],用药后4、8、16、24 h重症患者镇痛(CPOT)评分及躁动-镇静评分(RASS),药物起效时间、停药后拔管时间、停药后完全清醒时间、不良反应和谵妄发生率。结果 (1)用药后1 h,两组HR、RR、MAP均较用药前降低(P<0.05);(2)两组用药后4、8、16、24 h CPOT及RASS评分比较,差异无统计学意义(P＞0.05);(3)两组药物起效时间比较无统计学差异,但治疗组停药后拔管时间、停药后完全清醒时间[(112.3±18.6)、(43.8±7.6)min],均短于对照组[(175.1±20.4)、(116.2±27.3)min (P<0.01) ];(4)两组低血压、心动过缓发生率比较无统计学差异,但治疗组腹胀呕吐及谵妄发生率显著低于对照组(P<0.05)。结论 在腹部外科术后机械通气患者的镇静镇痛方面,右美托咪啶联合布托啡诺与咪达唑仑联合芬太尼的效果相近,但前者的谵妄、腹胀呕吐的发生率更低,安全性更好。     

以PIC窗为切换点治疗COPD所致呼吸衰竭的临床应用

目的:探讨PIC窗为切换点序贯治疗AECOPD所致呼吸衰竭患者的临床应用.方法:选择在ICU给予有创正压机械通气(IPPV)治疗的AECOPD患者30例作为序贯组,待患者出现肺部感染控制窗(PIC)后拔管,改为无创正压通气,(NIPPV)治疗,对照组为AECOPD合并呼衰的患者30例,常规有创机械通气治疗,比较两组患者又创通气时间、住院时间、VAP发生率、再插管率、病死率及住院费用.结果:序贯组与对照组比较,差异有统计学意义(P＜0.01).结论:PIC窗在AE-COPD所致呼吸衰竭患者序贯通气行有创-无创切换可降低再插管率,机械通气总时间以及ICU住院时间,具有重要的临床意义.     

序贯性血液净化治疗重度中毒48例疗效分析

 目的 探讨序贯性血液灌流(HP)与连续性静-静脉血液滤过(CVVH)对重度中毒患者的疗效.方法 在常规治疗的基础上,治疗组48例重度中毒患者行序贯性HP+CVVH治疗,对照组43例仅行HP治疗,观察两组昏迷至清醒时间、机械通气时间、平均住院天数、治愈率及病死率.结果 治疗组昏迷至清醒时间、机械通气时间与对照组比较明显减少(P＜0.05),平均住院天数缩短(P＜0.05),治愈率提高(P＜0.05),病死率降低(P＜0.05).结论 序贯性HP+CVVH治疗重度中毒优于单用HP治疗,能改善临床症状,有效提高抢救成功率,为临床救治各种重度中毒提供了新的方法.     

右美托咪定对舌癌术后机械通气患者的镇静效果

 目的 探讨右美托咪定对舌癌术后机械通气患者的镇静效果。方法 选取2015-06至2017-06收治的80例舌癌术后行机械通气的患者,随机分为对照组(42例)和治疗组(38例)。对照组予以咪达唑仑镇静治疗,治疗组予以右美托咪定镇静治疗。比较两组患者机械通气时间、气管导管带管时间、ICU住院时间等指标;比较两组患者术后0、4、8 h的心率(HR)、平均动脉压(MAP)、血氧饱和度(SaO₂)和动脉氧分压PaO₂等血流动力学指标及血气分析指标;比较两组术后4、8、12 h的RASS评分,以及机械通气治疗期间的不良反应发生情况。结果 手术后,治疗组机械通气时间、气管导管带管时间、ICU停留时间显著短于对照组(P<0.05或P<0.01)。术后4、8 h,两组HR、MAP、PaO₂水平均较同组0 h时有所改善,且治疗组4 h的HR、MAP显著优于对照组(P<0.05)。术后8、12 h,两组RASS评分均较术后4 h显著升高,治疗组术后8、12 h的RASS评分均显著高于对照组(P<0.05)。治疗组不良反应发生率为23.7%,对照组为26.2%。结论 将右美托咪定应用于舌癌术后患者维持镇静效果显著。     

肠内营养混悬液在重症胸部创伤患者中的早期应用

目的观察肠内营养混悬液(TPF-FOS)在重症胸部创伤患者早期肠内营养(EN)治疗中的疗效和安全性。方法 2010年1月～2012年1月,将收治的48例重症胸部创伤患者随机分成观察组和对照组,观察组于入住ICU 48 h内开始EN治疗(经鼻饲管给予TPF-FOS),对照组则在入住ICU 48 h后开始EN治疗,达到目标喂养量125.52 kJ(30 kcal)/(kg.d)至少3 d,观察患者入住ICU后1、3、5、7、10 d的血清蛋白水平、胃肠道不良反应发生率、机械通气时间、平均ICU住院时间等,并记录不良事件。结果早期EN支持后第7 d及第10 d,观察组血清前白蛋白水平明显优于对照组(P<0.05);第1 d至第10 d两组间血清白蛋白与转铁蛋白水平均无显著差异。两组间胃肠道反应发生率无显著差异,观察组的机械通气时间、平均ICU住院时间均少于对照组(P<0.05)。结论重症胸部创伤患者早期管饲TPF-FOS可使血清前白蛋白水平及早得到恢复,尽早改善患者的营养状态,缩短患者机械通气和ICU住院时间。     

早期气管切开对重型脑外伤的影响

目的 评价早期气管切开(early tracheostomy,ET)与晚期气管切开(late tracheostomy,LT)对重型脑外伤的影响.方法 回顾性分析2001年5月-2010年12月采用经皮扩张气管切开术(percutaneous dilational tracheostomy,PDT)行气管切开需长时间机械通气、GCS＜9分的重型脑外伤患者167例.依据口插管机械通气时间≤7d为ET组81例,＞7d为LT组86例,比较两组患者的临床基础特征、PDT前后机械通气时间、总机械通气时间、PDT后住ICU时间、ICU住院时间和住院时间以及死亡率.结果 两组在年龄、性别、急性生理和慢性健康状况评估Ⅱ(APACHEⅡ)评分、GCS评分、创伤指数和开颅手术率差异均无统计学意义(P＞0.05).ET组显著缩短了PDT前机械通气时间[(5.16±1.33)d∶(11.64±4.25)d,P＜0.01)]、PDT后机械通气时间(中位数15.0d∶17.0d,P＜0.05)、总机械通气时间(中位数18.0d∶26.0d,P＜0.05)以及PDT后住ICU时间(中位数16.0d∶21.0d,P＜0.01)和ICU住院时间(中位数21.0d∶32.0d,P＜0.01),两组住院时间差异无统计学意义(P＞0.05).两组ICU死亡率(17％∶14％,P＞0.05)和住院死亡率(25％∶28.4％,P＞0.05)差异均无统计学意义.Kaplan-Meier曲线显示ET组60d患者机械通气使用率和ICU住院率较LT组显著降低.结论 重型脑外伤患者行早期气管切开可缩短机械通气时间和ICU住院时间,但不影响患者的预后.对重型脑外伤患者可行早期气管切开.     

异丙酚在有ICU机磷农药中毒机械通气患者中的应用

目的 观察ICU有机磷农药中毒发生呼吸衰竭患者在机械通气期间使用异丙酚的镇静效果.方法 在ICU有机磷农药中毒发生呼吸衰竭使用呼吸机患者中随机选取42例,机械通气期间使用异丙酚镇静,观察用药前后患者心率、血压、呼吸、气道压力、氧合指数的变化并进行比较.结果 有机磷农药中毒患者发生呼吸衰竭进行机械通气时,使用异丙酚镇静能快速镇静,患者心率、血压、氧合指数、呼吸次数在用药后有明显改善(P<0.05).结论 异丙酚是ICU有机磷农药中毒呼吸衰竭患者使用机械通气时较为理想的镇静剂.     

集束化治疗急性呼吸窘迫综合征21例临床观察

目的:集束化治疗急性呼吸窘迫综合症(ARDS) 21例的临床观察.方法:采用与历史对照的前瞻性观察对照方法,纳入新疆兵团第二师焉耆医院ICU 23-65岁,符合1994年欧美联席会议ARDS诊断标准,以2011年3月-2014年2月收治的30例病人作为常规治疗对照组,以2014年3月-2017年12月收治的为前瞻性观察期21例病人作为集束化治疗组,集束化治疗组在积极治疗原发病的基础上采用集束化治疗,包括:限制性液体管理,呼吸支持治疗,大剂量沐舒坦联合血必净注射液治疗,呼吸机相关性肺炎(VAP)的预防,制定个体化镇静镇痛方案,重症患者应用连续性血液净化治疗,比较患者治疗5d后APACHEⅡ评分和氧合指数,以及患者机械通气时间,ICU住院时间,VAP发生率及28d死亡率.结果:两组患者性别、年龄、病因构成、病情严重程度等基础特征比较差异均无统计学意义(均P＞0.05),有可比性,与对照组比较,21例集束化治疗组治疗后APACHEⅡ评分无明显变化(P=0.11),氧合指数明显增加(P=0.03)机械通气时间明显缩短(P=0.02),VAP发生率明显下降(P=0.03),28d病死率明显降低(P=0.04),但集束化治疗组和对照组ICU住院时间差异无统计学意义(P=0.11).结论:集束化治疗干预能缩短ARDS患者的机械通气时间,减少VAP的发生率,改善预后.     

Changes in pCO2 during air medical transport of children with closed head injuries.

OBJECTIVES: Because low partial pressure of carbon dioxide (pCO2) can be associated with posttraumatic cerebral ischemia, we conducted a study to determine whether the pCO2 level in ventilated children with closed head injuries transported by a trained team to tertiary care was optimally maintained during transport and determine whether hand-bagging or mechanical ventilation resulted in more optimal pCO2 levels after transport. METHODS: We reviewed the hospital charts and transport records of all infants and children who had sustained a head injury and were transported by a specialized pediatric transport paramedic team to a single tertiary care facility during a 12-month period. All children were intubated and ventilated either mechanically or manually. Outcome measures were final pCO2 before transport and first pCO2 on arrival in the PICU. RESULTS: Twenty-nine children (age 0.6 to 16 years, mean 7.3, median 6) met the criteria. Fourteen patients were hand-bagged (HB), and 15 were mechanically ventilated (MV). Eleven patients (5 HB and 6 MV) started in the target pCO2 range of 35 to 40 mmHg. After transport, nine patients (all MV) had pCO2 within the target range (P < 0.01). Duration of transport (mean 63 minutes, range 15-200 minutes) did not contribute to the final pCO2 level. CONCLUSION: MV improves management of pCO2 during interfacility transport. HB significantly increases the incidence of suboptimal pCO2 and hence the risk of suboptimal cerebral blood flow. MV appears mandatory, and monitoring CO2 in transit (end-tidal or preferably point-of-care testing) should further reduce the likelihood of secondary complications from cerebral ischemia.     

盐酸右美托咪定对老年髋部骨折患者术后谵妄的影响

 目的 探讨盐酸右美托咪定对老年髋部骨折患者术后谵妄的影响。方法 选择在腰硬联合麻醉下择期行股骨粗隆间骨折髓内钉固定术81例,股骨颈骨折闭合复位内固定术55例,随机将患者分为盐酸右美托咪定组(69例)和对照组(67例),前者入ICU后20 min内给予盐酸右美托咪定持续静脉泵入,后者在相同时间内应用等量生理盐水,记录术后不同时点患者静脉自控镇痛(PCIA)应用情况,根据目测疼痛评分法(VAS)进行疼痛评分,记录Ramsay镇静评分,采用精神错乱评估法(CAM-ICU)诊断谵妄,观察谵妄发生率。结果 两组患者在入ICU即刻、术后6 h、12 h,静脉自控镇痛泵的总按压次数、有效按压次数、用药量、SpO₂和术后疼痛评分比较,差异均无统计学意义;盐酸右美托咪定组患者术后6 h、12 h心率和平均动脉压低于对照组,镇静评分高于同时间点对照组,盐酸右美托咪定组术后8~12 h CRP值低于对照组,6 h及12 h内睡眠时间长于对照组,差异均有统计学意义(P＜0.05);盐酸右美托咪定组术后12 h内出现谵妄7例(10.14%),对照组20例(29.85%),盐酸右美托咪定组谵妄发生率低于对照组,差异有统计学意义(P＜0.05)。结论 术后静脉持续输注盐酸右美托咪定可降低老年髋部骨折患者术后12 h内谵妄的发生率。     

Changes in pCO2 during Air Medical Transport of Children with Closed Head Injuries

Objectives: Because low partial pressure of carbon dioxide (pCO₂) can be associated with posttraumatic cerebral ischemia, we conducted a study to determine whether the pCO₂ level in ventilated children with closed head injuries transported by a trained team to tertiary care was optimally maintained during transport and determine whether hand-bagging or mechanical ventilation resulted in more optimal pCO₂ levels after transport. Methods: We reviewed the hospital charts and transport records of all infants and children who had sustained a head injury and were transported by a specialized pediatric transport paramedic team to a single tertiary care facility during a 12-month period. All children were intubated and ventilated either mechanically or manually. Outcome measures were final pCO₂ before transport and first pCO² on arrival in the PICU. Results: Twenty-nine children (age 0.6 to 16 years, mean 7.3, median 6) met the criteria. Fourteen patients were hand-bagged (HB), and 15 were mechanically ventilated (MV). Eleven patients (5 HB and 6 MV) started in the target pCO₂ range of 35 to 40 mmHg. After transport, nine patients (all MV) had pCO₂ within the target range (P < 0.01). Duration of transport (mean 63 minutes, range 15-200 minutes) did not contribute to the final pCO₂ level. Conclusion: MV improves management of pCO₂ during interfacility transport. HB significantly increases the incidence of suboptimal pCO₂ and hence the risk of suboptimal cerebral blood flow. MV appears mandatory, and monitoring CO₂ in transit (end-tidal or preferably point-of-care testing) should further reduce the likelihood of secondary complications from cerebral ischemia.     

Bispectral index monitoring for conscious sedation in intervention: better, safer, faster

AIM: The aim of this study was to compare subjective (Ramsay sedation score, RSS) with objective electroencephalogram-based bispectral index (BIS) assessment, and to validate the appropriate BIS range for measurement of conscious sedation in interventional procedures. MATERIALS AND METHODS: One hundred patients undergoing sedo-analgesia (midazolam and fentanyl) for interventional gastrointestinal procedures were divided into two groups. In group A (n=30) sedation was guided by the RSS with the operator blinded to the BIS recording. In group B (n=70) the operator titrated intravenous sedation to maintain an optimal BIS, predetermined from the results in group A. Recovery time, procedure duration, physiological parameters and unplanned events were recorded in both groups. RESULTS: There was a significant correlation between the BIS and RSS (p<0.001). BIS values of 87.2 and 80.9 corresponded to an RSS of 3 and 4, respectively. The optimal BIS level was defined as 80-85. Fifty-seven point five percent of readings were within this range in group B compared with 26.5% in group A (p<0.001). Sedation approaching general anaesthesia (BIS<60) occurred in 5.5% of patients in group A but not in group B. Mean recovery time, duration of procedure, midazolam and fentanyl doses were significantly reduced in group B. Unplanned events were reduced from 27 to 17%, but this was not statistically significant (p=0.29). CONCLUSION: BIS monitoring enables more effective titration of sedatives to maintain a suitable level of consciousness, whilst reducing procedure time. The BIS offers an objective, safe and reliable measure of sedation, without disturbing either patient or operator. BIS monitoring raises the standard of patient care, and in our view, should be used to augment standard assessment.     

Sedation procedures in MR imaging: safety, effectiveness, and nursing effect on examinations

PURPOSE: To measure the safety and effectiveness of conscious sedation in order to assess utilization and the effect on magnetic resonance (MR) imaging examinations. MATERIALS AND METHODS: A database of conscious sedation records for MR imaging at the Johns Hopkins Hospital, Baltimore, Md, from 1991 to 1998 was searched. Safety data according to medication and procedure duration for each nurse were tabulated for 6,093 patient records. Data were analyzed by using quality control statistical measures to determine time utilization and effectiveness. Break-even costs for the procedure were determined. RESULTS: Of 6,093 patients scheduled for examination, 4,761 patients (78.1%) received conscious sedation by the MR conscious sedation service. Complications were observed in 20 of the 4,761 patients (0.42%). No deaths occurred. The most common complication was oxygen desaturation (n = 8). Diagnostic and complete MR examinations were performed in 4,453 of the 4,761 patients (93.5%). The mean time to sedate the patient (+/- SD) was 23.6 minutes +/- 15.2 for specialized MR sedation nurses and 26.8 minutes +/- 20.1 for general radiology nurses (P: <.001). For inpatient nurses from the inpatient hospital units, the sedation time was considerably longer (47.3 minutes +/- 36.6, P: <.001) and more variable. Break-even costs were 37% ($11 vs $8 for MR room time) more for general radiology nurses than for specialized MR sedation nurses performing the procedure. CONCLUSION: Conscious sedation is safe and has a high effectiveness rate. A highly specialized nursing staff reduces procedure variability and cost.     

重症患者转运中不良事件原因分析

目的：分析重症患者转运时不良事件发生情况,为重症患者安全转运提供依据。方法收集我院2010年1月-2013年12月急性生理学及慢性健康状况评分系统（acute physiology and chronic health evaluation,APACHE）Ⅱ评分≥15分转运患者369例,其中重症医学科参与转运158例。确定转运不良事件标准为到达目的地时：心率变化≥30%;收缩压＜90 mmHg,调整治疗5 min后血压仍不能恢复者;出现严重缺氧并经皮氧饱和度≤80%者;需要紧急气管插管及心肺复苏者;入科30 min内死亡者。计算不良事件发生率。结果不良事件出现13例,发生率为3.5%。主要为缺氧、循环不稳定、不适宜搬动状态下转运等因素导致转运不良事件的发生。而重症医学科参与转运未发生不良事件,其中包括空中转运3例（飞行时间＞2 h）、长途转运（路程10 h以上）3例。结论转运前必须经过认真评估,做好充分转运准备,对可能的突发事件要有处理预案。经过转运培训,有经验的医护人员参与转运可减少不良事件的发生。     

Conscious sedation for endoscopic and non-endoscopic interventional gastrointestinal procedures: meeting patients' expectations, missing the standard

AIM: To assess the level of sedation, patient satisfaction and frequency of unplanned events with conscious sedation for interventional procedures. MATERIALS AND METHODS: One hundred and seventeen patients were assessed prospectively before, during and after procedures. Blood pressure, pulse, oxygen saturation and sedation level were monitored and patients followed up after 24 h. Sedation was scored after drugs were given in accordance with an established protocol. Doses were recorded, as were patients' weight, age and ASA grade and any unplanned events and their management. RESULTS: Seventy-six of the 117 patients (65%) had no unplanned event, 20 (17.1%) became agitated, 15 (12.8%) hypotensive, three (2.6%) hypoxic and three (2.6%) had more than one response. Twelve patients required active management. Fifty-two (44.4%) had a sedation level of 相似文献   

不同镇痛镇静方法对急性呼吸窘迫综合征病人心脏功能的影响

目的探讨不同镇痛镇静方法对急性呼吸窘迫综合征（ARDS）机械通气病人心脏功能的早期影响。方法对我院59例ARDS患者机械通气治疗时随机分为3组,分别采用改良冬眠合剂行持续镇静镇痛治疗21例（Ⅰ组）、力月西及芬太尼持续镇静镇痛治疗19例（Ⅱ组）、力月西和芬太尼或吗啡等间断镇痛镇静19例（Ⅲ组）,监测各组血液动力学和心肌酶学改变,并进行对比分析。结果 3组入ICU时体重、急性生理和慢性健康状态评分（APACHEⅡ）、氧合指数（O I）、血液动力学、心肌酶谱指标均无显著差异（P〉0.05）。在治疗24 h后,血液动力学指标均有明显改善（P〈0.05）,但Ⅰ、Ⅱ组改善幅度相似（P〉0.05）,且均较Ⅲ组更明显（P〈0.05）。心肌损伤的相关酶学均有不同程度变化,Ⅰ、Ⅱ组LDH、Mb均有下降（P〈0.05）,而CK-MB和Tn-T仅略有上升（P〉0.05）,Ⅲ组Mb、Tn-T、CK-MB及ASL仍然有明显升高（P〈0.05）。结论镇静镇痛有利于保护ARDS病人心功能,持续镇静镇痛可能是更好的方法。