ICU机械通气患者肺复张术的临床应用

目的探讨肺复张术对机械通气患者血压、血氧饱和度(SaO2)的影响及临床效果。方法选择2008年2月至2009年8月38例实施肺复张术患者,分析其复张效果、肺复张术的不良反应等。肺复张采取固定驱动压、逐渐增加呼气末正压(PEEP)的方法,所有肺复张患者均进行有创动脉血压监测。结果 38例患者进行了162次肺复张术,其中2例慢性阻塞性肺病急性加重(AECOPD)患者发生气胸,肺复张总有效率90%。肺复张中有效PEEP变化较大,最低6 cm H2O(1 cm H2O=0.098 kPa),最高30 cm H2O;SaO2维持最短0.5 h,最长126 h;平均每例患者接受4.26次,其中有1例患者最多接受8次肺复张术。18例(47%)患者在肺复张中曾经发生过低氧血症,162次肺复张术中发生72次(44%)低氧血症;开始诱发低氧血症的最低PEEP为6 cm H2O,最高为20 cm H2O,平均13.0 cm H2O。21例(55%)患者肺复张中曾发生过血压短暂降低,162次肺复张中有68次(41%)血压短暂降低;开始出现血压下降的最低PEEP为6 cm H2O,最高为21cm H2O,平均13.5 cm H2O。结论肺复张术可以有效改善SaO2,PEEP的设定应遵循个体化的原则。     

Hemodynamic changes during discontinuation of mechanical ventilation in medical intensive care unit patients.

BACKGROUND: Cardiac dysfunction can prevent successful discontinuation of mechanical ventilation. Critically ill patients may have undetected cardiac disease, and cardiac dysfunction can be produced or exacerbated by underlying pathophysiology. OBJECTIVE: To describe and compare hemodynamic function and cardiac rhythm during baseline mechanical ventilation with function and rhythm during a trial of continuous positive airway pressure in medical intensive care patients. METHODS: A convenience sample of 43 patients (53% men; mean age 51.1 years) who required mechanical ventilation were recruited for this pilot study. Cardiac output, stroke volume, arterial blood pressure, heart rate, cardiac rhythm, and plasma catecholamine levels were measured during mechanical ventilation and during a trial of continuous positive airway pressure. RESULTS: One third of the patients had difficulty discontinuing mechanical ventilation. Successful patients had significantly increased cardiac output and stroke volume without changes in heart rate or arterial pressure during the trial of continuous positive airway pressure. Unsuccessful patients had no significant changes in cardiac output, stroke volume, or heart rate but had a significant increase in mean arterial pressure. The 2 groups of patients also had different patterns in ectopy. Concurrently, catecholamine concentrations decreased in the successful patients and significantly increased in the unsuccessful patients during the trial. CONCLUSIONS: Patterns of cardiac function and plasma catecholamine levels differed between patients who did or did not achieve spontaneous ventilation with a trial of continuous positive airway pressure. Cardiac function must be systematically considered before and during the return to spontaneous ventilation to optimize the likelihood of success.     

机械通气患者发生谵妄的影响因素分析

目的 探讨ICU机械通气患者发生谵妄的影响因素,并对其发生风险进行预测。方法 收集2016年6月—2017年6月转入综合ICU的患者资料,用Logistic回归模型分析机械通气患者谵妄发生的危险因素,采用ROC曲线计算危险因素的曲线下面积及最佳截断值。结果共纳入398例患者,ICU机械通气患者发生谵妄163例,发生率为41.0%。Logistic回归模型结果显示,使用约束（OR=3.084）、镇静药（OR=2.255）、机械通气时长（OR=1.146）和入住ICU时长（OR=1.111）是ICU机械通气患者谵妄发生的独立预测因子。ROC曲线结果显示,使用约束、镇静药、机械通气时长、入住ICU时长的曲线下面积分别为0.580、0.566、0.787和0.774,其中机械通气时长和ICU时长的最佳截断值分别为7d和8d。结论ICU机械通气患者谵妄发生率仍处于较高水平,使用约束、镇静药、机械通气时长＞7d和入住ICU时长＞8d易诱发谵妄。     

Weaning from mechanical ventilation in pediatric intensive care patients

Objective: The development of weaning predictors in mechanically ventilated children has not been sufficiently investigated. The purpose of this study was to evaluate the accuracy of some weaning indices in predicting weaning failure. Design: Prospective, interventional study. Setting: University-affiliated children's hospital with a 19-bed intensive care unit. Patients: 84 consecutive infants and children requiring mechanical ventilation for at least 48 h and judged ready to wean by their primary physicians. Interventions: Patients who met the criteria to start weaning underwent a trial of spontaneous breathing lasting up to 2 h. Bedside measurements of respiratory function were obtained immediately before discontinuation of mechanical ventilation and within the first 5 min of spontaneous breathing. The primary physicians were blinded to those measurements, and the decision to extubate a patient at the end of the spontaneous breathing trial or reinstitute mechanical ventilation was made by them. Failure to wean was defined as the requirement for mechanical ventilation at any time during the trial of spontaneous breathing (trial failure) or needing reintubation within 48 h of extubation (extubation failure). Measurements and main results: Seventy-five patients had neither signs of respiratory distress nor deterioration in gas exchange during the trial and were extubated. Twelve patients required reintubation within 48 h. In 9 patients, mechanical ventilation was reinstituted after a median duration of the spontaneous breathing trial of 35 min. The only independent predictor of trial failure was tidal volume indexed to body weight [odds ratio 2.60, 95 % confidence interval (CI) 1.40 to 24.9]. The only independent predictor of extubation failure was frequency-to-tidal volume ratio indexed to body weight (odds ratio 1.23, 95 % CI 1.11 to 1.36). The sensitivity, specificity, and positive and negative predictive values to predict weaning failure were calculated for each of the above variables. These values were 0.48, 0.86, 0.53, and 0.83, respectively, for a frequency-to-tidal volume ratio higher than 11 breaths/min per ml per kg and 0.43, 0.94, 0.69, and 0.83, respectively, for a tidal volume lower than 4 ml/kg. Conclusions: Three-quarters of ventilated children can be successfully weaned after a trial of spontaneous breathing lasting 2 h. Both tidal volume and frequency-to-tidal volume ratio indexed to body weight were poor predictors of weaning failure in the study population. Received: 20 February 1998 Accepted: 10 June 1998     

Psychiatric patients' intensive care admission characteristics,weaning from mechanical ventilation and sedative drug use: A single center retrospective case-control study

PurposeTo describe the characteristics, treatment and outcome, in particular weaning from mechanical ventilation (MV), of critically ill Patients with prior psychiatric conditions (PPC).MethodsSingle center, 6-year, retrospective study comparing critically ill PPC to randomly sex and age matched cohort without PPC (1:1 ratio). Main outcome measure- adjusted mortality rates. Secondary outcome measures- unadjusted mortality, rates of MV, extubation failure and amount/dose of pre-extubation sedatives/analgesics.ResultsIncluded were 214 patients per group. PPC adjusted mortality rates were higher in the ICU (14.0% vs 4.7%; OR 3.058 [95%CI 1.380, 6.774]; p = 0.006) and in-hospital (26.6% vs 13.1%; OR 2.639 [95% CI 1.496, 4.655]; p = 0.001). PPC had higher MV rates (63.6% vs 51.4%; p = 0.011). These patients were more likely to have more than two weaning attempts (29.4% vs 10.9%; p < 0.001), more commonly treated with >2 sedative drugs in the 48-h pre-extubation (39.2% vs 23.3%; p = 0.026) and received more propofol in the 24-h pre-extubation. PPC were more likely to self-extubate (9.6% vs 0.9%; p = 0.004) and had lower likelihood of success in planned extubations (50.0% vs 76.4%; p < 0.001).ConclusionCritically ill PPC had higher mortality rates than their matched counterparts. They also had higher MV rates and were more difficult to wean.     

右美托咪定与咪达唑仑在机械通气 重症患者镇静治疗中的比较研究

目的 观察右美托咪定与咪达唑仑用于重症加强治疗病房(ICU)机械通气患者的镇静镇痛效果及成本-效益分析.方法 采用前瞻性随机对照临床研究,选择2014年1月至10月贵阳医学院附属医院ICU气管插管接受机械通气(24 h<机械通气时间<72 h)同时需要镇静镇痛治疗的患者80例,将患者按随机数字表法分为咪达唑仑组(39例)和右美托咪定组(41例).两组均静脉持续泵入芬太尼0.7~1.5μg·kg-1·h-1镇痛治疗,镇痛目标为重症监护疼痛观察工具(COPT)评分0~3分,每小时进行1次疼痛评分,当COPT评分> 4分时追加芬太尼用量0.5μg/kg.达到镇痛目标后给予镇静治疗,其中咪达唑仑组给予咪达唑仑,2 min静脉推注0.05 mg/kg负荷量,之后静脉泵入0.03~0.30 mg·kg-1·h-1;右美托咪定组给予右美托咪定,20 min缓慢静脉泵入0.5~1.0μg/kg负荷量,之后持续泵入0.2~0.7μg·kg-1·h-1;每小时进行1次镇静评分,躁动镇静评分量表(RASS)>0分时增加镇静药物用量,RASS<-2分时减少或停用镇静药物用量.在此过程中,观察患者心率、血压、镇静镇痛药物用量、机械通气时间、拔管时间、入住ICU时间、使用镇静药物总费用、使用芬太尼总费用、入住ICU总费用及不良反应.结果 右美托咪定组使用镇静镇痛药物总量(mg/kg:0.03±0.01比3.35±1.39)、每小时镇静镇痛药物使用量(μg·kg-1·h-1:0.66±0.13比59.78±19.44)、芬太尼用量(μg·kg-1·h-1:0.40±0.21比0.57±0.26)、每小时使用芬太尼总费用(元:1.41±0.86比2.00±0.84)、每小时ICU总治疗费(元:264.42±99.55比297.80±138.70)均较咪达唑仑组明显减少(均P<0.05);每小时使用镇静药物总费用较咪达唑仑组明显增加(元:8.97±5.05比7.78±4.22);机械通气时间〔h:43.58(39.83,53.58)比58.58(46.17, 65.50)〕、拔管时间〔h:1.00(1.67,0.58)比3.67(2.00,5.50)〕、入住ICU时间〔h:57.25(47.33,67.37)比75.58 (64.67,90.83)〕 均较咪达唑仑组缩短(均P<0.05);不良反应发生率较咪达唑仑组增高〔低血压:29.27%(12/41)比7.69%(3/39)、心动过缓:24.39%(10/41)比5.13%(2/39),均P<0.05〕;谵妄发生率较咪达唑仑组降低〔2.43%(1/41)比15.38%(6/39),P<0.05〕.结论 右美托咪定用于ICU患者镇静效果良好,可缩短机械通气时间、拔管时间及入住ICU时间,减少镇痛药物的使用量,降低ICU的治疗费用,是较为理想的镇静药物.     

Low melatonin excretion during mechanical ventilation in the intensive care unit

Biochemical markers for the circadian rhythm were studied in patients treated at the ICU (intensive care unit) of two regional hospitals. A normal rhythm is characterized by a relatively higher melatonin and a lower cortisol excretion at night. Disturbances affect sleep, mood and cognitive performance. All urine excreted between 07:00 and 22:00 hours (day) and between 22:00 and 07:00 hours (night) was collected and sampled throughout the entire ICU period (median, 10 days) in 16 patients for the excretion of 6-SMT (6-sulphatoxymelatonin), which is a metabolite of melatonin, and free cortisol. The overall excretion of 6-SMT was slightly lower and the cortisol excretion higher than reported for healthy reference populations. Mechanical ventilation was associated with a markedly lower 6-SMT excretion (median, 198 ng/h) compared with periods without such help (555 ng/h; P<0.0001), whereas infusion of adrenergic drugs increased the 6-SMT excretion (P<0.01). Five patients (31%) showed a virtually absent melatonin excretion for 24 h or more. The diurnal rhythms were consistently or periodically disturbed in 65% and 75% of the patients. These alterations cannot be explained by excessive exposure to light at night. In conclusion, there was hyposecretion of melatonin during mechanical ventilation, an overall high cortisol excretion and a disturbed diurnal rhythm of both of these hormones in most patients treated in two ICU departments.     

ICU患者在机械通气中应用异丙酚镇静的观察与护理

目的观察异丙酚在ICU机械通气患者的镇静效果及护理.方法选择40例在ICU接受气管插管、机械通气患者按住院号单双分成2组,观察组20例在上机后使用异丙酚,对照组20例给与其它镇静剂,观察2组机械通气时间、在ICU住院的时间.结果观察组的机械通气时间、在ICU住院时间,明显少于对照组(P＜0.01,P＜0.05).结论异丙酚用于ICU机械通气患者的镇静不仅能安全有效镇静,而且能减少机械通气时间和在ICU住院时间,使用异丙酚应严格无菌技术操作以防止发生医源性感染.     

ICU患者在机械通气中应用异丙酚镇静的观察与护理

目的观察异丙酚在ICU机械通气患者的镇静效果及护理.方法选择40例在ICU接受气管插管、机械通气患者按住院号单双分成2组,观察组20例在上机后使用异丙酚,对照组20例给与其它镇静剂,观察2组机械通气时间、在ICU住院的时间.结果观察组的机械通气时间、在ICU住院时间,明显少于对照组（P＜0.01,P＜0.05）.结论异丙酚用于ICU机械通气患者的镇静不仅能安全有效镇静,而且能减少机械通气时间和在ICU住院时间,使用异丙酚应严格无菌技术操作以防止发生医源性感染.     

Qualitative analysis of patients’ intensive care experience during mechanical ventilation

Aim. To understand patients’ intensive care experience while receiving mechanical ventilation in intensive care units. Background. The mechanically ventilated patient’s experience in the intensive care unit is unique. Notably lacking are international studies on patients’ experience, particularly those living in Asia. A better understanding of patients’ experience is needed for nurses to develop approaches to take care of these patients. Design. A phenomenological approach formed by the ideas of Heidegger was used. Methods. Eleven participants surviving from mechanical ventilation were interviewed in‐depth. Patients were asked to describe their experience by responding to the question ‘what is it like to experience mechanical ventilation treatment at an ICU?’. Giorgi’s phenomenological analysis procedure was used to analyse the data. Results. Five mutually exclusive themes emerged, which were: ‘being in an unconventional environment’, ‘physical suffering’, ‘psychological suffering’, ‘self‐encouragement’ and ‘self‐reflection’. ‘Self‐encouragement’ and ‘self‐reflection’ enhanced patients’ self‐confidence, which was beneficial to recovering. Conclusion. Patient’s experiences while receiving mechanical ventilation in the intensive unit were poignant and frightening. Relevance to clinical practice. Critical care nurses should place the highest priority on recognising and meeting the needs of ventilated patients in intensive care units. An intensive care unit should be a place for the patient to live as a human being; not just a place to survive.     

右美托咪啶与咪达唑仑用于外科重症监护病房术后机械通气患者镇静的比较研究

目的 研究右美托咪定和咪达唑仑用于外科重症监护病房(SICU)术后机械通气(MV)患者的镇静效果及安全性。方法 选择术后带气管导管人SICU行呼吸机辅助通气患者200例,按随机数字表法分为两组,分别给予咪达唑仑（98例）和右美托咪定(102例)镇静治疗,两组均常规给予芬太尼持续静脉泵入镇痛,根据Prince-Henry镇痛评分调整芬太尼剂量,使疼痛评分维持在1～2分;根据Riker镇静和躁动评分(SAS)调整镇静药剂量,使镇静深度评分控制在2～4分;连续监测记录呼吸机参数、心电图、心率、血压、呼吸、脉搏血氧饱和度,并进行血气分析。观察记录两组药物用量,MV时间,以及低血压、心动过缓、谵妄、恶心等副作用发生率。结果 右美托咪定与咪达唑仑均能使患者达到镇静及镇痛目标评分,右美托咪定组更易唤醒并保持安静。与咪达唑仑组比较,右美托咪定组芬太尼用量(μg．kg-1· h-1)明显减少（0.23±0.13比0.41±0.12,P＜0.01）,MV时间(h)明显缩短(7.20±6.29比12.44±8.96,P＜0.01),低血压发生率(27.45％比11.22％)和心动过缓发生率(24.51％比10.20％)明显升高(均P＜0.05),谵妄发生率明显降低（3.92％比31.63％,P＜0.01）,恶心发生率降低(9.80％比11.22％,P＞0.05)。将右美托咪啶组按是否发生低血压再分为两个亚组分析：低血压与非低血压组间术中失血量(ml/kg)、术中输液量(ml．kg-1．h-1)、术后当日及术后1d血乳酸含量(mmol/L)比较差异无统计学意义（术中失血量：12.79±12.13比13.52±11.62;术中输液量：11.91±4.59比13.09±7.05;术后当日乳酸含量：1.88±1.07比1.71±0.87,术后1d乳酸含量：1.43±0.98比1.37±0.79,均P＞0.05）。结论 右美托咪定用于外科术后MV患者镇静效果满意,易唤醒,谵妄发生率低,可缩短MV时间,减少芬太尼用量约50％,是一种较为理想的SICU镇静剂。但要加强用药期间的监测,防治低血压和心动过缓。     

Post-ICU consequences of patient wakefulness and sedative exposure during mechanical ventilation

Objective To determine the relationship between measures of critical illness (sedative/analgesic administration, wakefulness and organ dysfunction), intensive care unit (ICU) recall and symptoms of posttraumatic stress disorder. Design Prospective, observational study with post-ICU follow-up. Setting Medical and surgical ICUs at a teaching hospital. Patients Two hundred seventy-seven subjects requiring > 36 h of mechanical ventilation were enrolled; 149 completed follow-up interviews 2 months later and 80 at 6 months. Interventions None. Results ICU recall was greater for events occurring at the end of critical illness; however, 18% of subjects had amnesia for the entire ICU course. Factual ICU recall was weakly associated with increased wakefulness during mechanical ventilation (r ² = 0.03–0.11, p< 0.05). Posttraumatic stress disorder prevalence was 17% at 2 months and 15% at 6 months. The avoidance-numbing cluster had the highest specificity (91%) for a formal diagnosis and the re-experiencing cluster had the lowest (69%). Recall of a delirious memory during critical illness was associated with more severe posttraumatic stress symptoms, but there was no association between posttraumatic stress symptoms and factual recall of ICU events. Neither ICU recall nor posttraumatic stress symptoms were associated with the intensity of sedative administration during mechanical ventilation. Posttraumatic stress symptoms were lowest in patients either the most awake during mechanical ventilation or the least awake. Conclusion Wakefulness during mechanical ventilation has a greater influence on post-ICU recall and posttraumatic stress symptoms than sedative drug exposure or severity of illness. It is difficult to predict the future psychological consequences of an individual patient's critical illness. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users. Work supported by a grant from the National Institutes of Health to C. R. W.     

Education on invasive mechanical ventilation involving intensive care nurses: a systematic review

Background

Intensive care unit nurses are critical for managing mechanical ventilation. Continuing education is essential in building and maintaining nurses' knowledge and skills, potentially improving patient outcomes.

Aims

The aim of this study was to determine whether continuing education programmes on invasive mechanical ventilation involving intensive care unit nurses are effective in improving patient outcomes.

Methods

Five electronic databases were searched from 2001 to 2016 using keywords such as mechanical ventilation, nursing and education. Inclusion criteria were invasive mechanical ventilation continuing education programmes that involved nurses and measured patient outcomes. Primary outcomes were intensive care unit mortality and in‐hospital mortality. Secondary outcomes included hospital and intensive care unit length of stay, length of intubation, failed weaning trials, re‐intubation incidence, ventilation‐associated pneumonia rate and lung‐protective ventilator strategies. Studies were excluded if they excluded nurses, patients were ventilated for less than 24 h, the education content focused on protocol implementation or oral care exclusively or the outcomes were participant satisfaction. Quality was assessed by two reviewers using an education intervention critical appraisal worksheet and a risk of bias assessment tool. Data were extracted independently by two reviewers and analysed narratively due to heterogeneity.

Results

Twelve studies met the inclusion criteria for full review: 11 pre‐ and post‐intervention observational and 1 quasi‐experimental design. Studies reported statistically significant reductions in hospital length of stay, length of intubation, ventilator‐associated pneumonia rates, failed weaning trials and improvements in lung‐protective ventilation compliance. Non‐statistically significant results were reported for in‐hospital and intensive care unit mortality, re‐intubation and intensive care unit length of stay.

Conclusion

Limited evidence of the effectiveness of continuing education programmes on mechanical ventilation involving nurses in improving patient outcomes exists. Comprehensive continuing education is required.

Relevance to clinical practice

Well‐designed trials are required to confirm that comprehensive continuing education involving intensive care nurses about mechanical ventilation improves patient outcomes.

     

The effect of music on delirium,pain, sedation and anxiety in patients receiving mechanical ventilation in the intensive care unit

ObjectivesTo examine the effects of music for patients under mechanical ventilation support in the intensive care unit on their delirium, pain, sedation, and anxiety.Research methodology/designA single-blind, randomized, controlled trial.SettingThe study was conducted with delirium positive patients between August 2020 and September 2021 in the medical/surgical intensive care unit of a university hospital in Turkey.MethodsThe study sample was selected through a simple and stratified randomization method; patients who met the inclusion criteria were assigned to the music, noise reduction or control group. The data were collected by using a Confusion Assessment Method for the ICU (CAM-ICU), CAM-ICU-7, Critical Care Pain Observation Tool (CPOT), Richmond Agitation-Sedation Scale (RASS), Facial Anxiety Scale (FAS), PRE-DELIRIC model, and Glasgow Coma Scale (GCS). The interventions were repeated twice a day for five days.ResultsA total of 36 patients were included, with 12 patients in each group. Significant decreases were found in the severity of delirium and pain and the level of sedation and anxiety in the music compared to the other groups (p < 0.05). The number of patients with delirium and the number of days with mechanical ventilation was found to be significantly lower in the music group compared to the other groups (p < 0.05).ConclusionMusic intervention may be used as a nursing intervention to control delirium, pain, need for sedation and anxiety in intensive care unit patients. However, additional studies with larger sample is needed to validate findings.     

Decisions made by critical care nurses during mechanical ventilation and weaning in an Australian intensive care unit.

BACKGROUND: Responsibilities of critical care nurses for management of mechanical ventilation may differ among countries. Organizational interventions, including weaning protocols, may have a variable impact in settings that differ in nursing autonomy and interdisciplinary collaboration. OBJECTIVE: To characterize the role of Australian critical care nurses in the management of mechanical ventilation. METHODS: A 3-month, prospective cohort study was performed. All clinical decisions related to mechanical ventilation in a 24-bed, combined medical-surgical adult intensive care unit at the Royal Melbourne Hospital, a university-affiliated teaching hospital in Melbourne, Victoria, Australia, were determined. RESULTS: Of 474 patients admitted during the 81-day study period, 319 (67%) received mechanical ventilation. Death occurred in 12.5% (40/319) of patients. Median durations of mechanical ventilation and intensive care stay were 0.9 and 1.9 days, respectively. A total of 3986 ventilation and weaning decisions (defined as any adjustment to ventilator settings, including mode change; rate or pressure support adjustment; and titration of tidal volume, positive end-expiratory pressure, or fraction of inspired oxygen) were made. Of these, 2538 decisions (64%) were made by nurses alone, 693 (17%) by medical staff, and 755 (19%) by nurses and staff in collaboration. Decisions made exclusively by nurses were less common for patients with predominantly respiratory disease or multiple organ dysfunction than for other patients. CONCLUSIONS: In this unit, critical care nurses have high levels of responsibility for, and autonomy in, the management of mechanical ventilation and weaning. Revalidation of protocols for ventilation practices in other clinical contexts may be needed.     

Autonomic tone in medical intensive care patients receiving mechanical ventilation and during a CPAP weaning trial

Mechanical ventilator support and the resumption of spontaneous ventilation or weaning create significant alterations in alveolar and intrathoracic pressure that influence thoracic blood volume and flow. Compensatory autonomic tone alterations occur to ensure adequate tissue oxygen delivery, but autonomic responses may produce cardiovascular dysfunction with subsequent weaning failure. The authors describe autonomic responses of critically ill patients (n = 43) during a 24-hr period of mechanical ventilatory support and during the 24 hr that included their initial spontaneous breathing trial using continuous positive airway pressure. Nearly two thirds of these patients demonstrated abnormal autonomic function and this dysfunction was more severe in those patients who were unable to sustain spontaneous ventilation (n = 15). With further systematic study, autonomic responses may be useful in the identification of patients who are likely to develop cardiac dysfunction with the resumption of spontaneous breathing.