抗生素"降阶梯治疗"策略在ICU中的临床应用

本组病例来源于2004年2月～2004年6月间,我科ICU收治的8例危重病患者.用降阶梯治疗(DE-Escalation Therapy)取得较好疗效.     

抗生素降阶梯治疗在小儿重症肺炎中的临床应用观察

选取我院收治的100例小儿重症肺炎患者。随机分为A组和B组各50例。A组采用抗生素降阶梯治疗,选择亚胺培南抗生素;B组采用常规抗生素治疗法。比较两组患者在整个治疗过程中的痊愈率、总有效率、使用抗生素时间、住院时间、肺部感染吸收率,并观察不良反应情况。结果 A组治疗组患者的痊愈率为36%,总有效率为68%,B组的痊愈率为22%,总有效率为32%,A组的治疗效果明显优于B组(P0.05);A组患者使用抗生素时间、肺部感染吸收率、住院时长明显少于B组(P0.05);A、B两组治疗过程中不良反应方面无显著性差异,无统计学意义(P0.05)。采用抗生素降阶梯治疗小儿重症肺炎,可迅速控制患者感染病情,痊愈率和总有效率高,有效的减少了患者治疗时间、医治成本,效果显著,值得广泛推广。     

抗生素在院内感染中降阶梯治疗的新概念

2001年,在荷兰召开的第22届国际化学疗法会议上,一些专家强调指出,ICU中院内获得性感染的高病死率是起始治疗不当的结果[1-2],故主张起始治疗即使用足够广谱的抗生素,以覆盖所有可能的致病菌,待细菌培养、药敏结果出来后,再有针对性地换用窄谱抗生素,称之为降阶梯治疗(De-EscalationTherapy).     

重症肺炎初期经验治疗的抗生素选择及降阶梯疗法策略

１引言重症肺炎是指除肺炎常见呼吸系统症状外，尚有呼吸衰竭和其它系统明显受累的表现。重症肺炎既可发生于社区获得性肺炎（communityacquiredpneumonia，CAP）亦可发生于医院获得性肺炎（hospitalacquiredpneumonia，HAP），在HAP中以重症监护病房（ICU）里的获得性肺炎和呼吸机相关肺炎（ventilatorassociatedpneumonia，VAP）常见，此外，HAP亦常发生于免疫抑制宿主的肺炎以及其它重危患者的肺炎。２重症肺炎的诊断标准２００１年美国胸科学会（ATS）对重症肺炎制定了新的定义，主要标准有：①需要机械通气；②入院４８小时内…     

老年重症肺炎降阶梯治疗对预后的影响

目的：探讨抗生素降阶梯治疗对老年重症肺炎预后的影响。方法：39例老年重症肺炎患者行抗生素降阶梯治疗，对其资料进行回顾性分析。结果：老年重症肺炎患者早期、及时及正确选择使用抗生素，采用降阶梯治疗方法，病死率下降。结论：抗生素降阶梯治疗对改善老年重症肺炎的预后具有良好效果。     

抗生素降阶梯疗法治疗重症肺炎的效果观察

目的观察抗生素降阶梯疗法治疗重症肺炎的临床效果,探讨其临床价值。方法重症肺炎88例患者随机分为观察组及对照组各44例,给予营养支持、吸氧、化痰等对症治疗,并在必要时给予呼吸支持,应用抗生素前留取痰标本,进行细菌学及药物敏感实验。观察组采用降阶梯疗法,选用亚胺培南-西司他丁钠0.5g/6h静脉滴注,待细菌培养结果明确后降阶梯调整用药种类,针对性地选择窄谱抗生素治疗;对照组患者给予常规抗生素治疗。结果治疗7d时观察组治疗总有效率90.91%高于对照组的72.72%(P<0.05)。观察组静脉应用抗生素时间(11.21±2.67)d、住院时间(14.78±3.12)d、死亡率2.27%均低于对照组的(15.67±4.06)d、(20.34±5.03)d、15.91%(P<0.05)。结论重症肺炎使用抗生素降阶梯治疗,合理使用抗生素,提高治疗有效率,降低死亡率,值得临床推广应用。     

降阶梯思维在主动脉夹层患者急诊抢救护理中的应用

目的：探讨降阶梯思维在急性主动脉夹层（ AD）急诊抢救护理中的应用效果。方法将2012年1-12月在某院抢救的27例急性AD患者作为观察组以降阶梯思维方式抢救,2011年1-12月以传统的临床经验思维方式抢救的23例急性AD患者作为对照组,分析两组患者拟诊为急性AD的预警时间、抢救45 min和90 min确诊的例数,比较两者间的差异。结果观察组入抢救室后拟诊为急性AD的时间为（45＆#177;11）min,优于对照组的（77＆#177;9）min,差异有统计学意义（t＝2．8233,P＜0．05）;抢救45 min观察组确诊19例,优于对照组的5例,差异有统计学意义（χ2＝11．77,P＜0．01）。结论对突发胸背部剧痛的患者,急诊护士运用降阶梯思维方式实施抢救,能缩短对AD的预警时间和提高抢救的时效性。     

降阶梯思维在急诊分诊护士培训中的应用效果

目的探讨降阶梯思维在急诊分诊护士培训中的应用效果。方法 2012年1-3月,便利抽样法选择南京大学医学院附属鼓楼医院具有5年以上急诊临床工作经验的32名护士,运用降阶梯思维对其进行急诊分诊培训。结果培训后,分诊护士的理论成绩、分诊能力考核成绩较培训前均明显提高,差异有统计学意义(均P0.05);分诊护士对培训的满意度均较高,且培训后,急诊医生对分诊护士的满意度较培训前也明显增高,差异有统计学意义(χ2=5.19,P0.05);培训前、后的分诊准确率分别为96.90%、98.90%,差异有统计学意义(χ2=9.73,P0.01)。结论应用降阶梯思维能够激发分诊护士的学习兴趣,提高分诊护士的理论和分诊水平,有利于保证护理安全。     

急诊危重病合并感染的降阶梯治疗策略

急诊危重病并发感染是造成患者死亡的重要原因。随着抗生素大量使用 ,耐药菌株不断增加 ,使原来有效的抗生素变得无效 ,甚至出现交叉耐药 ,给曾经辉煌的抗生素时代笼罩上了阴影。合理、有效地使用抗生素是抗感染治疗的一项新挑战。抗感染治疗的主要目标是提高危重患者的存活率 ,并能防止产生细菌耐药性。急诊对危重病感染的治疗在初期阶段使用广谱抗生素是十分必要的 ,这已形成了一个具有国际性的共识 ,即采用降阶梯治疗 ( de escalation therapy)的策略。1　感染对危重病的预后产生不良影响感染一直是导致危重患者死亡最常见和重要的原因 ,…     

Student nurses’ de-escalation of patient aggression: A pretest-posttest intervention study

Background

Experts recommend staff training to prevent and manage aggressive situations involving patients or their relatives. However, in many countries this subject is not covered in pre-registration nursing education. In addition, the evidence regarding its impact on practical placements remains weak.

Objective

This study examines the influence of an aggression management training programme for nursing students on their performance in de-escalating aggressive patients.

Design

Pretest-posttest within-and-between-groups design.

Setting

A School of Nursing in Germany.

Participants

Convenience sample out of six classes of nursing students at differing educational levels (10th to 28th month of nursing education, n = 78, mean age = 22).

Methods

In a cross-sectional and longitudinal two groups before and after design nursing students encountered two scenarios (A or B) with simulation patients. After completing the training, each student was confronted with the unknown other scenario. De-escalation experts from three German-speaking countries evaluated 156 video scenes using the De-escalating Aggressive Behaviour Scale (DABS), not knowing whether the videos had been recorded before or after the training. Mean values and statistical significance tests were computed to compare the results.

Results

The performance levels of students who had been trained rose significantly from 2.74 to 3.65 as measured by the DABS on a 5-point Likert scale (Wilcoxon test p < .001). The trained students managed scenario A significantly better than the untrained students (untrained 2.50, trained 3.70; Mann-Whitney-U-test p < .001,). Similar results were found for scenario B (untrained 3.01, trained 3.61; Mann-Whitney-U-test p < .001). No significant differences were found in the pretest results irrespective the students’ age or duration of previous nursing education.

Conclusions

Aggression management training is able to improve nursing students’ performance in de-escalating aggressive behaviour. A maturation-effect on the de-escalating performance due to general nursing education or age is unlikely.     

导入"STAR"服务系统降低门诊服务投诉率

门诊是医院的重要组成部分,是面向社会的窗口,是提供优质服务的界面[1].预检护士是第一时间面对病人,为了变被动服务为主动服务,使病人在医院能安全、放心、满意地得到就诊、治疗和护理,我们于2007年5月开始将"STAR"服务系统导人到门诊护理服务中,收到了很好的成效.现将具体做法介绍如下.     

Decision analysis as a tool to support an analytical pattern-of-reasoning

Abstract Decision analysis is offered as a tool to aid nurses' decision-making in complex and troublesome situations where there are mutually exclusive actions and time is available for deliberation. Decision analysis can be formal or informal. Formal decision analysis provides a structure for representing the decision situation and a mathematical procedure for prescribing the alternative action that is most consistent with what is known and what one values. Informal decision analysis uses the concepts and sometimes the structure of decision analysis, but usually does not include the mathematical calculations. In the present paper, the authors illustrate how formal and informal decision analysis might be used by nurses to: (i) enhance their own decision-making; (ii) assist patients or family caregivers with decision-making and; (iii) promote informed health care policy development. Finally, the advantages and limitations of decision analysis are discussed.     

De-escalation of aggressive behaviour in healthcare settings: Concept analysis

BackgroundDe-escalation is the recommended first-line response to potential violence and aggression in healthcare settings. Related scholarly activity has increased exponentially since the 1980s, but there is scant research about its efficacy and no guidance on what constitutes the gold standard for practice.ObjectivesTo clarify the concept of de-escalation of violence and aggression as described within the healthcare literature.DesignConcept analysis guided by Rodgers’ evolutionary approach.Data sourcesMultiple nursing and healthcare databases were searched using relevant terms.Review methodsHigh quality and/or highly cited, or otherwise relevant published empirical or theoretical English language literature was included. Information about surrogate terms, antecedents, attributes, consequences, and the temporal, environmental, disciplinary, and theoretical contexts of use were extracted and synthesised. Information about the specific attributes of de-escalation were subject to thematic analysis. Proposed theories or models of de-escalation were assessed against quality criteria.ResultsN = 79 studies were included. Mental health settings were the most commonly reported environment in which de-escalation occurs, and nursing the disciplinary group most commonly discussed. Five theories of de-escalation were proposed; while each was adequate in some respects, all lacked empirical support. Based on our analysis the resulting theoretical definition of de-escalation in healthcare is “a collective term for a range of interwoven staff-delivered components comprising communication, self-regulation, assessment, actions, and safety maintenance which aims to extinguish or reduce patient aggression/agitation irrespective of its cause, and improve staff-patient relationships while eliminating or minimising coercion or restriction”.ConclusionsWhile a number of theoretical models have been proposed, the lack of advances made in developing a robust evidence-base for the efficacy of de-escalation is striking and must, at least in part, be credited to the lack of a clear conceptualisation of the term. This concept analysis provides a framework for researchers to identify the theoretical model that they purport to use, the antecedents that their de-escalation intervention is targeting, its key attributes, and the key negative and positive consequences that are to be avoided or encouraged.     

下呼吸道感染126例临床分析

目的探讨下呼吸道感染的临床对策。方法通过诊断,对症采用适当的抗生素。结果下呼吸道感染多为慢性肺部疾病与真菌感染。结论要重视患者基础疾病治疗,加强支持治疗和重建免疫机制,尽量减少并发症的发生;适当缩短住院时间合理使用抗菌素是减少呼吸病房内下呼吸道感染的主要措施。     

Nurses' clinical decision-making regarding the management of pain

Effective pain management remains an elusive goal within the profession of nursing. While considerable improvement has occurred, patients continue to experience inappropriate levels of pain. To date, research has focused on objective factors that influence pain management. Few studies have examined attitudinal factors that may influence nurses' decision-making. This quasi-experiment was based on preliminary data showing that nurses' preconceived notions regarding certain patient groups influenced their management of pain. An intervention was tested for its' effect on nurses' preconceived notions regarding specific patient groups. A significant difference in a positive direction was found. Nurses were more willing to spend time and energy managing pain across all patient groups following the intervention.     

Nurses' clinical decision-making regarding the management of pain

Effective pain management remains an elusive goal within the profession of nursing. While considerable improvement has occurred, patients continue to experience inappropriate levels of pain. To date, research has focused on objective factors that influence pain management. Few studies have examined attitudinal factors that may influence nurses' decision-making. This quasi-experiment was based on preliminary data showing that nurses' preconceived notions regarding certain patient groups influenced their management of pain. An intervention was tested for its' effect on nurses' preconceived notions regarding specific patient groups. A significant difference in a positive direction was found. Nurses were more willing to spend time and energy managing pain across all patient groups following the intervention.     

Determination of respiratory system compliance during pressure support ventilation by small variations of pressure support

In mechanically ventilated patients, measurement of respiratory system compliance (C_rs) is of high clinical interest. Spontaneous breathing activity during pressure support ventilation (PSV) can impede the correct assessment of C_rs and also alter the true C_rs by inducing lung recruitment. We describe a method for determination of C_rs during PSV and assess its accuracy in a study on 20 mechanically ventilated patients. To assess C_rs during pressure support ventilation (C_rs,PSV), we performed repeated changes in pressure support level by ±?2 cmH₂O. C_rs,PSV was calculated from the volume change induced by these changes in pressure support level, taking into account the inspiration time and the expiratory time constant. As reference methods, we used C_rs, measured during volume controlled ventilation (C_rs,VCV). In a post-hoc analysis, we assessed C_rs during the last 20% of the volume-controlled inflation (C_rs,VCV20). Values were compared by linear regression and Bland–Altman methods comparison. Comparing C_rs,PSV to the reference value C_rs,VCV, we found a coefficient of determination (r²) of 0.90, but a relatively high bias of ??7 ml/cm H₂O (95% limits of agreement ??16.7 to +?2.7 ml/cmH₂O). Comparison with C_rs,VCV20 resulted in a negligible bias (??1.3 ml/cmH₂O, 95% limits of agreement ??13.9 to +?11.3) and r² of 0.81. We conclude that the novel method provides an estimate of end-inspiratory C_rs during PSV. Despite its limited accuracy, it might be useful for non-invasive monitoring of C_rs in patients undergoing pressure support ventilation.     

Health promotion and some implications of consumer choice

AIM: To stimulate debate around how health promotion practices add to the choices confronting consumers in a health market place and some implications as a consequence. BACKGROUND: We live in a world characterized by consumerism, in which health professionals must compete with a wide array of other producers for the consumer's attention. EVALUATION: A critical review of consumer choice related to health applying theoretical insights from the works by Zygmunt Bauman. KEY ISSUES: Nurses working at influencing the health status of consumers at an individual level (whatever the setting) need to understand how to address the acknowledgement that people are confronted with a multiplicity of choices (good and bad) in their daily lives and from which they need to make a choice. How health promotion practices are 'sold' to consumers is an important consideration for nurses. CONCLUSIONS: The possibility for nurses to talk past consumers and vice versa exists. Choices made by consumers are premised on what is 'sold', how, by whom and why and has a lot to do with how to get the attention of the consumer.