張婷婷,李夢(mèng)媛,彭　歆,李文濤

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集束化鎮(zhèn)痛鎮(zhèn)靜策略在機(jī)械通氣病人應(yīng)用中的研究進(jìn)展

張婷婷,李夢(mèng)媛,彭歆,李文濤

摘要:臨床中接受鎮(zhèn)痛鎮(zhèn)靜治療的機(jī)械通氣病人數(shù)量不斷增加,鎮(zhèn)痛鎮(zhèn)靜在減少痛苦、保證病人舒適的同時(shí),也給病人帶來(lái)許多不良后果。集束化鎮(zhèn)痛鎮(zhèn)靜策略是以循證醫(yī)學(xué)為基礎(chǔ),各學(xué)科、各部門間相互協(xié)調(diào)實(shí)施的一種管理方法,可以提高護(hù)理質(zhì)量,改善病人預(yù)后。本研究回顧近年來(lái)國(guó)內(nèi)外有關(guān)集束化鎮(zhèn)痛鎮(zhèn)靜策略在機(jī)械通氣病人中的應(yīng)用情況,為臨床應(yīng)用提供參考。

關(guān)鍵詞:機(jī)械通氣；集束化護(hù)理；鎮(zhèn)痛；鎮(zhèn)靜

Research progress on application of cluster analgesia and sedation strategy in mechanical ventilation patients

Zhang Tingting，Li Mengyuan，Peng Xin，et al(Nursing College of Jilin University，Jilin 130021 China)

AbstractThe number of mechanical ventilation patients who received analgesia and sedation in clinical treatment is increasing graduatly.The analgesia and sedation could reduce pain and ensure the comfort of patients，but also could bring many adverse consequences for the patients.The cluster analgesia and sedation strategies were based on the evidence based medicine.It was a management method of coordinating the various disciplines and departments，which could improve the quality of nursing and improve the prognosis of patients.This study reviewed the application status of cluster analgesia and sedation strategies in mechanical ventilation patients at home and abroad in recent years，and provided a reference for clinical application.

Key wordsmechanical ventilation;cluster nursing;analgesia;sedation

隨著ICU的發(fā)展,機(jī)械通氣(mechanical ventilation,MV)病人的鎮(zhèn)靜鎮(zhèn)痛治療受到越來(lái)越多的關(guān)注[1],然而不恰當(dāng)?shù)逆?zhèn)痛鎮(zhèn)靜非但無(wú)益處,還可能使重癥病人處于危險(xiǎn)之中,如鎮(zhèn)痛鎮(zhèn)靜不足可引起躁動(dòng)、人機(jī)不協(xié)調(diào)、意外拔管,鎮(zhèn)痛鎮(zhèn)靜過(guò)度可引起循環(huán)波動(dòng)、脫機(jī)延遲、呼吸機(jī)相關(guān)肺炎(VAP)發(fā)生率增加等。集束化鎮(zhèn)痛鎮(zhèn)靜策略基于循證醫(yī)學(xué)[2],能夠?qū)C(jī)械通氣病人鎮(zhèn)痛鎮(zhèn)靜治療進(jìn)行有效管理。

1相關(guān)概念

1.1集束干預(yù)與集束化護(hù)理集束干預(yù)是集合一系列有循證基礎(chǔ)的治療及護(hù)理措施來(lái)處理某種難治的臨床疾患[3],其目的在于幫助醫(yī)務(wù)人員為病人提供盡可能優(yōu)化的醫(yī)療護(hù)理服務(wù)。集束化護(hù)理是指成組出現(xiàn)的護(hù)理干預(yù)措施,一個(gè)集束應(yīng)該包含3個(gè)～6個(gè)元素,每個(gè)元素都經(jīng)臨床證實(shí)能改善病人臨床結(jié)局,各元素的共同實(shí)施比單獨(dú)執(zhí)行更有效[3]。

1.2集束化鎮(zhèn)痛鎮(zhèn)靜護(hù)理策略Pandharipande等[4]最早闡述了以循證醫(yī)學(xué)為基礎(chǔ)建立起來(lái)的ABCDE集束化鎮(zhèn)痛鎮(zhèn)靜策略(the ABCDE bundle for analgosedation,ABCDE bundle),包括每日鎮(zhèn)靜中的喚醒、呼吸機(jī)撤離試驗(yàn)中的呼吸同步、鎮(zhèn)靜和鎮(zhèn)痛藥物的選擇或應(yīng)用、譫妄的監(jiān)測(cè)和處理、早期運(yùn)動(dòng)和鍛煉。目標(biāo)是減少過(guò)度鎮(zhèn)靜、機(jī)械通氣時(shí)間以及ICU獲得性譫妄和肌無(wú)力。

2集束化鎮(zhèn)痛鎮(zhèn)靜策略各項(xiàng)措施的證據(jù)支持及整體評(píng)價(jià)

集束干預(yù)策略中的每項(xiàng)措施通常由隨機(jī)對(duì)照實(shí)驗(yàn)或是系統(tǒng)評(píng)價(jià)論證,保證該項(xiàng)措施在安全有效的前提下實(shí)施[1]。

2.1每日喚醒鎮(zhèn)靜是ICU常用的治療措施[5],鎮(zhèn)靜的理想目標(biāo)為病人處于安靜狀態(tài)且易被喚醒,然而多數(shù)ICU病人存在鎮(zhèn)靜過(guò)度的問(wèn)題。Kress等[6]最先提出每日喚醒鎮(zhèn)靜策略(daily interruption of sedation),在適當(dāng)鎮(zhèn)痛的基礎(chǔ)上,調(diào)整鎮(zhèn)靜劑劑量達(dá)到目標(biāo)鎮(zhèn)靜,通過(guò)對(duì)128例機(jī)械通氣病人進(jìn)行隨機(jī)對(duì)照實(shí)驗(yàn)發(fā)現(xiàn),每日喚醒,又叫自發(fā)覺(jué)醒實(shí)驗(yàn)(spontaneous awakening trials,SATs),能減少鎮(zhèn)靜鎮(zhèn)痛藥物使用總劑量,縮短機(jī)械通氣時(shí)間及ICU住院時(shí)間,減少神經(jīng)功能評(píng)估實(shí)驗(yàn)人數(shù)。陳泓伯等[10]通過(guò)每日喚醒在機(jī)械通氣鎮(zhèn)靜病人中應(yīng)用效果的Meta分析顯示,每日喚醒能夠縮短機(jī)械通氣時(shí)間、ICU住院時(shí)間、降低氣管切開率。但是,Heffner[8]指出每日喚醒可能使病人遭受創(chuàng)傷后應(yīng)激障礙(post-traumatic stress disorder,PTSD)。Kress等[9]研究顯示,實(shí)施SATs的干預(yù)組病人出現(xiàn)PTSD的概率明顯低于對(duì)照組,兩組的焦慮及抑郁發(fā)生率相似。Jackson等[10]研究了ABC(awakening and breathing coordination)實(shí)驗(yàn)后1年病人的心理變化,結(jié)果顯示,兩組PTSD以及抑郁發(fā)生率無(wú)差異。這些研究結(jié)果表明,SATs沒(méi)有增加病人PTSD或其他心理異常的發(fā)生。Augustes等[11]通過(guò)Meta分析也證實(shí)了每日喚醒的安全性。

2.2呼吸同步自主呼吸實(shí)驗(yàn)(spontaneous breathing trials,SBTs)用于檢測(cè)病人是否有能力維持自主呼吸,從而預(yù)測(cè)撤機(jī)成功的可能性[12]。呼氣末正壓通氣(PEEP)、持續(xù)正壓通氣(CPAP)、T管是評(píng)價(jià)病人是否完全耐受自主呼吸最常用的3種方式[13]。Esteban等[14]報(bào)道,SBTs能夠縮短脫機(jī)時(shí)間。隨后,Ely等[15]報(bào)道,這種呼吸治療方案與醫(yī)生主導(dǎo)的脫機(jī)相比明顯縮短拔管時(shí)間。目前已確立了把SBTs作為預(yù)測(cè)早期機(jī)械通氣脫機(jī)的有效方法[12]。

2.3每日喚醒與呼吸同步策略結(jié)合Girard等[16]最早將SATs與SBTs相結(jié)合,對(duì)336例病人進(jìn)行隨機(jī)對(duì)照實(shí)驗(yàn),干預(yù)組將護(hù)士管理的SATs與呼吸治療師管理的SBTs相結(jié)合,使鎮(zhèn)靜和通氣管理更科學(xué)；對(duì)照組接受與SBTs結(jié)合的常規(guī)護(hù)理,結(jié)果顯示,干預(yù)組病人在無(wú)通氣支持下呼吸天數(shù)明顯高于對(duì)照組,昏迷時(shí)間縮短,而且追蹤調(diào)查發(fā)現(xiàn),1年病死率降低了14%。Jackson等[10]隨機(jī)對(duì)照實(shí)驗(yàn)表明,每日喚醒與呼吸同步策略能改善病人短期及長(zhǎng)期預(yù)后,未增加不良反應(yīng)發(fā)生率。

2.5譫妄的監(jiān)測(cè)和管理目前關(guān)于譫妄的監(jiān)測(cè)與管理這項(xiàng)措施尚無(wú)隨機(jī)對(duì)照實(shí)驗(yàn)支持,譫妄在重癥機(jī)械通氣病人中的發(fā)生率高達(dá)60%～80%[3],在非機(jī)械通氣病人中發(fā)生率達(dá)20%～50%[24],譫妄延長(zhǎng)了機(jī)械通氣時(shí)間、住院時(shí)間,損害病人認(rèn)知功能[25]。馮潔惠等[3]研究認(rèn)為,譫妄管理最重要的一步就是通過(guò)信效度高的評(píng)估工具進(jìn)行早期識(shí)別。

2.6早期運(yùn)動(dòng)ICU護(hù)理的重點(diǎn)主要是復(fù)蘇和生存,往往忽視了神經(jīng)肌肉功能的損傷[26],然而ICU獲得性肌無(wú)力在重癥病人中的發(fā)生率達(dá)25%～60%,延長(zhǎng)了機(jī)械通氣時(shí)間、ICU治療時(shí)間,增加了病死率[21]。重癥病人的早期運(yùn)動(dòng)在預(yù)防功能損傷方面是安全、可行、有益的[27-28]。Morris等[29]對(duì)330例機(jī)械通氣病人早期運(yùn)動(dòng)鍛煉的隨機(jī)對(duì)照實(shí)驗(yàn)發(fā)現(xiàn),早期運(yùn)動(dòng)組的首次離床時(shí)間早于對(duì)照組,ICU治療時(shí)間與總住院日低于對(duì)照組。Schweickert等[30]對(duì)104例機(jī)械通氣病人進(jìn)行了早期運(yùn)動(dòng)干預(yù)加每日喚醒的隨機(jī)對(duì)照實(shí)驗(yàn),觀察組病人在機(jī)械通氣早期進(jìn)行運(yùn)動(dòng)治療與鎮(zhèn)靜喚醒相結(jié)合,對(duì)病人實(shí)施呼吸肌鍛煉,對(duì)照組則按照常規(guī)運(yùn)動(dòng)治療進(jìn)行鍛煉,結(jié)果顯示早期物理治療能縮短譫妄持續(xù)時(shí)間,提高出院率,改善病人生活質(zhì)量。耿夢(mèng)雅等[31]研究結(jié)果與其大致相符。

2.7集束化鎮(zhèn)痛鎮(zhèn)靜策略的整體評(píng)價(jià)大多數(shù)支持集束化鎮(zhèn)痛鎮(zhèn)靜策略的理論依據(jù)都是通過(guò)對(duì)機(jī)械通氣病人進(jìn)行隨機(jī)對(duì)照實(shí)驗(yàn)得到的[32],且大部分隨機(jī)對(duì)照實(shí)驗(yàn)是獨(dú)立地評(píng)價(jià)各項(xiàng)措施的安全性和有效性。Balas等[33]為驗(yàn)證將集束化鎮(zhèn)痛鎮(zhèn)靜策略應(yīng)用到所有重癥病人(包括機(jī)械通氣病人和非機(jī)械通氣病人)是否都安全有效,對(duì)不同ICU的296例病人進(jìn)行研究的結(jié)果顯示,集束化鎮(zhèn)痛鎮(zhèn)靜策略的實(shí)施能減少病人機(jī)械通氣時(shí)間及譫妄時(shí)間,比實(shí)施普通護(hù)理的病人更早活動(dòng),說(shuō)明在管理重癥病人上,集束化鎮(zhèn)痛鎮(zhèn)靜策略是十分有價(jià)值的工具,能夠在ICU中廣泛應(yīng)用。

3實(shí)施集束化鎮(zhèn)痛鎮(zhèn)靜策略步驟

實(shí)施前,在ICU成立由醫(yī)生、呼吸治療師、物理治療師、藥劑師及護(hù)士組成的集束干預(yù)小組[34],小組成員經(jīng)過(guò)培訓(xùn)后開始實(shí)施集束化鎮(zhèn)痛鎮(zhèn)靜策略步驟。

3.1每日喚醒與自主呼吸每日上午中斷鎮(zhèn)痛鎮(zhèn)靜藥物注射,直到病人清醒并能遵照簡(jiǎn)單的指令動(dòng)作后開始進(jìn)行自主呼吸實(shí)驗(yàn),判斷病人能否脫機(jī)及拔除氣管導(dǎo)管。如病人需要再上呼吸機(jī),以停藥時(shí)鎮(zhèn)靜劑劑量的50%重新開始鎮(zhèn)靜,然后逐步調(diào)整至目標(biāo)鎮(zhèn)靜。該步驟由護(hù)士實(shí)施并評(píng)價(jià)。喚醒期間進(jìn)行自主呼吸試驗(yàn),觀察病人變化、呼吸機(jī)狀況及人機(jī)協(xié)調(diào)情況,自主呼吸實(shí)驗(yàn)的實(shí)施和效果評(píng)價(jià)由醫(yī)生、呼吸治療師及護(hù)士共同完成。

3.2鎮(zhèn)痛鎮(zhèn)靜藥物的選擇對(duì)病人的疼痛情況與精神狀態(tài)進(jìn)行評(píng)估,遵醫(yī)囑使用合適的鎮(zhèn)痛鎮(zhèn)靜及譫妄治療的藥物。2013年P(guān)AD指南推薦使用疼痛行為量表(BPS)或重癥疼痛觀察工具(CPOT)對(duì)ICU病人進(jìn)行疼痛客觀評(píng)估[35]；指南提出Richmond躁動(dòng)-鎮(zhèn)靜量表(RASS)和鎮(zhèn)靜-躁動(dòng)量表(SAS)是評(píng)估成年ICU病人鎮(zhèn)靜質(zhì)量與深度最為有效的工具[36]。經(jīng)常評(píng)估鎮(zhèn)靜深度和躁動(dòng)程度有助于選擇最佳鎮(zhèn)靜藥物，調(diào)整鎮(zhèn)靜藥物劑量,降低過(guò)度鎮(zhèn)靜的比例,達(dá)到合理的鎮(zhèn)靜水平,實(shí)現(xiàn)預(yù)期鎮(zhèn)靜目標(biāo)[37]。

3.3譫妄的監(jiān)測(cè)和處理譫妄評(píng)估工具中,信效度較好且最常用的兩種為ICU意識(shí)模糊評(píng)估法(CAM-ICU)和ICU譫妄篩查表(ICDSC),CAM-ICU是目前ICU醫(yī)生和護(hù)士使用最為廣泛的譫妄評(píng)估工具,平均評(píng)估時(shí)間僅需2 min～5 min[35]。護(hù)士將譫妄與鎮(zhèn)靜量表相結(jié)合對(duì)病人進(jìn)行譫妄評(píng)估,若為陽(yáng)性,再由醫(yī)生進(jìn)行鑒別診斷。

3.4早期運(yùn)動(dòng)和鍛煉根據(jù)病人的意識(shí)、病情、肌力分級(jí)進(jìn)行運(yùn)動(dòng)鍛煉[3]。目前,國(guó)際認(rèn)可的機(jī)械通氣病人早期運(yùn)動(dòng)治療方案為四步運(yùn)動(dòng)鍛煉方案[30]。首先判斷病人的意識(shí)是否清醒,然后根據(jù)病人運(yùn)動(dòng)反應(yīng)情況分層級(jí)進(jìn)行管理。原則上昏迷的病人應(yīng)進(jìn)行一級(jí)運(yùn)動(dòng)；經(jīng)口管氣管插管、氣管切開的病人應(yīng)進(jìn)行一級(jí)至二級(jí)運(yùn)動(dòng)；意識(shí)清醒的病人適宜二級(jí)、三級(jí)、四級(jí)運(yùn)動(dòng)方式[31]。

4護(hù)士在實(shí)施集束化鎮(zhèn)痛鎮(zhèn)靜策略中的角色

4.1觀察者和評(píng)估者護(hù)士在為病人實(shí)施每日喚醒、自主呼吸、鎮(zhèn)痛鎮(zhèn)靜期間要密切觀察病情變化,發(fā)現(xiàn)異常及時(shí)處理,以減少對(duì)病人的不良影響,確保治療安全。觀察和評(píng)估是護(hù)理工作的重要內(nèi)容,只有通過(guò)觀察、評(píng)估才能確定病人實(shí)施集束化鎮(zhèn)痛鎮(zhèn)靜策略的效果,為臨床決策提供依據(jù)[34]。

4.2溝通者和管理者集束化鎮(zhèn)痛鎮(zhèn)靜策略的每個(gè)步驟都需要護(hù)士參與或護(hù)士與其他參與者的溝通。確定能否拔除病人氣管插管需要護(hù)士與呼吸治療師及醫(yī)生協(xié)商,能否早期運(yùn)動(dòng)需要護(hù)士與物理治療師及醫(yī)生協(xié)商。護(hù)士也是將集束化鎮(zhèn)痛鎮(zhèn)靜策略實(shí)施到不同地區(qū)、不同機(jī)構(gòu)的管理者,護(hù)士了解所在醫(yī)院的條件,能夠在資源以及培訓(xùn)方面提出建設(shè)性的意見(jiàn),以促進(jìn)集束化鎮(zhèn)痛鎮(zhèn)靜策略的實(shí)施[5]。

4.3推動(dòng)者Reimers等[38]研究分三步強(qiáng)調(diào)了臨床護(hù)理專家(CNS)在實(shí)施集束化鎮(zhèn)痛鎮(zhèn)靜策略過(guò)程中作為推動(dòng)者的重要角色。第1步,CNS通過(guò)對(duì)護(hù)士、呼吸治療師做調(diào)查,了解其對(duì)機(jī)械通氣譫妄病人的認(rèn)知,再通過(guò)舉辦研討會(huì)、網(wǎng)上學(xué)習(xí)、電子郵件、交流公告、ICU查房等形式改變其對(duì)于譫妄管理的傳統(tǒng)觀點(diǎn)；第2步,確保臨床護(hù)士對(duì)CAM-ICU的正確使用；第3步,在外界支持下,對(duì)每個(gè)病人每日實(shí)行集束化鎮(zhèn)痛鎮(zhèn)靜策略。ICU獲得性譫妄和肌無(wú)力增加了醫(yī)院成本、病人住院時(shí)間及其他不良后果,但是,上述問(wèn)題能夠通過(guò)實(shí)踐中的密切觀察而預(yù)防或減輕。國(guó)外學(xué)者推薦實(shí)施ABCDE集束化鎮(zhèn)痛鎮(zhèn)靜策略,以改善重癥病人的機(jī)體功能和認(rèn)知能力[39]。然而這種集束干預(yù)在國(guó)內(nèi)還處于起步階段,只有馮潔惠等[3]進(jìn)行了相關(guān)的研究。雖然有利于ABCDE bundle實(shí)施的因素有很多,如ICU各學(xué)科間的交流、多樣化的培訓(xùn)、領(lǐng)導(dǎo)及相關(guān)文件的支持、ICU的大小[40]、ICU工作人員的經(jīng)驗(yàn)[41]、電子健康記錄[42]的使用等,但是想要成功實(shí)施ABCDE bundle仍有很多困難需要解決,包括ICU工作人員相關(guān)知識(shí)缺乏、人力耗費(fèi)導(dǎo)致的工作負(fù)擔(dān)加重、影響病人休息或安全及各學(xué)科間溝通的困難[3]等。因此,還應(yīng)進(jìn)一步探索及明確其意義,同時(shí)建立符合我國(guó)ICU的相關(guān)管理制度、技術(shù)規(guī)范來(lái)發(fā)揮其更大的效益。

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(本文編輯蘇琳)

(收稿日期:2015-07-02;修回日期:2016-02-18)

中圖分類號(hào)：R473

文獻(xiàn)標(biāo)識(shí)碼：A

doi:10.3969/j.issn.1009-6493.2016.09.003

文章編號(hào)：1009-6493(2016)03C-1031-04

作者簡(jiǎn)介張婷婷,碩士研究生在讀，單位：130021，吉林大學(xué)護(hù)理學(xué)院；李夢(mèng)媛、彭歆單位：130021，吉林大學(xué)護(hù)理學(xué)院；李文濤(通訊作者)單位：116622，大連大學(xué)護(hù)理學(xué)院。