护士主导的儿科镇痛与镇静方案可减轻儿科重症内科患者的戒断症状。
Nurse-driven pediatric analgesia and sedation protocol reduces withdrawal symptoms in critically ill medical pediatric patients.
作者信息
Neunhoeffer Felix, Kumpf Matthias, Renk Hanna, Hanelt Malte, Berneck Nicole, Bosk Axel, Gerbig Ines, Heimberg Ellen, Hofbeck Michael
机构信息
Department of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children's Hospital, Tübingen, Germany.
Hospital for Paediatric and Adolescent Medicine, Speyer, Germany.
出版信息
Paediatr Anaesth. 2015 Aug;25(8):786-794. doi: 10.1111/pan.12649. Epub 2015 Mar 24.
BACKGROUND
While several analgesia and sedation guidelines and protocols have been developed and implemented for adults, there is still little evidence of clinical use of analgesia and sedation protocols and the impact on withdrawal symptoms in critically ill children.
OBJECTIVE
The aim of this study was to evaluate the effects of a nurse-driven goal-directed analgesia and sedation protocol for mechanically ventilated pediatric patients (pASP) on duration of mechanical ventilation, pediatric intensive care unit (PICU) length of stay, total doses of opioids and benzodiazepines, and occurrence of withdrawal symptoms.
PATIENTS AND METHODS
This is a before and after protocol implementation study in a 14-bed medical-surgical-cardiac pediatric intensive care unit at a university children's hospital. A total of 337 medical pediatric patients requiring mechanical ventilation with PICU length of stay for at least 24 h were included. Prior to implementation of the protocol, analgesia and sedation was managed by the attending physician's order. Afterwards, postimplementation, nurses managed analgesia and sedation following a pASP, including COMFORT 'behavioral' Scale, Nurse Interpretation Sedation Scale, and Sophia Observation Withdrawal Symptoms Scale.
RESULTS
One hundred and sixty-five patients were included in the 15-month period before and 172 patients were included in the 15-month period after implementation of the pASP. Median duration of mechanical ventilation was 2.02 (0.96-25.0) days in the group preceding protocol implementation and 1.71 (0.96-66.0) days afterwards (P = 0.23). Median PICU length of stay was 5.8 (1-37.75) days in the preimplementation and 5.0 (1-120) days in the postimplementation group (P = 0.14). Total doses of opioids and benzodiazepines were 3.9 mg·kg(-1) ·day(-1) (0.1-70) vs 3.1 mg·kg(-1) ·day(-1) (0.05-56); P = 0.38 and 5.9 mg·kg(-1) ·day(-1) (0-82.0) vs 4.2 mg·kg(-1) ·day(-1) (0-66); P = 0.009 after implementation. Incidence of withdrawal was significantly lower over the postimplementation period (12.8% vs 23.6%; P = 0.005).
CONCLUSION
Implementation of a nurse-driven pASP reduced the total dose of benzodiazepines and the occurrence of withdrawal symptoms significantly.
背景
虽然已经为成人制定并实施了多项镇痛和镇静指南及方案，但关于镇痛和镇静方案在危重症儿童中的临床应用及其对戒断症状影响的证据仍然很少。
目的
本研究旨在评估护士主导的目标导向镇痛和镇静方案（pASP）对机械通气儿科患者的机械通气时间、儿科重症监护病房（PICU）住院时间、阿片类药物和苯二氮䓬类药物的总剂量以及戒断症状发生率的影响。
患者和方法
这是一项在一家大学儿童医院的拥有14张床位的内科 - 外科 - 心脏儿科重症监护病房进行的方案实施前后的研究。总共纳入了337名需要机械通气且在PICU住院至少24小时的儿科内科患者。在方案实施前，镇痛和镇静由主治医师医嘱管理。之后，在方案实施后，护士按照pASP管理镇痛和镇静，包括舒适度“行为”量表、护士镇静评估量表和索菲亚戒断症状观察量表。
结果
在pASP实施前的15个月期间纳入了165名患者，实施后的15个月期间纳入了172名患者。在方案实施前的组中，机械通气的中位时间为2.02（0.96 - 25.0）天，实施后为1.71（0.96 - 66.0）天（P = 0.23）。PICU住院时间的中位数在实施前为5.8（1 - 37.75）天，实施后组为5.0（1 - 120）天（P = 0.14）。阿片类药物和苯二氮䓬类药物的总剂量分别为3.9 mg·kg⁻¹·天⁻¹（0.1 - 70）对比3.1 mg·kg⁻¹·天⁻¹（0.05 - 56）；P = 0.38以及5.9 mg·kg⁻¹·天⁻¹（0 - 82.0）对比4.2 mg·kg⁻¹·天⁻¹（0 - 66）；实施后P = 0.009。在实施后的时间段内，戒断发生率显著降低（12.8%对比23.6%；P = 0.005）。
结论
护士主导的pASP的实施显著降低了苯二氮䓬类药物的总剂量和戒断症状的发生率。
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