University of Manchester, Manchester, UK.
J Clin Nurs. 2018 Apr;27(7-8):e1284-e1308. doi: 10.1111/jocn.14258. Epub 2018 Feb 11.
To critically review the evidence relating to the management of agitation within the Adult Critical Care Unit environment and identify any risks and benefits of current management strategies.
Admission to an Adult Critical Care Unit can be traumatic and potentially life altering for the patient. Patient agitation is common in Adult Critical Care Units and is associated with the potential for harm. Despite inherent safety risks, there is a paucity of evidence-based guidance underpinning the care of agitation in patients with critical illness.
Integrative review and narrative synthesis.
A systematic procedure for searching and selecting the literature was followed and applied to databases including CINAHL, British Nursing Index, Cochrane Library, ProQuest, Ovid including EMBASE and MEDLINE. Selected manuscripts were analysed using a structured narrative review approach.
A total of 208 papers were identified and following a systematic deselection process 24 original articles were included in the review. It was identified that agitation in the setting of Adult Critical Care Unit is associated with high-risk events such as unplanned removal of life-supporting devices. There were consistent links to sepsis, previous high alcohol intake and certain medications, which may increase the development of agitation. Prompt assessment and early liberation from mechanical ventilation was a major contributing factor in the reduction in agitation. Administration of antideliriogenic mediation may reduce the need for physical restraint. There was repeated uncertainty about the role of physical restraint in developing agitation and its effective management.
Our review has shown that there is a dearth of research focusing on care of agitated patients in the Adult Critical Care Unit, despite this being a high-risk group. There are dilemmas for clinical teams about the effectiveness of applying physical and/or pharmacological restraint. The review has highlighted that the risk of self-extubation increases with the presence of agitation, reinforcing the need for constant clinical observation and vigilance.
The importance of ensuring patients are re-orientated regularly and signs of agitation assessed and acted upon promptly is reiterated. Early identification of specific patient profiles such as those with previous high alcohol or psychoactive drug habit may enable more proactive management in agitation management rather than reactive. The prompt liberation from the restriction of ventilation and encouragement of family or loved ones involvement in care need to be considered.
批判性地回顾成人重症监护病房环境中治疗激越的证据，并确定当前管理策略的任何风险和益处。
进入成人重症监护病房可能对患者造成创伤，并可能改变其生活。成人重症监护病房中常见激越，且与潜在伤害相关。尽管存在固有安全风险，但对于危重病患者激越的护理，缺乏循证指导。
综合审查和叙述性综合。
遵循系统的文献搜索和选择程序，并应用于包括 CINAHL、英国护理索引、Cochrane 图书馆、ProQuest、Ovid（包括 EMBASE 和 MEDLINE）在内的数据库。使用结构化叙述性综述方法分析选定的手稿。
共确定了 208 篇论文，经过系统的淘汰过程，共有 24 篇原始文章纳入综述。研究发现，成人重症监护病房中的激越与高风险事件相关，例如意外移除生命支持设备。与脓毒症、先前高酒精摄入量和某些药物之间存在一致联系，这些可能会增加激越的发展。及时评估和尽早从机械通气中解脱是减少激越的主要因素。给予抗谵妄药物可能会减少对身体约束的需求。对于身体约束在激越发展及其有效管理中的作用，存在反复的不确定性。
我们的综述表明，尽管这是一个高风险群体，但针对成人重症监护病房中激越患者护理的研究很少。临床团队在应用身体和/或药物约束的有效性方面存在困境。该综述强调，存在激越时自我拔管的风险增加，这强调了需要持续进行临床观察和警惕。
再次强调了确保患者定期重新定向、评估激越迹象并迅速采取行动的重要性。早期识别特定的患者特征，例如那些有既往高酒精或精神活性药物习惯的患者，可能能够更积极地管理激越，而不是被动反应。需要考虑从通气限制中迅速解放并鼓励家属或亲人参与护理。
