Barra Megan E, Iracheta Christine, Tolland Joseph, Jehle Johnathan, Minova Ljubica, Li Karen, Amatangelo Mary, Krause Patricia, Batra Ayush, Vaitkevicius Henrikas
Department of Pharmacy, Massachusetts General Hospital, Boston, MA USA.
Department of Rehabilitation Services, Brigham and Women's Hospital, Boston, MA USA.
Neurohospitalist. 2023 Oct;13(4):351-360. doi: 10.1177/19418744231182897. Epub 2023 Jun 21.
Over-sedation may confound neurologic assessment in critically ill neurologic patients and prolong duration of mechanical ventilation (MV). Decreased sedative use may facilitate early functional independence when combined with early mobility. The objective of this study was to evaluate the impact of a stepwise, multidisciplinary analgesia-first sedation pathway and early mobility protocol on medication use and mobility in the neuroscience intensive care unit (ICU).
We performed a single-center prospective cohort study with adult patients admitted to a neuroscience ICU between March and June 2016-2018 who required MV for greater than 48 hours. Patients were included from three separate phases of the study: Phase I - historical controls (2016); Phase II - analgesia-first pathway (2017); Phase III - early mobility protocol (2018). Primary outcomes included propofol requirements during MV, total rehabilitation therapy provided, and functional mobility during ICU admission.
156 patients were included in the analysis. Decreasing propofol exposure was observed during Phase I, II, and III (median 2243.7 mg/day vs 2065.6 mg/day vs 1360.8 mg/day, respectively; P = .04 between Phase I and III). Early mobility was provided in 59.7%, 40%, and 81.6% of patients while admitted to the ICU in Phase I, II, and III, respectively (P < .01). An increased proportion of patients in Phase III were walking or ambulating at ICU discharge (26.7%; 8/30) compared to Phase I (7.9%, 3/38, P = .05).
An interdisciplinary approach with an analgesia-first sedation pathway with early mobility protocol was associated with less sedative use, increased rehabilitation therapy, and improved functional mobility status at ICU discharge.
过度镇静可能会混淆重症神经病患者的神经学评估，并延长机械通气（MV）时间。减少镇静药物的使用并结合早期活动，可能有助于患者早日实现功能独立。本研究的目的是评估逐步实施的多学科镇痛优先镇静方案和早期活动方案对神经科学重症监护病房（ICU）患者药物使用和活动能力的影响。
我们进行了一项单中心前瞻性队列研究，纳入了2016年3月至2018年6月期间入住神经科学ICU且需要机械通气超过48小时的成年患者。患者来自研究的三个不同阶段：第一阶段——历史对照（2016年）；第二阶段——镇痛优先方案（2017年）；第三阶段——早期活动方案（2018年）。主要结局包括机械通气期间丙泊酚的需求量、提供的康复治疗总量以及入住ICU期间的功能活动能力。
156例患者纳入分析。在第一、二、三阶段，丙泊酚的使用量逐渐减少（中位数分别为2243.7毫克/天、2065.6毫克/天和1360.8毫克/天；第一阶段和第三阶段之间P = 0.04）。在入住ICU的患者中，第一、二、三阶段分别有59.7%、40%和81.6%的患者接受了早期活动（P < 0.01）。与第一阶段（7.9%，3/38）相比，第三阶段在ICU出院时能够行走或活动的患者比例增加（26.7%；8/30，P = 0.05）。
采用镇痛优先镇静方案并结合早期活动方案的多学科方法，与较少的镇静药物使用、更多的康复治疗以及ICU出院时更好的功能活动状态相关。
