呼吸器重症病人疼痛與躁動之照護指引

Establish Clinical Management for Critical Patients with Mechanical Ventilation in Relieving Pain and Agitation

廖盈謹(Ying-Chin Liao) ； 蘇淑芬(Shu-Fen Su)

《醫學與健康期刊》 12卷2期 (2023/07) Pp. 1-21

摘要

疼痛和躁動是重症患者常見經驗，如何妥善鎮靜與止痛對重症患者非常重要，故本文目的為「應用實證於呼吸器重症病人疼痛與躁動之照護指引」，以供臨床醫護人員依循。於南部某教學醫院內科加護病房成立跨領域指引發展小組，遵循實證步驟，以問卷調查方式，邀請15位專家及50位醫療人員評估指引適用性。本指引包括疼痛／躁動的評估方法、疼痛／躁動的治療及管理方式三構面，共18項。於ICU施行12個月，多數重症患者疼痛分數（CPOT）由4～6分下降至0～1分，躁動－鎮靜分數（RASS）由1～2分下降至-2～0分，且非計畫性氣管內管滑脫率由（千分之3.62）降至（千分之2.80）。透過實證方法發展出適用醫院呼吸器重症病人疼痛與躁動之照護指引，經臨床施行12個月後，發現多數患者疼痛、躁動分數及非計畫性氣管內管滑脫率皆有效下降，目前繼續施行收案中，期望此指引可作為臨床團隊之實作參考，進一步具體成效後續將再分享。

關鍵字

呼吸器重症病人 ； 疼痛 ； 躁動 ； 鎮靜劑 ； 照護指引

並列摘要

Pain and agitation are common experiences in critically ill patients, and proper sedation and pain management are essential. The purpose of this study is to develop an evidence-based guideline for pain and agitation in critically ill patients on mechanical ventilation to provide clinical guidance for healthcare professionals. A cross-disciplinary guideline development team was established in the medical intensive care unit of a teaching hospital in southern Taiwan. Following the evidence-based steps, a questionnaire survey was conducted to invite 15 experts and 50 medical staff to evaluate the applicability of the guideline. The developed guideline includes three dimensions: assessment methods for pain and agitation, treatment and management for pain and agitation, and a total of 18 items.The score of Critical-Care Pain Observation Tool (CPOT) among the critically ill patients decreased from 4-6 points to 0-1 point, and the score of Richmond Agitation-Sedation Scale (RASS) was lowered from 1-2 point to 0-1 point. The rate of unplanned extubation decreased from (3.62 per mille) to (2.80 per mille). An evidence-based guideline for pain and agitation in critically ill patients on mechanical ventilation was developed and implemented in the ICU. After 12 months, the majority of patients' pain and agitation scores, as well as the rate of unplanned extubation, significantly decreased. The study is ongoing, and we hope this guideline can serve as a practical reference for clinical teams. Further specific effects will be shared in the future.

並列關鍵字

Critically ill patients on mechanical ventilation ； Pain ； Agitation ； Sedative ； Guideline

參考文獻

Mansouri P, Javadpour S, Zand F, et al.: Implementation of a protocol for integrated management of pain, agitation, and delirium can improve clinical outcomes in the intensive care unit: A randomized clinical trial. J Crit Care 2013; 28:918-22.

Brophy A, Cardinale M, Andrews LB, et al.: Prospective observational evaluation of sedation and pain management guideline adherence across new Jersey intensive care units. J Pharm Pract 2018;1.

Frade-Mara MJ, Regueiro-Díaz N, Díaz-Castellano L, et al.: A first step towards safer sedation and analgesia: A systematic evaluation of outcomes and level of sedation and analgesia in the mechanically ventilated critically ill patient. Enferm Intensive 2016;27:155-67.

Luetz A, Balzer F, Radtke FM, et al.: Delirium, sedation and analgesia in the intensive care unit: a multinational, two-part survey among intensivists. PLoS One 2014;9: 110935.

Seo Y, Lee HJ, Ha EJ, et al.: 2021 KSCCM clinical practice guidelines for pain, agitation, delirium, immobility, and sleep disturbance in the intensive care unit. Acute Crit Care 2022;37:1-25.