腦部傷患在急性期抽痰對腦血流變化之影響

Intracranial Effects of Endotracheal Suctioning in Acute Phase of Head Injury

李芳珊(Fang-Shan Li)

指導教授 ： 邱艷芬

國立臺灣大學/醫學院/護理學研究所/碩士(2005年)

https://doi.org/10.6342/NTU.2005.02541

摘要

抽痰是眾多護理活動中頻率很高也很常見的活動，也是最常被提及其對腦部傷患影響很大的活動，對其影響過程愈瞭解愈可以知道如何避免造成影響，本研究目的在探討急性腦傷病患在急性期氣管內管抽痰對腦組織灌流變化的影響與其相關因素，以釐清抽痰前、中、後期之灌流變化。本研究採立意取樣，收案條件為年齡在十八歲以上、腦部傷患在急性期之病患，無冠狀動脈性心臟病、鬱血性心衰竭疾病、無藥物成癮。研究對象於住院時有裝置顱內壓監視器，以隨時了解病患實際之顱內壓，在配合病程之需要下，給與標準抽痰程序。共收案位病患6位完整收集31筆資料，收案期間自93年08月至93年11月，病患於腦部受傷急性期顱內壓監視器仍留置時，每天下午與晚間會客中間或晚間會客後，沒有任何治療或護理活動，使用Manitol超過2小時，病患若有需要，由研究者於執行標準抽痰程序時，以床旁監視器監測心跳、血壓、呼吸次數與動脈血氧飽和度的在安全範疇，確保病患之安全，用儀器自動記錄血壓、顱內壓、潮氣末二氧化碳濃度、心跳、腦灌流壓及腦血流之變化，分析比較病患在執行抽痰護理活動前、中、後各時期實際數據，並加以分析。
本研究將以SPSS 12.0套裝軟體進行資料分析，研究結果發現如下：
一、準備良好的標準抽痰程序去抽痰可以先有效降顱內壓，使抽痰過程中顱內壓的上升，恢復期的斜率雖與0無異但顱內壓平均值仍低於基準值。
二、血壓仍然會上升，顱內壓回復至基準值時血壓尚需一段時間才可以下降至基準值。
三、EtCO2降低到一定程度其改變就無統計上之差異。
四、心跳仍然會上升，顱內壓回復至基準值時心跳亦很快下降至基準值。
五、腦灌流壓一定會上升，顱內壓回復至基準值時腦灌流壓仍較基準值為高。
六、腦血流是會下降，其下降程度測量值與基準值相比無統計上的差異，顱內壓回復至基準值時腦血流會較基準值為高，維持較好的血流供應。
七、鎮靜劑的使用對於顱內壓較高或是顱內壓變化較大的病患是需要的，且若病患較敏感易有咳嗽反應則應並用肌肉鬆弛劑。
本研究的結果有助於神經外科加護單位的同仁，更清楚知道，是抽痰的那些動作造成影響需加以避免，如不能免如何不造成傷害，可做為神經加護單位執行抽痰護理活動的指引，以建立最適當的照護模式。對於學校或臨床在職教育教學的內容，提供有關神經外科手術後加護照護的護理觀念，亦可引導護理人員瞭解澄清良好抽痰準備在血液動力學上的變化，加以注意不造成傷害。護理研究方面本研究是藉由床邊實地測量，以實際連續數字呈現，此種記錄方式在國內護理的研究中應為首篇，可做為相關研究的參考，應用到去瞭解其他護理活動對病患生理的瞭解中。

關鍵字

抽痰 ； 顱內壓 ； 腦灌流壓 ； 急性腦傷

並列摘要

The purpose of this study was to evaluate the impact of endotracheal suctioning on intracranial dynamics in the acute phase of head injury. This study applied prospective nonrandomized research design and will include patients who admitted into neurosurgical ICU with intracranial pressure monitor (ICP monitor) in a medical center in Taipei city during August to November 2004. The researcher will visit to recruit subjects and subjects will be enrolled into investigate group after their family signing their informed consents. There were 6 Patients with 31 subjects were enrolled. During their stay in ICU, they will be suctioning when they need. Their heart rate, blood pressure, respiration rate, O2 Saturation (SpO2), ICP, EtCO2 and cerebral perfusion pressure (CPP) will be measured in the time.
The results revealed that: (1)There was significant difference between basic lining and recovery stage in ICP; (2) The BP still increased until the ICP had already recovered; (3) There was significant difference between basic lining and 1st hyperventilation stage in the changes of EtCO2; (4) The HR came back to the basic lining when the ICP had recovered; (5) The CPP was increased, when the ICP had back to the basic lining, it was still higher than the basic lining; (6) The CBF was decreased in suctioning, but the recovery stage was higher than the basic lining; (7) Sedation was useful to stabilize ICP.
This study can be used as a reference for nursing staff noticed in suctioning. Health care educators may integrate the results shown in this thesis into their curriculums. To care for a IICP patient, using this evidence-based practice, nurses can offer safe and scientific suctioning intervention to patients.

並列關鍵字

endotracheal suctioning ； intracranial pressure ； cerebral perfusion pressure ； acute head injury

參考文獻

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Carhuapoma, J. R., & Williams, M. A. (1999). Endotracheal suctioning and cerebral ischemia in traumatic brain injury: The "phantom menace?". Divisions of Neurosciences Critical Care, 27(12), 2843-2844.