發(fā)布時(shí)間：2018-01-12 06:15

  本文關(guān)鍵詞：早期康復(fù)訓(xùn)練對(duì)冠狀動(dòng)脈搭橋術(shù)后脫呼吸機(jī)困難患者治療的影響　出處：《青島大學(xué)》2017年博士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 冠狀動(dòng)脈搭橋術(shù) 脫呼吸機(jī)困難 ICU獲得性衰弱 康復(fù)訓(xùn)練

【摘要】：目的:冠狀動(dòng)脈搭橋術(shù)(Coronary Artery Bypass Graft,CABG)是嚴(yán)重冠狀動(dòng)脈病變患者的有效治療方案,重癥患者常需術(shù)后入住重癥醫(yī)學(xué)科(ICU)繼續(xù)治療。CABG術(shù)后患者常出現(xiàn)脫呼吸機(jī)困難,目前報(bào)道較多的康復(fù)訓(xùn)練均是針對(duì)CABG術(shù)后能夠自主呼吸的患者,尚無針對(duì)ICU的CABG術(shù)后脫呼吸機(jī)困難患者進(jìn)行早期康復(fù)訓(xùn)練治療的報(bào)道。因此,我們進(jìn)行了以下臨床實(shí)驗(yàn)研究:(1)早期康復(fù)訓(xùn)練對(duì)ICU的機(jī)械通氣患者治療的安全性和有效性評(píng)估;(2)早期康復(fù)訓(xùn)練對(duì)ICU的CABG術(shù)后脫呼吸機(jī)困難患者治療的安全性和效果,并探討其可能的機(jī)制。方法:(1)選擇2010年5月至2012年5月在青島大學(xué)附屬醫(yī)院重癥醫(yī)學(xué)科(ICU)住院治療的氣管插管或者氣管切開的機(jī)械通氣患者60例,隨機(jī)分為康復(fù)組和對(duì)照組,每組各30例。早期康復(fù)訓(xùn)練包括循序漸進(jìn)的6個(gè)步驟:主動(dòng)抬頭、由平臥位到坐位、端坐床邊、床旁坐位、床旁站立和床旁行走。最初在護(hù)士和醫(yī)師的協(xié)助下完成,逐漸過渡到患者獨(dú)立完成。每日進(jìn)行兩次康復(fù)訓(xùn)練,每一次都是從主動(dòng)抬頭開始,如果達(dá)到試驗(yàn)終止的標(biāo)準(zhǔn),當(dāng)日活動(dòng)結(jié)束,第二天活動(dòng)照常進(jìn)行�；颊咴诳祻�(fù)訓(xùn)練中暫停腸內(nèi)營(yíng)養(yǎng),白天停用鎮(zhèn)靜劑或者在活動(dòng)前1~2 h停用藥物,停藥后當(dāng)患者能夠聽懂指令,并能夠做出配合性指令動(dòng)作時(shí),再進(jìn)行康復(fù)訓(xùn)練。在康復(fù)訓(xùn)練期間連續(xù)監(jiān)測(cè)患者的脈搏氧飽和度,心電圖和血壓。(2)選擇2012年6月至2015年5月在青島大學(xué)附屬醫(yī)院重癥醫(yī)學(xué)科(ICU)的CABG術(shù)后患者106例,隨機(jī)分為早期康復(fù)訓(xùn)練組(53例)和對(duì)照組(53例)。術(shù)前向患者及家屬介紹冠心病及CABG的基本知識(shí)及術(shù)后的康復(fù)訓(xùn)練,及時(shí)解除患者的焦慮和恐懼心理,以及如何避免心血管疾病的危險(xiǎn)因素包括控制血糖、降低血脂、減肥以及降低高血壓、戒煙、穩(wěn)定情緒等,以及飲食指導(dǎo)、心理咨詢等。早期康復(fù)訓(xùn)練由循序漸進(jìn)的6個(gè)步驟組成:主動(dòng)抬頭、由平臥位到坐位、端坐床邊、床旁坐位、床旁站立和床旁行走。早期康復(fù)訓(xùn)練組患者在ICU接受早期康復(fù)訓(xùn)練,對(duì)照組在轉(zhuǎn)出ICU后進(jìn)行康復(fù)治療。康復(fù)訓(xùn)練步驟及注意事項(xiàng)同方法(1)。在進(jìn)行康復(fù)訓(xùn)練計(jì)劃前和轉(zhuǎn)出ICU時(shí)對(duì)患者進(jìn)行肌力評(píng)分,采用英國(guó)醫(yī)學(xué)研究委員會(huì)(Medical Research Council,MRC)量表作為工具,選取患者的頸部和上肢及下肢的共6組肌肉群進(jìn)行評(píng)價(jià),每個(gè)肌肉群的得分范圍為0分(癱瘓)~5分(正常肌力),最高分為60分。如果評(píng)估的總分48分,即可診斷為ICU獲得性衰弱。結(jié)果:(1)兩組患者的年齡、性別、體重指數(shù)、APACHE II評(píng)分、最高Fi O2、最低Pa O2/Fi O2、住院死亡率無明顯差別(P0.05)。早期康復(fù)訓(xùn)練顯著減少了康復(fù)組的首次床旁坐位時(shí)間(康復(fù)組:3.8±1.2 d;對(duì)照組:14.9±4.7 d,P0.01)、機(jī)械通氣時(shí)間(康復(fù)組:5.6±2.1 d;對(duì)照組:7.3±2.8 d,P0.01)和ICU住院時(shí)間(康復(fù)組:12.7±4.1 d;對(duì)照組:15.2±4.5 d,P0.01)。(2)早期康復(fù)訓(xùn)練顯著減少了CABG術(shù)后患者的機(jī)械通氣時(shí)間(早期康復(fù)訓(xùn)練組:8.1±3.3 d;對(duì)照組:13.9±4.1 d,P0.01)、總住院時(shí)間(早期康復(fù)訓(xùn)練組:22.0±3.8 d;對(duì)照組:29.1±4.6 d,P0.01)和ICU住院時(shí)間(早期康復(fù)訓(xùn)練組:11.7±3.2 d;對(duì)照組:18.3±4.2 d,P0.01),MRC評(píng)分較高(康復(fù)訓(xùn)練組:52±3.8;對(duì)照組:45±3.7,P0.01),ICU-AW的患者明顯減少(康復(fù)訓(xùn)練組:0;對(duì)照組:28,P0.01),Pa O2/Fi O2較高(康復(fù)訓(xùn)練組:253.2±29.2mm Hg;對(duì)照組:224.2±43.1mm Hg,P0.01)。Kaplan-Meier統(tǒng)計(jì)結(jié)果表明,經(jīng)過七天的康復(fù)訓(xùn)練,對(duì)照組的患者需要機(jī)械通氣的比例明顯高于早期康復(fù)訓(xùn)練組(log-rank檢驗(yàn):P0.01)。兩組的住院死亡率沒有顯著差異(P=0.65)。采用線性回歸方法對(duì)年齡、體重指數(shù)、Pa O2/Fi O2、MRC評(píng)分和APACHE II評(píng)分等機(jī)械通氣時(shí)間的影響因素進(jìn)行分析,APACHE II評(píng)分的決定系數(shù)大于其他參數(shù)�？祻�(fù)訓(xùn)練組中2例患者和對(duì)照組中3例患者在轉(zhuǎn)至普通病房后,死于疾病的并發(fā)癥。在康復(fù)訓(xùn)練組的53例患者中,沒有嚴(yán)重的不良事件發(fā)生,只有2例患者在康復(fù)訓(xùn)練站起來后出現(xiàn)體位性低血壓,立即上床平臥位,很快好轉(zhuǎn)。結(jié)論:(1)ICU的機(jī)械通氣患者進(jìn)行適度的早期康復(fù)訓(xùn)練是安全的,可明顯改善患者的預(yù)后。(2)對(duì)ICU的CABG術(shù)后脫呼吸機(jī)困難患者進(jìn)行早期康復(fù)訓(xùn)練是安全有效的,早期康復(fù)訓(xùn)練減少了患者的機(jī)械通氣時(shí)間、總住院時(shí)間和ICU住院時(shí)間及ICU-AW的例數(shù)。APACHE II評(píng)分用來評(píng)估機(jī)械通氣的時(shí)間可能更準(zhǔn)確,APACHE II評(píng)分越高的患者進(jìn)行機(jī)械通氣的時(shí)間越長(zhǎng)。意義:當(dāng)前,重癥醫(yī)學(xué)領(lǐng)域的醫(yī)療技術(shù)水平飛速提高,越來越多的危重病患者經(jīng)過救治能夠存活下來。但是,很多危重病患者因?yàn)镮CU-AW而出現(xiàn)了機(jī)械通氣時(shí)間延長(zhǎng),脫呼吸機(jī)困難。住ICU的時(shí)間和總住院時(shí)間延長(zhǎng),甚至在出院后遺留機(jī)體功能障礙,最終使患者的存活率下降,影響了出院后的生活質(zhì)量。CABG是嚴(yán)重的三支冠狀動(dòng)脈(即左前降支、回旋支、右冠狀動(dòng)脈)發(fā)生病變的患者的有效治療方案之一。在CABG術(shù)后,即使針對(duì)發(fā)生脫呼吸機(jī)困難的危險(xiǎn)因素進(jìn)行預(yù)防,仍然會(huì)出現(xiàn)呼吸機(jī)依賴的情況,甚至出現(xiàn)急性心功能衰竭和惡性心律失常等不良事件。對(duì)于CABG術(shù)后的患者進(jìn)行心臟康復(fù),包括:早期康復(fù)訓(xùn)練、醫(yī)學(xué)綜合評(píng)價(jià)、管控危險(xiǎn)因子、醫(yī)學(xué)營(yíng)養(yǎng)指導(dǎo)以及心理咨詢等,可以早日撤離呼吸機(jī),轉(zhuǎn)出ICU,改善患者預(yù)后,減少住院費(fèi)用及護(hù)理負(fù)擔(dān)。由于CABG的患者病情重,甚至在早期時(shí)生命體征不平穩(wěn),因此進(jìn)行早期康復(fù)訓(xùn)練有一定難度。在我們的研究中,患者在一個(gè)護(hù)士和一個(gè)醫(yī)師的幫助下即可以完成早期康復(fù)訓(xùn)練,需要的設(shè)備也是日常經(jīng)常使用的,因此這種模式可以被廣泛推廣。
[Abstract]:Objective: coronary artery bypass grafting (Coronary Artery Bypass Graft, CABG) is an effective treatment for patients with severe coronary artery disease, patients often need postoperative stay in ICU (ICU) to treat.CABG patients often appear off the ventilator difficulties, the rehabilitation training reported were aimed at CABG after operation can be independent breathing, there is no ICU for CABG patients off ventilator difficulties reported early rehabilitation training in the treatment. Therefore, we conducted the following experiments: (1) the clinical safety and efficacy of early rehabilitation training on patients with ICU mechanical ventilation treatment evaluation; (2) early rehabilitation training on CABG operation ICU off after the treatment of patients with ventilator difficult safety and efficacy, and to explore its possible mechanism. Methods: (1) from May 2010 to May 2012 in the Affiliated Hospital of Qiingdao University hospital (ICU) The treatment of tracheal intubation or tracheotomy for mechanical ventilation in patients with 60 cases, were randomly divided into rehabilitation group and control group, 30 cases in each group. Early rehabilitation training includes 6 steps: step by step active up, from supine to sitting, sitting beside the bed, bedside sitting, standing and walking beside the bed beside the bed. The initial completion the nurse and doctor's help, a gradual transition to the patients independently. Daily rehabilitative training for two times, each time from the beginning of active rise, if reached the end of the experiment of the standard, the end of the event, the second day activities as usual. Patients with suspension of enteral nutrition in the rehabilitation of the disabled in the daytime, tranquilizers or before the 1~2 h stop taking the drug after the drug was stopped when the patient can understand instructions, and be able to make the instruction with the action, then the rehabilitation training in rehabilitation training. During the continuous monitoring of pulse oxygen saturation and electrocardiogram of patients. Blood pressure. (2) from June 2012 to May 2015 in the Affiliated Hospital of Qiingdao University (ICU) in 106 patients after CABG were randomly divided into early rehabilitation group (53 cases) and control group (53 cases). Preoperative rehabilitation training to the patients and their family members introduced the basic knowledge of coronary heart disease and CABG and postoperative, relieve the patient's anxiety and fear in a timely manner, and how to avoid the risk factors of cardiovascular disease including control of blood glucose, reduce blood fat, lose weight and reduce blood pressure, smoking, emotional stability, and diet guidance, psychological counseling and early rehabilitation training. By 6 steps: step by step from supine position to head up actively. Sitting, sitting beside the bed, bedside sitting, standing and walking beside the bed beside the bed. Early rehabilitation group received early rehabilitation training in ICU, the control group in the roll out of ICU after rehabilitation. Rehabilitation training steps and precautions with 鏂規(guī)硶(1).鍦ㄨ繘琛屽悍澶嶈��緇冭�″垝鍓嶅拰铦{鍑篒CU鏃跺�规�(zhèn)ｈ，

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