【原创-专家共识】成人机械通气患者主动活动的安全标准

河南省医呼吸内科2020-06-29 07:54:36



Acquired Neuromuscular Disorders in the ICU

ICU-acquired weakness (ICUAW) refers to clinically detectable muscle weakness in

critically ill patients, in the absence of weakness caused by factors other than critical illness.Approximately one-third of critically ill patients have ICUAW.Possible etiologies may includemuscle atrophy/wasting, CIP, CIM, or a combination of these factors.

【翻译】ICU获得性神经肌肉紊乱

ICU获得性虚弱是指危重患者在缺乏虚弱致病因素条件下临床上可检测到的肌肉力量减弱,大约有三分之一的危重患者存在ICU获得性虚弱,可能的病因可能包括肌肉萎缩/消瘦,重症多发神经病变(critical illness polyneuropathy,CIP),重症多发肌肉病变(critical illness myopathy,CIM),或综合因素。

Risk Factors for Neuromuscular Disorders and Functional Impairment:

bed rest, corticosteroids, and neuromuscular blockers (NMBs). Among potential risk factors, bed rest is an important modifiable risk factor. Early mobilization and rehabilitation of critically ill patients may help prevent or mitigate the sequelae of bed rest and improve patient outcomes.

【翻译】神经肌肉紊乱和功能损害的危险因素

卧床、激素、神经肌肉阻断剂的使用,潜在的风险因素中,卧床制动是一个重要但可改变的危险因素。危重患者早期活动和康复可能有助于预防或减轻卧床制动的后遗症和改善患者的预后。

Sequelae of Neuromuscular Disorders

ICU-associated neuromuscular disorders have short- and long-term sequelae. Several

studies reported an association between ICUAW and delayed weaning from mechanical ventilation, increased in-hospital costs, and increased mortality.In addition, patients with ICUAW may have a significantly increased risk of death after discharge,and significant impairments in respiratory muscle strength, physical function, and health-related quality of life that persist for at least 2 years. Persistent physical impairment was also reported in other longitudinal studies that followed ARDS survivors up to 5 years following discharge.

【翻译】神经肌肉紊乱的后遗症

ICU相关性神经肌肉紊乱有短期和长期后遗症,一些研究报道了ICUAW和机械通气脱机延迟、增加住院費用以及增加死亡率之间的关联性。除此之外,ICU获得性虚弱的患者出院后死亡的风险大大增加,而且呼吸肌肉力量明显损害、身体功能和健康相关生活质量下降,这种影响至少持续2年之久。持续的身体损害在ARDS幸存者出院后长达5年的纵向研究中也有报道。

Safety of Early Mobilization and Rehabilitation

Mechanically ventilated patients are often considered to have a vulnerable hemodynamic and respiratory status, among other perceived barriers, that may interfere with mobilization.However, the reported rate of adverse events is very low, mostly in the form of transient physiological derangements that resolve without the need for any additional therapy. There is expert consensus that early mobilization and rehabilitation is safe and does not expose mechanically ventilated patients to any significant additional risk, as long as they are closely monitored during and after mobilization.

【翻译】早期活动和康复的安全性

影响机械通气患者活动的障碍中,最主要的是人们认为其呼吸循环状态脆弱,然而报道的不良事件的发生率是非常低的,大部分是短暂的生理性紊乱但很快就恢复了,不需要额外治疗。专家共识也同意早期动员和康复是安全的,只要医务人员在活动中和活动后密切监测,不会使机械通气患者有任何显著的额外风险。

Commonly Perceived Barriers to Early Mobilization and Rehabilitation

Cultural Barriers

In many centers, current ICU culture represents an important and potentially modifiable

barrier to early mobilization and rehabilitation. Insufficient coordination, timing conflicts with different procedures, and competing patient priorities are common.21,55,56,45 Overcoming these barriers requires a structured multidisciplinary effort, with clear communication and recognition of the importance of early mobilization and rehabilitation.57 Provision of critical care in an ICU with a culture that prioritizes early rehabilitation has been shown to increase the number of mechanically ventilated patients ambulating by three-fold.

【翻译】早期活动和康复的常见障碍

文化障碍

在很多重症医学中心,当前的ICU文化是早期活动和康复的一个重要和有可能改变的障碍。不充分的配合、不同治疗程序的时间冲突以及病人的选择,这些问题是常见的障碍。克服这些障碍需要一个有组织的多学科的共同努力,清楚的沟通和对早期活动和康复重要性的认识。具有优先进行早期康复理念的ICU提供的重症医学护理能够增加3倍的可运动的机械通气患者。

Sedation

The widespread use of sedation in the ICU can be a major barrier to mobilizing critically

ill patients.Combining sedation minimization with early mobility can be done via

implementing the ABCDE bundle,in which all patients undergo daily coordinated spontaneous awakening trials, spontaneous breathing trials, sedation and delirium screening, and early mobility and rehabilitation.A pre-post prospective study of 296 patients showed that applying this bundle was feasible and improved patient outcomes, such as reducing delirium and increasing mobilization out of bed.

Tips:(ABCDE bundle :the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle.)

镇静

ICU里广泛使用镇静剂可能是危重患者活动的一个主要的障碍。通过使用ABCDE bundle 策略可以把镇静最小化和早期活动联合起来。其中所有的患者接受每日唤醒试验,自主呼吸试验,镇静和谵妄筛查,以及早期活动和康复。一个纳入了296例患者的前-后对比的前瞻性研究表明,应用这一bundle策略是可行的而且改善了患者预后,如降低谵妄和增加床下活动能力。

Endotracheal Tube (ETT)

The presence of an ETT is another commonly perceived barrier.To assist with

overcoming this barrier, one study detailed the steps undertaken to start PT and OT interventions after a median of only 1.5 days of intubation in 49 endotracheally intubated patients.Patients underwent daily screening for ten contraindications to PT/OT interventions, followed by daily interruption of sedation until they achieved wakefulness, with PT/OT interventions initiated thereafter. Initiation of PT/OT interventions was preceded by securing the ETT, removing unnecessary noninvasive devices, and disconnecting enteral feedings. Rehabilitation interventions were completed on 90% of patient days. One third of sessions involved intubated patients moving from bed to chair and standing, and 15% involved intubated patients ambulating. Therapy was stopped prematurely in only 4% of all sessions, mostly due to ventilator dysynchrony.Figure 1

illustrates a patient mechanically ventilated via an ETT ambulating with a physical therapist in the ICU

气管内插管

气管内插管的存在是另外一个常见的障碍,为了帮助克服这一障碍,一个研究详细的说明了49例气管插管患者、平均插管后只有1.5天就介入物理治疗PT和作业治疗OT的流程,PT/OT每天筛查患者的十个禁忌症,调整镇静剂量直到患者保持清醒,随后PT/OT开始介入。首先确定气管内导管安全、移除不必要的无创的设备、断开肠内营养,然后进行具体的操作。康复介入天数约占患者住院天数的90%。三分之一的治疗过程包括插管病人从床上移动到座椅和站立,15%涉及插管患者的行走,仅仅只有4%的治疗过程大部分因通气不同步治疗出现短暂的暂停,上述图片举例说明了ICU里物理治疗师帮助一个气管插管机械通气的病人行走。

Femoral Catheters

Femoral catheters are a perceived barrier to early rehabilitation due to risk of accidental

removal, bleeding or infection.29 However, a study observed 101 MICU patients with a femoral catheter (81% venous, 29% arterial, and 6% hemodialysis) who had 253 PT sessions over 210 ICU days. Patients were able to perform in-bed exercises, supine cycle ergometry, and stand or walk in 38%, 12%, and 23% of days, respectively. There were no catheter-related adverse events.69 Similar results were obtained by other studies.

股导管

股导管因担心运动有导管意外脱出、出血、感染的风险而成为早期康复的另一障碍。然而有一项研究,对MICU里101例置有股导管的患者(81%静脉置管、29%动脉置管、6%血液透析置管)进行观察。在住院210天里进行了253节物理治疗,患者能够做到床上运动、仰卧位脚踏车运动、站立或步行的天数分别占到38%、12%和23%的总天数。而没有发生导管相关性的不良事件,其他的一些研究也得到了相似的结果。

Continuous Renal Replacement Therapy (CRRT)

The use of CRRT is another perceived barrier.21 However, a prospective single center

study including 57 consecutive patients (79% receiving mechanical ventilation) who received at least one PT session while undergoing CRRT demonstrated no safety events associated with CRRT.There was a total of 268 PT sessions that included in-bed exercises (29%), supine cycle ergometry (27%), sitting on edge of bed (30%), transferring to chair (5%), and standing or marching in place (9%). Similar results were obtained in another prospective study that also demonstrated potential improved CRRT filter life with patient mobilization.

持续性肾脏替代治疗(CRRT)

CRRT的使用是另一障碍。然而,一个包含57例患者(79%的患者存在机械通气)的单中心的前瞻性研究在CRRT运行中接受了至少一节PT治疗的情况下证明没有安全事件的发生。一共有268节PT治疗包括床上运动(29%)、仰卧位脚踏车运动(27%)、做在床边(30%)、转移到椅子上(5%)和在原地站立或步行(9%)。在另一项前瞻性研究也得到相似的结果,表明让患者活动可能改善CRRT滤芯使用时间。

Costs

Increased staffing and costs associated with early rehabilitation are commonly perceived

barriers. A controlled trial using a dedicated mobility team did not result in increased overall costs after accounting for extra costs related to the mobility team,39 with evidence of significantly decreased risk of readmission or death in the year after ICU dishcarge.74 Similarly, a QI project demonstrated a significant decrease in average MICU and hospital LOS.47 Using data from the QI project and other publications, a financial model for introducing ICU early mobilization and rehabilitation had 24 possible scenarios (ranging from conservative to best-case scenarios), 83% of which had net savings。

花费

增加人力成本和花费是开展早期康复常见的障碍。一项使用专门的康复训练团队的对照试验显示,康复训练团队的使用,在核算完额外的費用外并没有增加总成本,但是明显降低了ICU出院后一年中再入院或死亡的风险。类似地,一个质量改进项目也证明康复训练能够显著地降低平均MICU住院日和总住院日。介绍ICU早期活动和康复的24种可能的情况(从保守的到最好的情况)的一个财物模型,使用该项目和其他论著的数据,结果显示其中83%的项目是有净余额的。

专家共识和推荐成人机械通气患者主动活动安全标准的详细内容

【对象】ICU成人机械通气患者(病人主动参与且使用他们自己的肌肉力量和控制来协助活动)

医务人员:多学科团队(物理治疗师、医生、护士),临床医生有最终的决策权。

【方法】床上活动:病人在床上坐着或躺着的任何活动,例如:翻身、搭桥 、上肢负重训练(any activity undertaken whilst the patient is sitting or lying in bed such as rolling, bridging, upper-limb weight training)

       下床活动:病人坐在床的边缘上的任何活动(腿垂到床边晃来晃去),站立,走路,在原地行走或坐在床外的椅子上。(any activity where the patient sits over the edge of the bed (dangling), stands, walks, marches on the spot or sits out of bed.)

【强度】运动的强度,应由病人的力量和耐力以及评估安全标准来决定。The level of mobilization should be determined by the patient’s strength and endurance, as well as an assessment of the safety criteria.)

【时机评估】The safety criteria covered by the consensus group were divided into four categories: (1) respiratory considerations, including intubation status, ventilatory parameters and the need for adjunctive therapies; (2) cardiovascular considerations,including the presence of devices, cardiac arrhythmias and blood pressure; (3) neurological considerations, including level of consciousness, delirium and intracranial pressure, and (4) other considerations, including lines and surgical or medical conditions.

【翻译】由专家共识组所涵盖的安全标准为分为四大类:(1)呼吸道的考虑,

包括插管状态、通气参数和需要的辅助治疗;(2)心血管方面的考虑,

包括使用的设备,心律失常和血压;(3)神经系统的考虑,包括意识水平、谵妄和颅内压力(4)其他考虑,包括连接导管、外科或内科情况。

【评估方法】The consensus group agreed that a standard traffic-light system of recommendations would be used to assist clinicians in evaluating safety criteria, where red would indicate the need for caution as the risk of an adverse event, or consequences of an adverse event, was high, yellow would indicate that mobilization was possible, but only after further consideration and/or further discussion among the ICU multidisciplinary team, and green would indicate that the patient was safe to be mobilized (see Figure 1). It was agreed that the most conservatively scored parameter must take precedence over all other scores (for example, a single red would be sufficient to caution about the potential for high risk of an adverse event during mobilization, even if all other parameters were green).

【翻译】专家共识小组同意且推荐用交通灯系统帮助临床医生评估安全标准,红灯预示着需要小心不良事件发生的风险,或者不良事件的影响水平是高的;黄灯预示着患者活动是可能的,但是需要更深入的考虑和/或ICU多学科团队之间更加深入的讨论;绿灯预示着动员患者是安全的。而且认为评估风险时,最需谨慎的评分项目一定要高于所有其他的评分项目(如果只有一个红灯,而其他的参数都是绿灯,这一个红灯也足以表明患者运动中出现危险事件的潜在高风险性)。


Figure 1 Color coding definitions.





参考文献:Hashem MD, Parker AM, Needham DM, Early Mobilization and Rehabilitation of the Critically Ill Patient, CHEST (2016), doi: 10.1016/j.chest.2016.03.003.

Hodgson et al. Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults  Critical Care (2014) 18:658 DOI 10.1186/s13054-014-0658-y

翻译校对:林松(物理治疗学硕士,MPT)、忽新刚、刘智达


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