ICU机械通气患者早期目标导向康复锻炼安全标准的系统评价

Safety criteria for early goal-oriented rehabilition exercise in patients undergoing mechanical ventilation in intensive care unit:a systematic review

目的通过系统评价方法确定重症加强治疗病房(ICU)机械通气患者早期目标导向康复锻炼的安全标准。方法应用计算机检索中国生物医学文献数据库(CBM)、中国期刊全文数据库(CNKI)、万方数据库、美国国立医学图书馆PubMed数据库、Cochrane图书馆数据库、科学网(Web of Science)数据库发布的有关ICU机械通气患者早期活动的随机对照临床试验(RCT)和队列研究,并辅以其他检索方法,检索时间为建库至2018年3月。RCT研究的干预方案为对照组采用ICU常规护理,观察组在对照组基础上进行早期活动;队列研究的干预方案为早期活动,无对照组。早期活动方案主要包括床上主被动活动、坐立、床椅转移、站立和行走。由2名研究者独立进行文献筛选及资料提取,收集安全标准涉及的心血管系统、呼吸系统、神经系统、骨科系统和其他的相关变量或参数,并针对每个系统收集至少3篇文献使用的变量或参数;分别根据Cochrane5.1.0系统评价方法或纽卡斯尔-渥太华文献质量评价量表(NOS)对RCT研究或队列研究进行质量评价。结果共纳入24篇有关ICU机械通气患者早期活动的文献,涉及患者4647例,其中RCT研究11项,涉及患者1031例,对照组509例、观察组522例;队列研究13项,涉及患者3616例。系统评价显示,ICU机械通气患者早期活动的安全标准共涉及5个系统、20个变量或参数。其中心血管系统8个变量或参数,包括40次/min<心率(HR)<130次/min(n=4)、血流动力学稳定(n=5)、无心肌梗死(n=3)、无心律失常(n=4)、无血管活性药物(n=4)、90mmHg<收缩压(SBP)<200mmHg(1mmHg=0.133kPa,n=4)、65mmHg≤平均动脉压(MAP)≤110mmHg(n=3)、无心肺复苏(CPR)史(n=5)。呼吸系统4个变量或参数,包括5次/min<呼吸频率(RR)<40次/min(n=5)、吸入氧浓度(FiO2)≤0.60和呼气末正压(PEEP)≤10cmH2O(1cmH2O=0.098kPa,n=4)、FiO2<0.60或PEEP<10cmH2O(n=3)、脉搏血氧饱和度(SpO2)>0.88(n=5)。神经系统4个变量,包括无神经肌肉疾病(n=7)、无颅内压升高(n=7)、无昏迷(n=4)、理解并做出正确动作(n=4)。骨科系统2个变量,包括无骨折(n=3)、无不稳定性骨折(n=8)。其他因素2个变量,包括无腹部开放性伤口(n=4)、无姑息治疗(n=3)。结论ICU机械通气患者早期目标导向康复锻炼的安全标准涉及心血管系统、呼吸系统、神经系统、骨科系统和其他5个方面,其中心血管系统和呼吸系统变量或参数最多;目前不同文献报道各系统安全标准及其变量或参数的一致性较高,但具体参数仍有待高质量研究进一步验证。

Objective To determine the safety criteria for early goal-oriented rehabilition exercise in patients undergoing mechanical ventilation in intensive care unit (ICU) by systematic review. Methods Randomized controlled trails (RCTs) and cohort studies about early goal-oriented rehabilition exercise in patients undergoing mechanical ventilation in ICU were retrieved in CBM, CNKI, Wanfang Data, PubMed, Cochrane Library and Web of Science from their foundation to March 2018, and other sources as supplement was also retrieved. The intervention program of RCT study was ICU routine nursing in control group, early activity in observation group, and early activity in cohort study without control group. Early activities included active and passive activities on the bed, sitting upright, bed-chair transfer, standing and walking. Literature screening and data extraction were performed independently by two researchers. Variables or parameters related to cardiovascular, respiratory, nervous, orthopedic and other systems were collected for safety criteria. Variables or parameters used in at least three literatures were collected for each system. Cochrane 5.1.0 was used to evaluate the quality of RCT study, and Newcastle-Ottawa scale (NOS) was used to evaluate the quality of cohort study. Results A total of 24 articles about early activity of patients undergoing mechanical ventilation in ICU were enrolled, involving 4647 patients, including 11 RCT studies involving 1031 patients, 509 in control group and 522 in observation group;13 cohort studies including 3616 patients. It was shown by systematic review that safety criteria for early activity in patients undergoing mechanical ventilation in ICU involved five systems, 20 variables or parameters. The cardiovascular system included 8 variables or parameters, such as 40 bpm < heart rate (HR) < 130 bpm (n = 4), hemodynamic stability (n = 5), no myocardial infarction (n = 3), no arrhythmia (n = 4), no vascular active drugs (n = 4), 90 mmHg < systolic blood pressure (SBP) < 200 mmHg (1 mmHg = 0.133 kPa, n = 4), 65 mmHg ≤ mean arterial pressure (MAP) ≤ 110 mmHg (n = 3), no history of cardiopulmonary resuscitation (CPR, n = 5). The respiratory system included 4 variables or parameters, involving 5 times/min < respiratory rate (RR) < 40 times/min (n = 5), fraction of inspired oxygen (FiO2) ≤ 0.60 and positive end-expiratory pressure (PEEP) ≤ 10 cmH2O (1 cmH2O = 0.098 kPa, n = 4), FiO2 < 0.60 or PEEP < 10 cmH2O (n = 3), pulse blood oxygenation (SpO2) > 0.88 (n = 5). The nervous system included 4 variables, including no neuromuscular disease (n = 7), no increase in intracranial pressure (n = 7), no coma (n = 4), understand and do the right thing (n = 4). The orthopedic system included 2 variables, including no fracture (n = 3), no unstable fracture (n = 8). Other factors included 2 variables, including no open abdomen wound (n = 4), and no palliative care (n = 3). Conclusions This study identified safety criteria for early goal-directed rehabilition exercise in patients undergoing mechanical ventilation in ICU included five systems of cardiovascular, respiratory, neurological, orthopedic, and other systems, in which cardiovascular and respiratory systems were the most frequently cited variables or parameters. The consistency of each system security criteria or variables reported by different literatures was high, but the parameters need to be further verified by high-quality study.