一例热射病导致横纹肌溶解综合征合并多器官功能衰竭综合征患者的循证护理

Evidence-based nursing of one heat stroke patient with rhabdomyolysis and multiple organ dysfunction syndrome

目的：运用循证护理方法,为一例采用连续性肾脏替代治疗（ CRRT）热射病（ HS）导致横纹肌溶解综合征（ RM）并合并多器官功能衰竭综合征（ MODS）患者制订合理的护理方案。方法在充分评估患者病情的基础上,根据 PICO 原则,提出临床问题,检索 Cochrane 图书馆、MEDLINE、PubMed、EBMR循证医学数据库、美国指南网、加拿大安大略注册护士协会、中国生物医学文摘数据库（ CBM）、万方数据库、中国期刊全文数据库（ CNKI）、中华医学会重症医学分会临床指南,查找高质量临床证据,并根据患者情况及家属意愿制订合理护理方案。结果共检索出有关HS/RM患者进行CRRT研究10篇, ICU中血液净化的应用指南1篇。证据表明：（1）HS合并RM患者应尽早给予CRRT,不仅可以早期降低体核温度,还能有效清除肌红蛋白,显著改善肾功能；（2）首选股静脉置管建立血管通路；（3）采用普通肝素全身抗凝时应定期行凝血的化验检查,密切观察出血情况；（4）不建议常规应用0.9%氯化钠溶液间断冲洗管路。综合文献信息并结合患者具体病情,通过与患者家属协商,为其制订出如下护理方案：早期采用CRRT,选择股静脉置管,给予普通肝素全身抗凝方案,密切观察出血情况,根据活化部分凝血酶时间（APTT）调整肝素剂量,没有使用0.9%氯化钠溶液间断冲洗管路。经过CRRT等综合治疗,患者七日后苏醒。肌红蛋白由入院的1455 ng/ml降到200 ng/ml,生命体征平稳。结论 HS合并RM患者应尽早给予CRRT,首选股静脉置管建立血管通路,采用普通肝素全身抗凝时应定期行凝血的化验检查,密切观察出血情况,不必常规应用0.9%氯化钠溶液间断冲洗管路。

Objective Using evidence-based nursing method to formulate an nursing program for one heat stroke （ HS） with rhabdomyolysis （ RM） and multiple organ dysfunction syndrome （ MODS） patient, who were treated by continuous renal replacement therapy（ CRRT） . Methods Based on fully assessing the patients′conditions, the clinical problems were put forward according to PICO principles. The Cochrane library, MEDLINE, PubMed, EBMR inquiry evidence-based medicine databases, National Guideline Clearinghouse, RNAO, CBM, WanFang database, CNKI and Critical Care Medicine Branch of Chinese Medical Association clinical guidelines were retrieved to collect high quality clinical evidence, and then the optimum nursing program was designed in line with patients′conditions and relatives′willingness. Results Ten trials and one application guideline were included. The available clinical evidence displayed that：（1）HS patient with RM should be given CRRT as soon as possible, it could not only reduce core body temperature, but also effectively removed myoglobin and significantly improved renal function; （ 2 ） Femoral vein catheter was the first choice for establishing vascular access;（3）The systemic anticoagulation with un-fractionated heparin should be scheduled for coagulation laboratory examination and closely observed the hemorrhage; （ 4 ） Routine use of intermittent saline flush pipes was not recommended. So finally a nursing plan was made in combination with literature evidence, patients′ condition and relatives′ willingness： we used CRRT early; choose femoral vein catheter;closely observed of hemorrhage and adjusted the dose of heparin according to activated partial thromboplastin time （ APTT） when using systemic anticoagulation with un-fractionated heparin, not used intermittent saline flush pipes. After CRRT and other comprehensive treatment, the patient regained consciousness after seven days. Myoglobin was down to 200 ng/ ml from 1 455 ng/ ml admission, with astable vital signs. Conclusions HS patients with RM should be given CRRT as soon as possible. Femoral vein catheter is the first choice for establishing vascular access. The systemic anticoagulation with un-fractionated heparin should be scheduled for coagulation laboratory examination and closely observed of hemorrhage. Routine use of intermittent saline flush pipes is not recommended.