经食管心脏超声在ICU机械通气患者中应用的学习曲线研究

Learning curve for transesophageal echocardiography applied in mechanically ventilated patients in intensive care unit

目的 探讨经食管心脏超声（TEE）在外科重症医学科（SICU）中应用的学习曲线.方法 采用前瞻性观察性研究方法,连续纳入2016年12月至2017年6月中山大学附属第一医院SICU收治的需行TEE检查的机械通气患者60例,由同一位具有熟练经胸心脏超声（TTE）操作技能的医师对患者完成TEE检查.观察TEE插管情况（插管次数、一次成功插管时间、插管时间）、TEE检查情况（TEE检查评分、TEE检查时间）及TEE并发症;按TEE检查顺序,每12例为一组进行统计学分析,通过学习曲线观察该SICU医师经过多少例TEE检查可以熟练掌握该技术.结果 随着该SICU医师完成TEE检查例数的增加,一次成功插管时间、全部插管时间均逐渐缩短;TEE检查评分逐渐增加,TEE检查时间逐渐缩短.①TEE插管情况：60例患者的插管次数均衡（F=0.258,P=0.904）.该SICU医师完成12例TEE插管后,一次成功插管时间即明显缩短（s：22.24±18.37比34.88±1.65,P＜0.05）,之后稳定在16~23 s.学习曲线显示,完成24例TEE插管后即基本掌握插管技术.②TEE检查情况：该SICU医师完成24例TEE插管后,TEE检查评分明显升高（分：40.08±7.27比23.67±9.70,P＜0.05）,之后稳定在40~47分;完成24例TEE插管后,TEE检查时间明显缩短（min：39.97±6.67比58.22±14.19,P＜0.05）,并在完成36例后进一步缩短（31.04±7.84比39.97±6.67,P＜0.05）.学习曲线显示,完成36例TEE检查即基本掌握TEE检查技术.结论 一位具有熟练TTE操作经验的SICU医师通过36次TEE检查,即可基本掌握该技术,48次可达到较为熟练的程度,一次成功插管时间可稳定在约20 s,检查时间稳定在约30 min.

Objective To investigate the learning curve of transesophageal echocardiography （TEE） applied in mechanically ventilated patients in intensive care unit （ICU）.Methods A prospective observation study was conducted. A total of 60 consecutive patients necessary for mechanical ventilation and TEE examination admitted to the Department of Surgical ICU of the First Affiliated Hospital of Sun Yat-Sen University from December 2016 to June 2017 were enrolled. The TEE examination was performed by the same ICU physician who was skilled in transthoracic echocardiography （TTE）. The TEE probe intubation （trial numbers of TEE intubation, the duration for a successful intubation at the first attempt, the total time for successful intubation）, TEE examination （the scores of TEE examination, the duration of TEE examination）, and the complication during examination were observed, with learning curve established. According to the date of examination, a statistical analysis was carried out for each group of 12 cases. Through the learning curve, that TEE examinations in how many cases should be performed by the ICU physician to master the skill was observed.Results With the increase of TEE examinations performed by the physician, the duration for a successful intubation at the first attempt and the total time for successful intubation were gradually reduced; the scores of TEE examination were gradually increased, and the duration of TEE examination gradually reduced. ① TEE intubation： there was no statistical significant difference among the 60 patients in the number of intubation attempts （F = 0.258,P = 0.904）. After the SICU doctor completed TEE intubations in 12 cases, the duration for a successful intubation at the first attempt was significantly reduced （seconds： 22.24±18.37 vs. 34.88±1.65,P 〈 0.05） and then tended to stabilize in the 16 - 23 seconds. The learning curve indicated that the physician could basically master the intubation skills after performing TEE intubations in 24 cases. ② TEE examination： after the physician completed TEE intubations in 24 cases, the TEE examination scores were increased significantly （40.08±7.27 vs. 23.67±9.70,P 〈 0.05）, and then tended to stabilize in the 40 - 47 scores; after TEE intubations were performed in 24 cases, the examination duration was significantly shortened （minutes： 39.97±6.67 vs. 58.22±14.19,P 〈 0.05）, and after 36 cases were completed, the duration could be further shortened （minutes：31.04±7.84 vs. 39.97±6.67,P 〈 0.05）. The learning curve indicated that the ICU physician could basically master the examination skills when TEE examinations were completed in 36 cases. In addition, no serious complications occurred during the TEE examination.Conclusions A SICU physician with skilled TTE experience can basically master the TEE technology through 36 times of examinations, and reach full mastery after 48 times, the duration for a successful intubation at the first attempt could be stabilized at 20 seconds, and the examination duration could be stabilized at 30 minutes.