体外循环心脏手术中体温管理循证实践

Evidence-based Body Temperature Management in Cardiopulmonary Bypass Surgery

目的通过应用前期研究制定的体外循环心脏手术中体温管理证据,以规范术中体温管理操作行为保障患者安全。方法采用JBI循证实践证据应用程序,按照基线审查、临床实践变革、证据应用后质量审查3个阶段实施循证实践。根据前期研究获得的证据制订临床审查指标进行基线审查,分析障碍因素,制订行动策略将证据在临床应用,然后实施证据应用后审查。结果证据应用前后,术中鼻咽温、氧合器动脉出口温度、氧合器静脉入口温度比较,差异无统计学意义(P>0.05),术中膀胱温比较差异有统计学意义(P<0.05);不同时间点的鼻咽温、氧合器动脉出口温度、氧合器静脉入口温度比较,差异有统计学意义(P<0.05),膀胱温比较差异无统计学意义(P>0.05);不同时间点的鼻咽温、膀胱温、氧合器动脉出口温度、氧合器静脉入口温度与证据应用前后交互无统计学意义(P>0.05)。证据应用后低体温、寒颤、躁动发生率分别为16.7%、6.7%、13.3%,对比基线审查时分别为36.7%、26.7%、40.0%,差异具有统计学意义(P<0.05)。培训前后心脏专科小组护士及体外循环师相关知识考核成绩分别为(76.25±9.62)分,(91.25±6.35)分,差异具有统计学意义(P<0.001)。基线审查时手术室护士对审查指标1、2、3的执行率分别为63%、27%、100%,其余审查指标执行率均在20%以下,证据应用后,审查指标2、4-15的执行率均有明显提高,差异具有统计学意义(P<0.05)。结论基于证据的体温管理策略在体外循环心脏手术中应用,可规范临床操作行为,提高护士术中体温管理的科学性与执行依从性,有效保护术中心肌、大脑细胞及神经组织,降低相关并发症,确保体外循环手术患者术中安全。

Objective To formulate body temperature management plan in cardiopulmonary bypass surgery based on evidence-based practice and to standardize clinical practice and promote continuous quality improvement of body temperature management.Methods With the JBI model of evidence-based healthcare(baseline data review,clinical reform and evidence audit),according to the evidence obtained in the preliminary research,corresponding clinical review indicators and review methods were developed,obstacles were reviewed and analyzed,then the strategies were formulated and the evidence was audited after the application.Results There was no significant difference in the intraoperative nasopharyngeal temperature,oxygenator artery outlet temperature and oxygenator venous inlet temperature before and after the application of the evidence(P>0.05),and the difference in intraoperative bladder temperature was statistically significant(P<0.05).There were statistically significant differences in nasopharyngeal temperature,oxygenator arterial outlet temperature and oxygenator venous inlet temperature at different time points(P<0.05),and the difference in bladder temperature was not statistically significant(P>0.05);at different time points the nasopharyngeal temperature,bladder temperature,oxygenator artery outlet temperature and the oxygenator vein inlet temperature were not statistically significant(P>0.05)before and after the application of the evidence.The incidences of hypothermia,chills,and restlessness after the application of the best evidence were 16.7%,6.7%,and 13.3%respectively.The difference before the application of the evidence was statistically significant(P<0.001).After the evidence was applied,the intraoperative nasopharyngeal temperature and bladder temperature,oxygenator artery outlet and venous inlet temperature were uniformly lower,and the cooling and rewarming rates were both<0.5℃/min.Before and after the training,the score of intraoperative temperature management related knowledge of the nurses in cardiology specialist team and cardiopulmonary bypass specialists was 76.25±9.62 and 91.25±6.35 respectively,and the difference was statistically significant(P<0.001).Before the application of the best evidence,the operating room nurses'implementation rate of the review indicators 1,2 and 3 was 63%,27%,and 100%,respectively.The implementation rate of the remaining review indicators was all below 20%.After the best evidence was applied,the implementation rate of 2,4-15 had been significantly improved,and the difference was statistically significant(P<0.05).Conclusion Evidence-based temperature management strategies in cardiopulmonary bypass surgery are beneficial for standardizing clinical practice,improving the compliance of nurses in intraoperative temperature management for effective protection of intraoperative myocardium,brain cells and nerve tissue,and reducing related complications to ensure the safety of patients undergoing cardiopulmonary bypass surgery.