重症监护环境下实施早期渐进性活动对卒中伴机械通气患者的影响

Effect of early progressive mobilization for stroke patients with mechanical ventilation in the neurointensive care unit

目的探讨在神经重症监护环境下对机械通气的重症卒中患者实施早期渐进性活动的安全性及有效性。方法回顾性连续纳入2018年4月至2019年7月首都医科大学宣武医院神经重症监护病房(NICU)收治的卒中患者42例,均为首次卒中且发病时间<48 h,平均美国国立卫生研究院卒中量表(NIHSS)评分为(19±4)分。根据干预方式的不同,将42例患者分为渐进性活动组和常规护理组,每组各21例。两组患者均接受常规临床治疗,包括生命体征及神经系统体征的监测和治疗、营养支持。常规护理组对患者进行吸痰、各类管路的护理及翻身叩背活动。渐进性活动组则依据多学科小组制定的渐进性活动策略在常规临床治疗的基础上实施从第一阶段至第四阶段包括身体功能训练、日常活动、环境干预等的康复活动。渐进性活动与翻身叩背活动每周连续5 d,1次/d,直至患者转出NICU。记录两组患者的总活动次数(渐进性活动组每进行1次渐进性活动或常规护理组每进行1次翻身扣背活动则记录为1次活动次数),收集患者的基线资料(性别、年龄、病史及卒中类型、卒中部位、NIHSS评分)、有效性评价指标(机械通气时间、谵妄发生率及NICU住院时长)及安全性评价指标(不良事件及潜在不良事件发生率)。结果两组患者各项基线资料差异均无统计学意义(均P>0.05)。安全性指标中,渐进性活动组的总活动次数227次,常规护理组的总活动次数(翻身扣背活动)309次,渐进活动组不良事件发生次数占总活动次数的1.76%(4/227),常规护理组占0.32%(1/309),组间差异无统计学意义(χ^(2)=0.168,P=0.168);渐进性活动组潜在不良事件发生率明显高于常规护理组[3.52%(8/227)比0.65%(2/309)],差异有统计学意义(χ^(2)=0.021,P=0.021)。有效性指标中,渐进性活动组患者的机械通气时间[(10±5)d比(15±8)d,t=2.070]、NICU住院时长[(14±6)d比(20±9)d,t=2.590]及谵妄发生率[9.52%(2/21)比42.86%(9/21)]均低于常规护理组,组间差异有统计学意义(均P<0.05)。结论NICU环境下,在多学科小组协作下实施多维度的早期渐进性活动,能够缩短重症卒中患者的机械通气时间,减少NICU住院时长并降低谵妄发生率,虽未出现严重安全事件,不良事件的发生率也较低,但早期活动可能导致更多潜在不良事件的发生,在活动实施过程中应更多关注潜在不良事件,以确保活动实施的安全性。

Objective To explore the safety and efficacy of implementing early progressive mobilization for mechanically ventilated stroke patients in the neurointensive care unit(NICU).Methods Forty-two stroke patients admitted to the NICU of Xuanwu Hospital,Capital Medical University from April 2018 to July 2019 were retrospectively included,all with first stroke and onset time<48 h.The National Institutes of Health stroke scale score was(19±4).According to the different ways of intervention,42 patients were divided into the progressive mobilization group and the standard nursing group with 21 patients in each group.Patients in both groups received routine clinical management,including monitoring and treatment of vital signs and neurological signs,and nutritional support.The standard nursing group received suctioning,lines care,turning and percussion activity.While,the progressive mobilization group received progressive mobilization(including mobilizations such as body function training,activities,environmental intervention,etc from the first stage to the fourth stage)based on a progressive mobilization strategy developed by a multidis ciplinary team.Turning and percussion activity and progressive mobilization for 5 consecutive days per week,once a day,until the patients were discharged from the NICU.Record the total number of mobilizations of patients in both groups(every one mobilization in the progressive mobilization group and one turn and percussion activity in the standard nursing group as once mobilization).The patients′baseline data(gender,age,medical history,stroke type,stroke location,NIHSS score),efficacy(duration of mechanical ventilation,incidence of delirium and length of stay in NICU)and safety indicators(incidence of adverse events and potential adverse events)of the treatment were collected.Results There was no statistically significant difference in baseline data between the two groups(all P>0.05).Among the safety indicators,the total number of mobilization in the progressive mobilization group was 227,and the total number of mobilization(turning and percussion activity)in the standard nursing group was 309.The incidence of adverse events was 1.76%(4/227)in the progressive mobilization group and 0.32%(1/309)in the standard nursing group.The comparison between the two groups was not statistically significant(χ^(2)=0.168,P=0.168).For potential adverse events,the incidence was significantly higher in the progressive mobilization group than in the standard nursing group(3.52%[8/227]vs.0.65%[2/309]),and the difference between the two groups was statistically significant(χ^(2)=0.021,P=0.021).Among the efficacy indicators,the duration of mechanical ventilation([10±5]d vs.[15±8]d,t=2.070),length of stay in NICU([14±6]d vs.[20±9]d,t=2.590)and incidence of delirium(9.52%[2/21]vs.42.86%[9/21])in the progressive mobilization group were lower than those in the standard nursing group,and the comparison between the two groups was statistically significant(all P<0.05).Conclusions The implementation of multi-dimensional early progressive mobilization in NICU with the collaboration of a multidisciplinary team has been found to shorten the duration of mechanical ventilation,reduce the length of stay in NICU and decrease the incidence of delirium in patients with severe stroke.Although there were no serious safety events and the incidence of adverse events was low,early mobilization may lead to more potential adverse events and more attention should be given to potential adverse events during the implementation of the mobilization to ensure the safety of the mobilization.