改良护理治疗策略对老年免疫抑制肺部感染脓毒症患者预后的影响

Effect of improved nursing strategy on prognosis of older immunosuppressed patients with pneumonia and sepsis

目的:探讨改良护理治疗策略对老年免疫抑制肺部感染脓毒症患者预后的影响。方法:采用前瞻性研究方法,选择2017年1月至2022年7月北京协和医院重症医学科和急诊重症监护病房(ICU)收治的老年免疫抑制肺部感染脓毒症患者。第一阶段(2017年1月至2019年12月)患者接受原护理治疗策略(原护理治疗策略组),包括护理人员随机分组、常规终末消毒、每日2次ICU环境消毒、每日2次洗必泰口腔护理及原有肺部物理治疗〔床头抬高30°~45°、维持镇静深度Richmond躁动?-?镇静评分(RASS)-2~1分、按需吸痰〕;护理人员及相关医护人员经1个月改良护理治疗策略的学习和培训后,第二阶段(2020年2月至2022年7月)患者接受改良护理治疗策略(改良护理治疗策略组),即在原护理治疗策略基础上改良院感防控策略及肺部物理治疗策略,包括护理人员固定分组、对患者采取单独物理隔离、强化终末消毒策略、每日4次ICU环境消毒、加强护理人员手卫生教育及培训、每日1次2%葡萄糖酸洗必泰擦浴、6 h 1次洗必泰联合多黏菌素口腔护理、定植菌监测、改良肺部物理治疗策略(在原有肺部物理治疗基础上进行常规谵妄评分以指导患者早期活动;强化气道引流,适度气道湿化,目标痰液黏度Ⅱ级;床旁超声评估肺部情况,肺不张者采取高侧卧位及肺复张)。收集患者性别、年龄、基础疾病、患者来源、疾病严重程度评分、生命体征、呼吸机参数、血气分析结果、生命支持治疗、实验室指标、感染及炎症指标、感染病原体和药物治疗情况;主要结局为28 d病死率,次要结局为机械通气时间、ICU住院时间和ICU病死率。采用多因素Logistic回归分析筛选老年免疫抑制肺部感染脓毒症患者28 d死亡危险因素。结果:最终共纳入550例患者,其中原护理治疗策略组199例,改良护理治疗策略组351例。两组患者性别、年龄、基础疾病、患者来源、疾病严重程度评分、生命体征、呼吸机参数、血气分析结果、生命支持治疗、实验室指标、感染及炎症指标、感染病原体和药物治疗等差异均无统计学意义。与原护理治疗策略组相比,改良护理治疗策略组患者机械通气时间及ICU住院时间均明显缩短〔机械通气时间(d):5(4,7)比5(4,9),ICU住院时间(d):11(6,17)比12(6,23),均 P<0.01〕,ICU病死率和28 d病死率均明显降低〔ICU病死率:23.9%(84/351)比32.7%(65/199),28 d病死率:23.1%(81/351)比33.7%(67/199),均 P<0.05〕。多因素Logistic回归分析显示,改良护理治疗策略是老年免疫抑制肺部感染脓毒症患者28 d死亡的保护因素〔优势比( OR)=0.543,95%可信区间(95% CI)为0.334~0.885, P=0.014〕。 结论:改良护理治疗策略缩短了老年免疫抑制肺部感染脓毒症患者机械通气时间及ICU住院时间,降低了患者ICU病死率及28 d病死率,可明显改善此类患者的短期预后。

ObjectiveTo investigate the effect of improved nursing strategy on prognosis of older immunosuppressed patients with pneumonia and sepsis.MethodsA prospective study was conducted.The older immunosuppressed patients with pneumonia and sepsis admitted to the department of intensive care medicine and emergency intensive care unit(ICU)of Peking Union Medical College Hospital from January 2017 to July 2022 were enrolled.In the first stage(from January 2017 to December 2019),patients received the original nursing strategy(original nursing strategy group),including:①nurses were randomly assigned;②routine terminal cleaning;③ICU environmental cleaning twice a day;④oral care was performed with chlorhexidine twice a day;⑤original lung physiotherapy[head of bed elevated at 30°-45°,maintaining a Richmond agitation-sedation scale(RASS)-2 to 1,sputum aspiration as needed].After 1 month of learning and training of the modified nursing treatment strategy for nurses and related medical staff,the patients in the second stage(from February 2020 to July 2022)received the improved nursing strategy(improved nursing strategy group).The improved nursing strategy improved the hospital infection prevention and control strategy and lung physical therapy strategy on the basis of the original nursing strategy,including:①nurses were fixed assigned;②patients were placed in a private room;③enhanced terminal cleaning;④ICU environmental cleaning four times a day;⑤education and training in hand hygiene among health care workers was improved;⑥bathing with 2%chlorhexidinegluconate was performed once daily;⑦oral care with a combination of chlorhexidine and colistin was provided every 6 hours;⑧surveillance of colonization was conducted;⑨improved lung physiotherapy(on the basis of the original lung physiotherapy,delirium score was assessed to guide early mobilization of the patients;airway drainage was enhanced,the degree of airway humidification was adjusted according to the sputum properties,achieving sputum viscosity gradeⅡ;lung ultrasound was also used for lung assessment,and patients with atelectasis were placed in high lateral position and received the lung recruitment maneuver).Baseline patient information were collected,including gender,age,underlying diseases,source of admission,disease severity scores,vital signs,ventilatory parameters,blood gas analysis,life-sustaining treatments,clinical laboratory evaluation,indicators of infection and inflammation,pathogens and drug therapy.The primary outcome was 28-day mortality,and the secondary outcomes were duration of mechanical ventilation,length of ICU stay,and ICU mortality.Multivariate Logistic regression analysis was used to determine the risk factors for 28-day death in older immunosuppressed patients with pneumonia and sepsis.ResultsFinally,550 patients were enrolled,including 199 patients in the original nursing strategy group and 351 patients in the improved nursing strategy group.No significant differences were found in gender,age,underlying diseases,source of admission,disease severity scores,vital signs,ventilatory parameters,blood gas analysis,life-sustaining treatments,clinical laboratory evaluation,indicators of infection and inflammation,coexisting pathogens or drug therapy between the two groups.Compared with patients in the original nursing strategy group,those in the improved nursing strategy group had significantly fewer duration of mechanical ventilation and length of ICU stay[duration of mechanical ventilation(days):5(4,7)vs.5(4,9),length of ICU stay(days):11(6,17)vs.12(6,23),both P<0.01],and lower ICU mortality and 28-day mortality[ICU mortality:23.9%(84/351)vs.32.7%(65/199),28-day mortality:23.1%(81/351)vs.33.7%(67/199),both P<0.05].Multivariate Logistic regression analysis showed that the improved nursing strategy acted as an independent protective factor in 28-day death of older immunosuppressed patients with pneumonia and sepsis[odds ratio(OR)=0.543,95%confidence interval(95%CI)was 0.334-0.885,P=0.014].ConclusionImproved nursing strategy shortened the duration of mechanical ventilation and the length of ICU stay,and decreased ICU mortality and 28-day mortality in older immunosuppressed patients with pneumonia and sepsis,significantly improving the short-term prognosis of such patients.