本帖最後由 lsc0019 於 2009-5-28 22:33 編輯
作者：Laurie Barclay, MD
出處：WebMD醫學新聞
May 13, 2009 — 根據發表於5月13日線上版Lancet期刊的隨機控制試驗結果，重症病患在使用機械性輔助呼吸治療的最初幾天中斷鎮靜，進行物理和職能治療，結果會比標準照護為佳。
賓州大學的William D. Schweickert醫師寫道，重症病患的長期併發症包括加護病房(ICU)造成的虛弱以及神經精神疾病。因為鎮靜而造成的無法移動可能會惡化這些問題。我們併用日間中斷鎮靜與物理及職能治療，評估對於在加護病房內接受機械式輔助呼吸病患之功能性結果的影響。
納入規範包括使用鎮靜劑的成人、18歲以上、於醫院的ICU住院、使用機械式輔助呼吸至少72小時、預期仍需繼續使用機械式輔助呼吸至少24小時、開始時有功能性獨立。我們使用電腦產生的塊狀排列隨機分派，將兩家大學醫院的104名病患指派到介入組(n = 49)或控制組(n = 55)。在日間中斷鎮靜的期間，介入組的病患接受物理和職能治療進行早期的運動與移動。控制組病患依照最初照護團隊處方的治療進行日間鎮靜中斷。
由不清楚本項治療方式的治療師為病患進行評估。研究的主要結果是在出院時恢復到獨立功能狀態的病患數，獨立功能狀態的定義為可獨立步行且可以進行6種日常活動。次級結果測量為住院的最初28天內發生瞻妄的期間以及不用呼吸器的天數。
所有104名病患都被納入治療意向分析，出院時，介入組有29名(59%)病患恢復到獨立功能狀態，控制組則有19名(35%) (P = .02; 勝算比 2.7; 95% CI，1.2 - 6.1)。相較於控制組病患，介入組病患的瞻妄期間較短(平均2.0天; 四分位差[IQR]0.0 - 6.0，相較於平均4.0天；四分位差2.0 - 8.0；P = .02)。在28天的追蹤期間，介入組的病患不用呼吸器的天數比控制組多(平均23.5天；IQR7.4 - 25.6，相較於平均21.1天；IQR 0.0 - 23.8；P = .05)。
在全部的498次治療療程中，有1例嚴重不良反應，氧氣飽和度低於80%。全部療程中，因為病患不穩定性而導致中斷治療的有19次(4%)，多數是因為病患-呼吸器之間無法同步。
研究作者寫道，相較於標準照護組，全身復健的策略－中斷鎮靜，在重症初期進行物理和職能治療－是安全且耐受良好的，且在出院時獲得較佳的功能性結果，較短的瞻妄期間，不用呼吸器的天數較多。此研究指出，對於接受機械式輔助呼吸之重症病患，協同有助於存活和心理及生理恢復之多元療法，可以達成很好的結果。
研究限制包括缺乏不知情的病患和健康照護提供者，研究規範未能管理處置決策，其他可能的干擾因素，缺乏運用到所有接受機械式輔助呼吸病患的一般性。
瑞士柏恩大學醫院的Stephan M. Jakob醫師和Jukka Takala醫師在編輯評論中指出，透過運動保留肌肉強度可以改善重症病患的結果。
Jakob醫師和Takala醫師寫道，雖然物理治療在美國經常被用於加護病房的重症復原病患，各類醫院和臨床狀況下，物理治療類型和頻率有著相當大的差異。雖然早期運動對於機械輔助呼吸天數、獨立功能以及行走的效果是可以理解的，但對於瞻妄的影響仍需多加注意。
本研究未接受資金，研究作者與評論人宣告沒有相關資金上的往來。
Lancet. 線上發表於2009年5月13日。
Interrupting Sedation for Early Mobilization in Critically Ill Patients May Improve Outcomes
By Laurie Barclay, MD
Medscape Medical News
May 13, 2009 — Interrupting sedation in the earliest days of treatment to give mechanically ventilated, critically ill patients physical and occupational therapy was associated with better outcomes than standard care, according to the results of a randomized controlled trial reported in the May 13 Online First issue of The Lancet.
"Long-term complications of critical illness include intensive care unit (ICU)-acquired weakness and neuropsychiatric disease," write William D. Schweickert, MD, from the University of Pennsylvania in Philadelphia. "Immobilisation secondary to sedation might potentiate these problems. We assessed the efficacy of combining daily interruption of sedation with physical and occupational therapy on functional outcomes in patients receiving mechanical ventilation in intensive care."
Inclusion criteria were sedated adults, 18 years or older, hospitalized in the ICU, using mechanical ventilation for less than 72 hours, expected to need mechanical ventilation for at least 24 hours, and functional independence at baseline. With use of computer-generated, permuted block randomization, 104 patients at 2 university hospitals were assigned to an intervention group (n = 49) or to a control group (n = 55). During periods of daily interruption of sedation, patients in the intervention group received early exercise and mobilization with physical and occupational therapy. Patients in the control group had daily interruption of sedation with therapy as prescribed by the primary care team.
Patients were evaluated by therapists blinded to treatment assignment. The main outcome of the study was the number of patients who at hospital discharge had returned to independent functional status, which was defined as independent ambulation and the ability to perform 6?activities of daily living. Secondary outcome measures were duration of delirium and ventilator-free days during the first 28 days of hospitalization.
All 104 patients were included in the analysis, which was by intent-to-treat. At hospital discharge, 29 patients (59%) in the intervention group had returned to independent functional status, as had 19 patients (35%) in the control group (P = .02; odds ratio, 2.7; 95% CI, 1.2 - 6.1). Compared with patients in the control group, those in the intervention group had shorter duration of delirium (median, 2.0 days; interquartile range [IQR], 0.0 - 6.0 vs median, 4.0 days; IQR, 2.0 - 8.0; P = .02). During the 28-day follow-up period, patients in the intervention group also had more ventilator-free days vs patients in the control group (median, 23.5 days; IQR, 7.4 - 25.6 vs median, 21.1 days; IQR, 0.0 - 23.8; P = .05).
In a total of 498 therapy sessions, there was 1 serious adverse event, which was desaturation less than 80%. Patient instability resulting in discontinuation of therapy occurred in 19 (4%) of all sessions, most often because of perceived patient-ventilator asynchrony.
"A strategy for whole-body rehabilitation — consisting of interruption of sedation and physical and occupational therapy in the earliest days of critical illness — was safe and well tolerated, and resulted in better functional outcomes at hospital discharge, a shorter duration of delirium, and more ventilator-free days compared with standard care," the study authors write. "This study highlights the robust outcomes that can be achieved with the coordinated efforts of multiple disciplines dedicated to the survival and mental and physical recovery of critically ill patients receiving mechanical ventilation."
Limitations of this study include lack of blinding of patients and healthcare providers, management decisions not controlled by protocol, other possible confounding factors, and lack of generalizability to all patients receiving mechanical ventilation.
In an accompanying comment, Stephan M. Jakob and Jukka Takala, from University Hospital in Bern, Switzerland, note that preservation of muscle strength through exercise could improve outcomes in critically ill patients.
"Although physiotherapy is commonly administered to patients in intensive care during recovery from critical illness in the USA, the frequency and type of physiotherapy greatly varies between the type of hospital and clinical scenarios," Drs. Jakob and Takala write. "Although the effect of early exercise on days on mechanical ventilation, independent function, and ambulation is comprehensible, the effect on delirium deserves further attention."
This study has received no funding, and the study authors and commentators have disclosed no relevant financial relationships.
Lancet. Published online May 13, 2009. |
|
