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2015-CC-ICU機(jī)械通氣患者早期活動(dòng)與預(yù)后
ICU機(jī)械通氣患者早期活動(dòng)與預(yù)后兩個(gè)國(guó)家、多中心、前瞻性隊(duì)列研究Introduction: The aim of this study was to investigate current mobilization practice, strength at ICUdischarge and functional recovery at 6 months among mechanically ventilated ICUpatients.目的：探討ICU機(jī)械通氣患者住院時(shí)早期活動(dòng)情況及出ICU時(shí)力量與6個(gè)月功能恢復(fù)之間的關(guān)系。Method: This was aprospective, multi-centre, cohort study conducted in twelve ICUs in Australiaand New Zealand. Patients were previously functionally independent and expectedto be ventilated for >48 hours. We measured mobilization during invasiveventilation, sedation depth using the Richmond Agitation and Sedation Scale(RASS), co-interventions, duration of mechanical ventilation, ICU-acquiredweakness (ICUAW) at ICU discharge, mortality at day 90, and 6-month functionalrecovery including return to work.方法：本研究為澳大利亞和新西蘭12個(gè)ICU進(jìn)行的前瞻性、多中心、隊(duì)列研究，納入發(fā)病前肢體活動(dòng)功能正常，預(yù)計(jì)機(jī)械通氣時(shí)間大于48h的患者。評(píng)估有創(chuàng)機(jī)械通氣時(shí)活動(dòng)程度、采用RASS評(píng)價(jià)鎮(zhèn)靜深度，記錄合并治療、機(jī)械通氣持續(xù)時(shí)間、轉(zhuǎn)出ICU時(shí)是否出現(xiàn)ICU獲得性肌無(wú)力(ICUAW)，90天病死率以及6個(gè)月(包括恢復(fù)工作后)功能恢復(fù)情況。Results: We studied 192patients (mean age 58.1 ± 15.8 years; mean Acute Physiology and Chronic HealthEvaluation (APACHE) (IQR) II score, 18.0 (14 to 24)). Mortality at day 90 was26.6% (51/192). Over 1,351 study days, we collected information during 1,288planned early mobilization episodes in patients on mechanical ventilation forthe first 14 days or until extubation (whichever occurred first). We recordedthe highest level of early mobilization. Despite the presence of dedicatedphysical therapy staff, no mobilization occurred in 1,079 (84%) of theseepisodes. Where mobilization occurred, the maximum levels of mobilization wereexercises in bed (N = 94, 7%), standing at the bed side (N = 11, 0.9%) orwalking (N = 26, 2%). On day three, all patients who were mobilized weremechanically ventilated via an endotracheal tube (N = 10), whereas by day five50% of the patients mobilized were mechanically ventilated via a tracheostomytube (N = 18). In 94 of the 156 ICU survivors, strength was assessed at ICUdischarge and 48 (52%) had ICU-acquired weakness (Medical Research CouncilManual Muscle Test Sum Score (MRC-SS) score <0.0001).結(jié)果：本研究共納入192例患者(平均年齡58.1±15.8歲，平均APACHE評(píng)分18(14~24)。90天病死率為26.6%(51/192)。在1351個(gè)研究日內(nèi)，記錄患者機(jī)械通氣14天內(nèi)或拔管前(機(jī)械通氣14天或拔管前取其短)的共1288次計(jì)劃早期活動(dòng)事件，并記錄機(jī)械通氣患者早期活動(dòng)最大程度。結(jié)果發(fā)現(xiàn)盡管有專業(yè)理療師參與，仍有1079(84%)次患者沒(méi)有進(jìn)行早期活動(dòng)。而進(jìn)行早期活動(dòng)患者的最高程度是臥床鍛煉(N=94，7%)，站立(N=11，0.9%)或者散步(N=26，2%)。在機(jī)械通氣第三天活動(dòng)的患者都是經(jīng)氣管插管進(jìn)行機(jī)械通氣(N=10)，而在機(jī)械通氣第五天，50%活動(dòng)患者是經(jīng)氣管切開(kāi)進(jìn)行機(jī)械通氣。
156例存活患者中有94例存活患者在出ICU時(shí)進(jìn)行了活動(dòng)力量的評(píng)價(jià)，其中48例(52%)發(fā)生了ICU獲得性肌無(wú)力(醫(yī)學(xué)研究理事會(huì)人工肌肉測(cè)試評(píng)分，MRC-SS<48/60)。進(jìn)行早期活動(dòng)的機(jī)械通氣患者M(jìn)RC-SS評(píng)分明顯高于未活動(dòng)的患者(50±11.2比42.0±10.8，P=0.003)。另外，出ICU時(shí)存活而在90天內(nèi)死亡患者平均MRC評(píng)分(28.9±13.2)明顯低于90天存活患者(44.9±11.4，P<0.0001)。Conclusions: Earlymobilization of patients receiving mechanical ventilation was uncommon. Morethan 50% of patients discharged from the ICU had developed ICU-acquiredweakness, which was associated with death between ICU discharge and day-90.結(jié)論：ICU內(nèi)機(jī)械通氣患者早期活動(dòng)較少。超過(guò)50%的出ICU患者出現(xiàn)ICU獲得性肌無(wú)力，ICU獲得性肌無(wú)力與患者出ICU 后90天內(nèi)死亡相關(guān)。文/劉松橋，陳紅齊 文審/邱海波 排版/張星星 審核/劉松橋，謝劍鋒
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