早期康复训练对冠状动脉搭桥术后脱呼吸机困难患者治疗的影响

发布时间：2018-01-12 06:15

  本文关键词：早期康复训练对冠状动脉搭桥术后脱呼吸机困难患者治疗的影响　出处：《青岛大学》2017年博士论文　论文类型：学位论文

  更多相关文章： 冠状动脉搭桥术 脱呼吸机困难 ICU获得性衰弱 康复训练

【摘要】：目的:冠状动脉搭桥术(Coronary Artery Bypass Graft,CABG)是严重冠状动脉病变患者的有效治疗方案,重症患者常需术后入住重症医学科(ICU)继续治疗。CABG术后患者常出现脱呼吸机困难,目前报道较多的康复训练均是针对CABG术后能够自主呼吸的患者,尚无针对ICU的CABG术后脱呼吸机困难患者进行早期康复训练治疗的报道。因此,我们进行了以下临床实验研究:(1)早期康复训练对ICU的机械通气患者治疗的安全性和有效性评估;(2)早期康复训练对ICU的CABG术后脱呼吸机困难患者治疗的安全性和效果,并探讨其可能的机制。方法:(1)选择2010年5月至2012年5月在青岛大学附属医院重症医学科(ICU)住院治疗的气管插管或者气管切开的机械通气患者60例,随机分为康复组和对照组,每组各30例。早期康复训练包括循序渐进的6个步骤:主动抬头、由平卧位到坐位、端坐床边、床旁坐位、床旁站立和床旁行走。最初在护士和医师的协助下完成,逐渐过渡到患者独立完成。每日进行两次康复训练,每一次都是从主动抬头开始,如果达到试验终止的标准,当日活动结束,第二天活动照常进行。患者在康复训练中暂停肠内营养,白天停用镇静剂或者在活动前1~2 h停用药物,停药后当患者能够听懂指令,并能够做出配合性指令动作时,再进行康复训练。在康复训练期间连续监测患者的脉搏氧饱和度,心电图和血压。(2)选择2012年6月至2015年5月在青岛大学附属医院重症医学科(ICU)的CABG术后患者106例,随机分为早期康复训练组(53例)和对照组(53例)。术前向患者及家属介绍冠心病及CABG的基本知识及术后的康复训练,及时解除患者的焦虑和恐惧心理,以及如何避免心血管疾病的危险因素包括控制血糖、降低血脂、减肥以及降低高血压、戒烟、稳定情绪等,以及饮食指导、心理咨询等。早期康复训练由循序渐进的6个步骤组成:主动抬头、由平卧位到坐位、端坐床边、床旁坐位、床旁站立和床旁行走。早期康复训练组患者在ICU接受早期康复训练,对照组在转出ICU后进行康复治疗。康复训练步骤及注意事项同方法(1)。在进行康复训练计划前和转出ICU时对患者进行肌力评分,采用英国医学研究委员会(Medical Research Council,MRC)量表作为工具,选取患者的颈部和上肢及下肢的共6组肌肉群进行评价,每个肌肉群的得分范围为0分(瘫痪)~5分(正常肌力),最高分为60分。如果评估的总分48分,即可诊断为ICU获得性衰弱。结果:(1)两组患者的年龄、性别、体重指数、APACHE II评分、最高Fi O2、最低Pa O2/Fi O2、住院死亡率无明显差别(P0.05)。早期康复训练显著减少了康复组的首次床旁坐位时间(康复组:3.8±1.2 d;对照组:14.9±4.7 d,P0.01)、机械通气时间(康复组:5.6±2.1 d;对照组:7.3±2.8 d,P0.01)和ICU住院时间(康复组:12.7±4.1 d;对照组:15.2±4.5 d,P0.01)。(2)早期康复训练显著减少了CABG术后患者的机械通气时间(早期康复训练组:8.1±3.3 d;对照组:13.9±4.1 d,P0.01)、总住院时间(早期康复训练组:22.0±3.8 d;对照组:29.1±4.6 d,P0.01)和ICU住院时间(早期康复训练组:11.7±3.2 d;对照组:18.3±4.2 d,P0.01),MRC评分较高(康复训练组:52±3.8;对照组:45±3.7,P0.01),ICU-AW的患者明显减少(康复训练组:0;对照组:28,P0.01),Pa O2/Fi O2较高(康复训练组:253.2±29.2mm Hg;对照组:224.2±43.1mm Hg,P0.01)。Kaplan-Meier统计结果表明,经过七天的康复训练,对照组的患者需要机械通气的比例明显高于早期康复训练组(log-rank检验:P0.01)。两组的住院死亡率没有显著差异(P=0.65)。采用线性回归方法对年龄、体重指数、Pa O2/Fi O2、MRC评分和APACHE II评分等机械通气时间的影响因素进行分析,APACHE II评分的决定系数大于其他参数。康复训练组中2例患者和对照组中3例患者在转至普通病房后,死于疾病的并发症。在康复训练组的53例患者中,没有严重的不良事件发生,只有2例患者在康复训练站起来后出现体位性低血压,立即上床平卧位,很快好转。结论:(1)ICU的机械通气患者进行适度的早期康复训练是安全的,可明显改善患者的预后。(2)对ICU的CABG术后脱呼吸机困难患者进行早期康复训练是安全有效的,早期康复训练减少了患者的机械通气时间、总住院时间和ICU住院时间及ICU-AW的例数。APACHE II评分用来评估机械通气的时间可能更准确,APACHE II评分越高的患者进行机械通气的时间越长。意义:当前,重症医学领域的医疗技术水平飞速提高,越来越多的危重病患者经过救治能够存活下来。但是,很多危重病患者因为ICU-AW而出现了机械通气时间延长,脱呼吸机困难。住ICU的时间和总住院时间延长,甚至在出院后遗留机体功能障碍,最终使患者的存活率下降,影响了出院后的生活质量。CABG是严重的三支冠状动脉(即左前降支、回旋支、右冠状动脉)发生病变的患者的有效治疗方案之一。在CABG术后,即使针对发生脱呼吸机困难的危险因素进行预防,仍然会出现呼吸机依赖的情况,甚至出现急性心功能衰竭和恶性心律失常等不良事件。对于CABG术后的患者进行心脏康复,包括:早期康复训练、医学综合评价、管控危险因子、医学营养指导以及心理咨询等,可以早日撤离呼吸机,转出ICU,改善患者预后,减少住院费用及护理负担。由于CABG的患者病情重,甚至在早期时生命体征不平稳,因此进行早期康复训练有一定难度。在我们的研究中,患者在一个护士和一个医师的帮助下即可以完成早期康复训练,需要的设备也是日常经常使用的,因此这种模式可以被广泛推广。
[Abstract]:Objective: coronary artery bypass grafting (Coronary Artery Bypass Graft, CABG) is an effective treatment for patients with severe coronary artery disease, patients often need postoperative stay in ICU (ICU) to treat.CABG patients often appear off the ventilator difficulties, the rehabilitation training reported were aimed at CABG after operation can be independent breathing, there is no ICU for CABG patients off ventilator difficulties reported early rehabilitation training in the treatment. Therefore, we conducted the following experiments: (1) the clinical safety and efficacy of early rehabilitation training on patients with ICU mechanical ventilation treatment evaluation; (2) early rehabilitation training on CABG operation ICU off after the treatment of patients with ventilator difficult safety and efficacy, and to explore its possible mechanism. Methods: (1) from May 2010 to May 2012 in the Affiliated Hospital of Qiingdao University hospital (ICU) The treatment of tracheal intubation or tracheotomy for mechanical ventilation in patients with 60 cases, were randomly divided into rehabilitation group and control group, 30 cases in each group. Early rehabilitation training includes 6 steps: step by step active up, from supine to sitting, sitting beside the bed, bedside sitting, standing and walking beside the bed beside the bed. The initial completion the nurse and doctor's help, a gradual transition to the patients independently. Daily rehabilitative training for two times, each time from the beginning of active rise, if reached the end of the experiment of the standard, the end of the event, the second day activities as usual. Patients with suspension of enteral nutrition in the rehabilitation of the disabled in the daytime, tranquilizers or before the 1~2 h stop taking the drug after the drug was stopped when the patient can understand instructions, and be able to make the instruction with the action, then the rehabilitation training in rehabilitation training. During the continuous monitoring of pulse oxygen saturation and electrocardiogram of patients. Blood pressure. (2) from June 2012 to May 2015 in the Affiliated Hospital of Qiingdao University (ICU) in 106 patients after CABG were randomly divided into early rehabilitation group (53 cases) and control group (53 cases). Preoperative rehabilitation training to the patients and their family members introduced the basic knowledge of coronary heart disease and CABG and postoperative, relieve the patient's anxiety and fear in a timely manner, and how to avoid the risk factors of cardiovascular disease including control of blood glucose, reduce blood fat, lose weight and reduce blood pressure, smoking, emotional stability, and diet guidance, psychological counseling and early rehabilitation training. By 6 steps: step by step from supine position to head up actively. Sitting, sitting beside the bed, bedside sitting, standing and walking beside the bed beside the bed. Early rehabilitation group received early rehabilitation training in ICU, the control group in the roll out of ICU after rehabilitation. Rehabilitation training steps and precautions with 鏂规硶(1).鍦ㄨ繘琛屽悍澶嶈��缁冭�″垝鍓嶅拰杞�鍑篒CU鏃跺�规偅瑁�

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