Implementation and evaluation of a paediatric nurse-driven sedation protocol in a paediatric intensive care unit
Implementation and evaluation of a paediatric nurse-driven sedation protocol in a paediatric intensive care unit
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DOI：
10.1186/s13613-017-0256-7
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发表时间：
2017-03-24
影响因子：
8.1
通讯作者：
Bordet, Fabienne
中科院分区：
文献类型：
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作者：
Dreyfus, Lelia;Javouhey, Etienne;Bordet, Fabienne
背景：最佳镇静和镇痛是儿科重症监护病房 (PICU) 的一项挑战，因为评分系统存在困难，且特定代谢会导致耐受和戒断。过度镇静与长时间机械通气和住院治疗有关。成人和儿童数据表明，目标导向的镇静算法可缩短机械通气的持续时间。我们在 PICU 实施了护士驱动的镇静方案并评估了其影响。方法：我们对 2013 年 1 月至 2015 年 3 月期间需要机械通气至少 24 小时的 0-18 岁儿童群体进行了方案实施前后研究。2014 年 1 月方案实施后，护士按照包括舒适行为量表 (COMFORT-B) 的算法管理镇痛和镇静。机械通气持续时间是主要结果；次要结局是药物总剂量和持续时间、PICU 住院时间、呼吸机相关肺炎的发生率以及戒断症状的发生率。采用前后分析和中断时间序列分段回归分析来评估方案的效果。结果：总共分析了 200 名儿童，其中方案实施前 107 名，方案实施后 93 名。方案实施后，每天机械通气的 COMFORT-B 评分总数显着增加，从实施前的 3.9 +/- 2.5 次增加到实施后的 6.6 +/- 3.5 次 (p < 10(-3))。实施后期间机械通气的平均持续时间往往较短（8.3 +/- 7.3 vs 6.6 +/- 5.6 天，p = 0.094），但通过分段回归分析，从实施前到实施后每三个月的趋势变化（p = 0.933）或实施后的立即变化（p = 0.923）并不显着。实施前后镇静剂总剂量、戒断症状、躁动发作或计划外气管拔管方面没有显着变化。结论：这些结果是有希望的，表明在 PICU 中实施护士驱动的镇静方案是可行的。方案实施后镇静镇痛效果评价较好；机械通气的持续时间和戒断症状的发生趋于减少。
Background: Optimal sedation and analgesia is a challenge in paediatric intensive care units (PICU) because of difficulties in scoring systems and specific metabolism inducing tolerance and withdrawal. Excessive sedation is associated with prolonged mechanical ventilation and hospitalisation. Adult and paediatric data suggest that goal-directed sedation algorithms reduce the duration of mechanical ventilation. We implemented a nurse-driven sedation protocol in a PICU and evaluated its impact.Methods: We conducted a before and after protocol implementation study in a population of children aged 0-18 years who required mechanical ventilation for at least 24 h between January 2013 and March 2015. After the protocol implementation in January 2014, nurses managed analgesia and sedation following an algorithm that included the COMFORT behaviour scale (COMFORT-B). Duration of mechanical ventilation was the primary outcome; secondary outcomes were total doses and duration of medications, PICU length of stay, incidence of ventilator-associated pneumonia, and occurrence of withdrawal symptoms. Pre-post analysis followed with segmented regression analysis of interrupted time series was used to assess the effect of protocol.Results: A total of 200 children were analysed, including 107 before implementation and 93 children after implementation of the protocol. After implementation of the protocol, the total number of COMFORT-B scores per day of mechanical ventilation significantly increased from 3.9 +/- 2.5 times during the pre-implementation period to 6.6 +/- 3.5 times during the post-implementation period (p < 10(-3)). Mean duration of mechanical ventilation tended to be lower in the post-implementation period (8.3 +/- 7.3 vs 6.6 +/- 5.6 days, p = 0.094), but changes in either the trend per trimester from pre-implementation to post-implementation (p = 0.933) or the immediate change after implementation (p = 0.923) were not significant with segmented regression analysis. No significant change between pre- and post-implementation was shown for total dose of sedatives, withdrawal symptoms, agitation episodes, or unplanned endotracheal extubations.Conclusions: These results were promising and suggested that implementation of a nurse-driven sedation protocol in a PICU was feasible. Evaluation of sedation and analgesia was better after the protocol implementation; duration of mechanical ventilation and occurrence of withdrawal symptoms tended to be reduced.