| BackgroundPainless endoscopy means patients feel no pain and no consciousness during the procedure, at the same time, patients can maintain hemodynamic and respiratory stability, as well as avoid restlessness. Clinical study of USA chest Department of internal medicine physicians2011retrospective study and Taiwan Chang Gung Memorial Hospital were found that, in the absence of clear contraindications, using a combination of surface anesthesia, sedation and analgesia can make patients more tolerance for the examination and improve the patient’s satisfactory, and reduce complications.Bispectral index and cerebral state monitoring are kinds of intuitive sedation assessment technology. In1998, the application of cerebral state monitor in elderly patients undergoing general anesthesia operation, reduce the operation risk and accident occurred during general anesthesia in elderly patients. In2002, cerebral state monitoring is widely used in critically ill patients in ICU in the USA, provide strong support for the intermittent sedation, to shorten the average waiting time of mechanical ventilation and the time.stay in ICU. Since2003, China has such reports: "The feasibility of the sedation sedation in patients with with Midazolam administered by target-controlled infusion in surgical Intensive Care Unit patients on the feedback of Bispectral Index’and "The application of cerebral state monitoring in coma patients with consciousness state evaluation.’After10years development, although the cerebral state monitoring has been widely used, there are no reports of cerebral state monitor used in painless fiberoptic bronchoscopy. The reason may be the following several aspects:first, the painless fiberoptic bronchoscopy in outpatients always be short, and the patients general condition often stable, so the sedative drugs make less effects on their hemodynamic and respiratory. For saving medical cost, the painless fiberoptic bronchoscopy in outpatients with no sedation monitoring. Second, the bedside monitoring technology tightly support patients in ICU, ICU doctors are good at respiratory and cardiovascular system, abnormal situation can be effective treatment to correct, so there is no sedative depth monitoring.In fact, fiberoptic bronchoscopy often stimulate patients throat which results strong discomfort, cough, vomiting and other symptoms. Patients with throat reaction is often accompanied by hemodynamic changes, such as increased heart rate, increase or decrease blood pressure etc. Patients with Coronary disease may lead to myocardial ischemia and sudden crisis life. Although the monitoring instrument in ICU can detect these changes, but how to avoid this abnormal volatility is more important than treatment, because life signs and hemodynamic stability is much more important for critically ill patients. In this study, the cerebral state monitor is using in painless fiberoptic bronchoscopy, not only control the dose of sedative drugs which can maintain the stable of hemodynamics,but also provide technical support for nursing.The purpose of the study The cerebral state monitor is using on patients with the painless fiberoptic bronchoscopy procedure in Emergency Intensive Care Unit (EICU). To evaluate the effect and depth of sedation, regulation of drugs, individualize the drugs for patients, to get the purpose of reducing the hemodynamic fluctuations, and guide nursing observations.Research methods1. The object of study subjects(1) Source and quantityAccording to the inclusion criteria, we choose60cases, during2011October to2012October. Randomly divided into2groups.(2) The inclusion criteria and exclusion criteriaInclusion criteria:①patients with bedside fiberoptic bronchoscope treatment in EICU;②without the history of drinking and long-term use of drugs;③hmodynamics stable.Exclusion criteria:①chronic obstructive pulmonary emphysema in acute period;②the early time of acute respiratory distress syndrome;③coagulation abnormalities;④the hemodynamic instability, need of vasoactive drugs to maintain blood pressure, severe shock patients;⑤damage of brain function;⑥severe electrolyte disorder.2. Methods(1)Grouping and evaluation standardThe observation group connected to the cerebral state monitor, to complete the fiberoptic bronchoscopy examination with sustained sedation depth monitoring; the control group using Ramsay Score to evaluate the sedation depth. The both group adjust the dose of sedation drugs according to the monitoring results. At the end, compare the dose and frequency of sedation drugs, hemodynamic changes, blood gas changes, the incidence of adverse events and the difference of nursing workload.(2)Method for cerebral state monitoring In this study, the cerebral state monitoring instrument is UP-800awareness level multi parameter monitor and its sub machine, used in this study is the sub machine part. The sub machine to data line by connecting in patients with frontal, temporal and ear electrodes mastoid obtaining natural EEG patients (Spontaneous EEG) by fuzzy logic analyzer (adaptive neural fuzzy inference system ANFIS) derived CSI quantify the patient’s brain function state and level of consciousness, wireless data transmission to CSM host acquired obtain real-time monitoring image and can persist through numerical data, sub machine can directly read the cerebral state index, to understand the depth of sedation in patients with.(3) Ramsay score methodAdequate sedation:Ramsay score is level5-6; diagnostic and therapeutic procedures: Ramsay score is level3-4. Fiberoptic bronchoscopy in the treatment of operation, so the control group sedation depth should be controlled in Ramsay score level3-4.(4) TreatmentBefore the operation, we need to explain the operation and applications to patients and their families and get theit consent. All cases were monitoring by the bedside multifunctional monitor(heart rate, blood pressure, oxygen saturation, breathing)during the fiberoptic bronchoscopy.After intravenous injection of propofol, to make sure patients get the target of sedation, began bronchoscopy after given Lidocaine surface anesthesia.Continuous monitoring of vital signs in the whole operation process, including heart rate, pulse, respiration and blood pressure; continuous monitoring of sedation depth, and determine whether to additional drugs, according to the evaluation results.(5) Nursing measuresThe both group were given nursing measures for the same. Before the operation, nurse have to explain the details of the bronchoscopy to obtain the cooperation of the patients.During the operation, nurses need to pay more attention to observe the changes of vital signs,especially to the early signs of complications and adverse events, such as laryngeal spasm, hypoxemia, cardiac arrhythmia, irritability and so. After the operation, close monitoring of vital signs of patients for30minutes.3. Evaluation indexIn the whole operation process,60patients will be continuous monitoring invasive blood pressure, heart rate and oxygen saturation, we get the figure in every3minutes during the procedure, the blood gas, the species and frequency of adverse events and the nursing workload. Using SPSS16.0to analysis the difference of hemodynamics stabilization and workload between the two group which has different sedation depth.4. Statistical methods(1Statistical analysis using SPSS16.0software(2) Using Paired Samples t Test to analysis vital signs.(blood pressure, breath, pulse, heart rate, pH value, PO2,PCO2)(3) Using Repeated Measures Analysis of Variance to analysis the repeated figure of vital signs during the procedure.(4) Using Mean-Whitney Test to analysis the delivery frequency, delivery amount and the time cumulative.(5)Using T test to analysis the nursing workload.(6) Using the Chi square test to analysis the difference of adverse event rates between the two group.(7) Using T test to analysis the investigation result of the comfort of patients and the satisfactory of doctors.Result1. Hemodynamic changes60patients in the whole operation process for continuous invasive monitoring of blood pressure, and systolic blood pressure, diastolic blood pressure, heart rate and oxygen saturation in the pre operation, operation and operation (maximum and minimum value) value. After statistical analysis, to observe the minimum set of systolic and diastolic blood pressure and the control group had significant difference, but the two groups of patients with systolic pressure, diastolic pressure in significant difference before and after operation and the maximum difference of continuous measurement (P<0.001), the patients with systolic and diastolic blood pressure changes smaller than, hemodynamics stable. In addition, blood gas analysis, the observation group pH value close to the normal value than that of the control group, suggesting that the observation group pH values better returned to the normal range have significant difference (t=4.794,P<0.001).2.The use of sedative drugsThe observation group and the control group of the times of administration by significantly different (Z=3.891, P<0.001), suggesting that the observed group administration times less than that of the control group, there was statistically significant difference; there are significant sedative drugs (Z=4.442, P<0.001), the total description of the observation group use sedative doses significantly less than the control group(Z=8.781, P<0.001). Using the cerebral state monitor real-time observation can reasonably control the depth of sedation sedative drugs.3. Adverse events and nursingAdverse events observed in this study include choking, bite tube, and tube and a large amount of bleeding, the observation group and the control group in all the incidence of adverse events were not statistically significant, given by a small amount of expected sedative sedative effect.The observation group nurses can directly read the cerebral state monitor numerical report doctor, immediately decide whether to medicine, sedation assessment of patients in the control group of patients, pat must call, pain and other behavior to the current, so the observation group nurses for assessing the depth of sedation time is less than that of control group,(t=0.405, P<0.001),there were significant differences. The nurse for close observation of the disease changes and operate with less time, affecting the quality of care.Fiberoptic bronchoscopy often make patients feel mental and physical discomfort. The patient’s reactions are not identical. The aim of providing them sedation is using drugs reasonable, make patients who is undergoing bronchoscopy feel with comfortable, quiet cooperation or state of forgetfulness, provide comfortable nursing to patients. In order to adjust the sedative drugs according to the needs of the principle of individual and patient dosage, application of cerebral state monitor can make our team the sedation depth correctly, reliably assessed, and improve patient comfort,improve the connotation of holistic nursing care.Conclusion... |
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