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1 ! 234!"# 1 I= 1 I= 1 I= :;9<!"#$%&'()*+,-"./ :!"#$%&'()*+,-./0diprivan dormicum morphine fentanyl 234!"#$%&'!()*+,-./$ :; 23% :;< 35.0% 10.2%!"#$%&'()* +,-./012345!"#$%&3.7% p<0.001!"#$%&'$()*+,- $ ,9:;1!"#$%&'()!!" #$%&!!"#$%&'(!"# Joint Commission on Accreditation of Healthcare Organizations JCAHO 2006!"#$%&!"#$%&'!" 85%!" #$%!"#$%&'() *+,-./0!"#$%&'()*+,-.$+,!"# $ 10~15% 1!!"#$%&'()*+,-./0!"#$%&'()*+,-! 20-30%!" 20-30!" #$%&'( )&*+, 1-3! !"#$%&' dormicum diprivan!" morphine fentanyl!"#$%& '()*+,-"#!"# 35.0%!"#$ %&'!"#$%&'()*+,-./-0! 114!"#$%&'( 325!"#$% victor99@ndmctsgh.edu.tw!"#$%&'( 1 156

2 ICU sedation & analgesia / / % / Ramsay score %~89% % APACHE II TISS

3 2,9,14 1,2 15 9, dormicum diprivan morphine fentanyl Ramsay Sedation Score RSS 2003 TQIP 14a- 4 % diprivan dormicum morphine fentanyl 100% diprivan dormicum : dormicum diprivan morphine fentanyl

4 ICU % % 35.8% 33.2% 18.7% / 9.2% 35.0% =72 159

5 / / ~ ~ morphine fentanyl RSS RSS RSS 5 20% 160

6 ICU!"#$%&'()*+,-./!"#$%& '()*+,!"#$%&'()'*+,!"#!"#$ 10-25%!"# 3.!"#$%& 1 diprivan dormicum morphine fentanyl! "#$% &'$%!"#$%&'()*#+,-!"#$%&'()*+,-.!" 2!"#$%&!"#$%&'()*+,-$!"#$%&'()*+,-.!" 3!"#$%&'!"#$%&'(&)*+,!"!#$%&'()*+,-!"#$%&'()*+,-.!"#$ 4.!"#$%&'()*+,-.!"#$%&'()*+!",!"#$%&'()*+, ~ !"#$%&'($%)*+,+!"#$%&'()*+,-"#$!"#$!% &'!()*+,'-!"#$%&'()*+,-)./0!"#$%&'()*!+,-./)!"# $%&'()*+,-"./!"#$%&'()*+,'-./0!"# ~ !"#$%&'()*+, !"#$%&'()*!"#$!"#$%&'()*+, !"#$%&!"#$%&'()*+!",-.!!"#!"#$%&'()*+,-./!"# $%&'( )*+,-./!"#$%&'()*+$%,-./!"#$%& SAS 9.1!"#$!"#$%&!"#!!"#$%&'()*+,-!!!"#!!"#$%&'()*+,-./*0!!"#$%&'()*+,!!"#$%&'()*+,-. APACHE II 15 TISS 25!"#$%&'()*+,-.*/!!"#$%&'()*+,-. /!"# $%&'()*+,-./0!"#$%&'()*+,-./0!"#$%&!!"#$%&'(%)*+,!!"!"#$%&'(! 35.0%!"!"#$ 10.2%!"#$! 3.7%!"#$%&'()*+, p<0.001! APACHE II TISS!"!"#$%&'()%*+,-!"!"#$%&'() 161

7 P,%,%,% < < < < < p SAS TISS APACHE II p=0.040 / 162

8 ICU APPACH TISS < P <25 25 P % % % p -1 APACHE II APACHE II < P,%,% p SAS 9.1 APACHE II 163

9 n=1308 n=984 n= / / morphine fentanyl 2 morphine fentanyl 35.8% / 33.2% 18.7% 164

10 ICU Walker & Gillen % 84% 78% 55% RSS % 3.7% p< % 17.4% / 9.2% 4.3% RSS APACHE II p = APACHE II <15 14 APACHE II > APACHE II < % 26.1% / 33.2% 34.8% 165

11 01. Bateman S, Grap MJ. Sedation and analgesia in the mechanically ventilated patient. American journal of Nursing. 2003;103:64AA,64CC,64EE-FF passim. 02.,,, ;2: Kress JP, Hall JB. Sedation in the mechanically ventilated patient. Crit Care Med. 2006;34: ,,.Propofol..2001;8: , : ,, : , ;23: ,,, ;20: Egerod I. Uncertain terms of sedation in ICU: How nurses and physicians manage and describe sedation for mechanically ventilated patients. Journal of clinical nursing. 2002;11: Weinert CR, Chlan L, Gross C. Sedating critically ill patients: factors affecting nurses'delivery of sedative therapy. Am J Crit Care. 2001;10: Walker N, Gillen P. Investigating nurses'perceptions of their role in managing sedation in intensive care: An exploratory study. Intensive and Critical Care Nursing. 2006;22: Paqueron X, Lumbroso A, Mergoni P, Aubrun F, Langeron O, Loriat P, et.al. Is morphine-induced sedation synonymous with analgesia During intravenous morphine titration?. Anesthesia. 2002;89: O'Donnell JM, Bragg k, Sell k. Procedural sedation: safety navigating the twilight zone. Nursing. 2003;33: 36-41, Willison A. How to avoid mistakes in medicine administration. Nursing Time. 1996;92: Arbour R. Sedation and pain management in critically ill adults. Critical nurse. 2000;20:39-56, quiz Powers J. A sedation protocol for preventing patient self-extubation. DCCN- dimensions of critical care nursing. 1999;18:

12 ICU!"#$%&'()*+,-./ DECREASING THE ADVERSE REACTIONS OF SEDATION AND ANALGESIC MEDICINE IN THE INTENSIVE CARE UNIT Hui-Ju Chen 1, Ling-Tzu Weng 1, Wen-Jinn Liaw 1, Bieng-Yi Chang 2 Abstract This project was aimed to decrease the incidence of adverse effects of Sedation and Analgesic medicine. All data was collected from a surgical intensive care unit of a medical center in Northern Taiwan. Patients who had been administrated with at least one medicine of Diprivan Dormicum Morphine or Fentanyl for more than four hours were recruited. There were three strategies adopted including modifying the drug-administration process of Sedation and Analgesic medicine, establishing the standard steps for assessment and holding staff training and education programs. The incidence of adverse effects of Sedation and Analgesic medicine had significantly decreased from 35% to 10.2%, and further decreased to 3.7% (p<0.001). Continuing staff training programs are recommended to build up consensus on treatment goals of Sedation and Analgesic medicine use and to decrease the incidence of adverse effects. Key words: Sedation, Analgesia, Adverse effect Correspondence: Bieng-Yi Chang Nursing Department, Tri-Service General Hospital; 325, Sec. 2, Chenggong Rd., Taipei 114, Taiwan Phone: ext ; victor99@ndmctsgh.edu.tw Division of Surgical Intensive Care 1, Tri-Service General Hospital, Taiwan 167

21 4 37% 8 5 1 1 31 3.6 2 現況分析 ( 一 ) 單位簡介 11 21 94.7% 1 25 5 4.6 67 APACHE-II score 2 14 21 6% 6.6 ( 二 ) 執行導管照現況 2 降 olume 14. Number 1. F

21 4 37% 8 5 1 1 31 3.6 2 現況分析 ( 一 ) 單位簡介 11 21 94.7% 1 25 5 4.6 67 APACHE-II score 2 14 21 6% 6.6 ( 二 ) 執行導管照現況 2 降 olume 14. Number 1. F 降降邱咨華徐盈真* 林麗芬王雅香** 中文摘要導管為常見留置的管路而是院發生最高亦為本冠故著手進行經查檢分析確立問題為缺乏預防照標準理人員對控制照不正確缺乏集容器清潔規範組員參考文獻及發揮創意擬定對策包括修訂預防照標準修訂擦澡及理常規模式舉辦在職教育課程成立手部衛生種子人員及製訂集容器清潔規範等對策於實施措施後由3.6 下降為本的實施確實也提升理人員