! 234!"# 1 I= 1 I= 1 I= 2 23456789:;9<!"#$%&'()*+,-"./01234562345789:!"#$%&'()*+,-./0diprivan dormicum morphine fentanyl 234!"#$%&'!()*+,-./$0123456789:; 23%45-.6789:;< 35.0% 10.2%!"#$%&'()* +,-./012345!"#$%&3.7% p<0.001!"#$%&'$()*+,- $2345678,9:;1!"#$%&'()!!" #$%&!!"#$%&'(!"# Joint Commission on Accreditation of Healthcare Organizations JCAHO 2006!"#$%&!"#$%&'!" 85%!" #$%!"#$%&'() *+,-./0!"#$%&'()*+,-.$+,!"# $ 10~15% 1!!"#$%&'()*+,-./0!"#$%&'()*+,-! 20-30%!" 20-30!" #$%&'( )&*+, 1-3! 2006 6 1 8 31!"#$%&' dormicum diprivan!" morphine fentanyl!"#$%& '()*+,-"#!"# 35.0%!"#$ %&'!"#$%&'()*+,-./-0! 114!"#$%&'( 325!"#$% 02-87923311 17362 E-mail victor99@ndmctsgh.edu.tw!"#$%&'( 1 156
ICU sedation & analgesia / / 4 1. 20% 4 2. 20-30 / 5 3. 10 6 4. 5 7 5. 8 6. 9 7. 1-6 Ramsay score 3 5 2 8. 1. 10 11 2. 83%~89% 12 3. 48% 13 4. APACHE II TISS 12 157
2,9,14 1,2 15 9,16 12 13 dormicum diprivan morphine fentanyl Ramsay Sedation Score RSS 2003 TQIP 14a- 4 % diprivan dormicum morphine fentanyl 100% diprivan dormicum : 2006 6 1 8 31 dormicum diprivan morphine fentanyl 1308 158
ICU 458 35.0 % 2006 9 1 9 31 316 80 20 87.7% 35.8% 33.2% 18.7% / 9.2% 35.0% 5 1 72 33 8 =72 159
/ 32 38 36 106 36 38 35 119 / 34 31 27 92 31 26 26 83 40 35 26 101 30 22 23 75 33 29 23 85 38 35 29 102 12 9 10 31 19 19 20 58 28 28 24 80 1~5 2006 9 1 2007 8 31 12 2006 9 1 ~2006 12 31 1. 1 morphine fentanyl 2 2. 1 RSS 2-3 4-5 2 3 RSS RSS 5 20% 160
ICU!"#$%&'()*+,-./!"#$%& '()*+,!"#$%&'()'*+,!"#!"#$ 10-25%!"# 3.!"#$%& 1 diprivan dormicum morphine fentanyl! "#$% &'$%!"#$%&'()*#+,-!"#$%&'()*+,-.!" 2!"#$%&!"#$%&'()*+,-$!"#$%&'()*+,-.!" 3!"#$%&'!"#$%&'(&)*+,!"!#$%&'()*+,-!"#$%&'()*+,-.!"#$ 4.!"#$%&'()*+,-.!"#$%&'()*+!",!"#$%&'()*+, 2006 12 20 ~2007 8 31!"#$%&'($%)*+,+!"#$%&'()*+,-"#$!"#$!% &'!()*+,'-!"#$%&'()*+,-)./0!"#$%&'()*!+,-./)!"# $%&'()*+,-"./!"#$%&'()*+,'-./0!"# 2007 4 1 ~2007 8 31!"#$%&'()*+, 2006 6 1 2007 8 20!"#$%&'()*!"#$!"#$%&'()*+, 2006 9 1 2007 8 20!"#$%&!"#$%&'()*+!",-.!!"#!"#$%&'()*+,-./!"# $%&'( )*+,-./!"#$%&'()*+$%,-./!"#$%& SAS 9.1!"#$!"#$%&!"#!!"#$%&'()*+,-!!!"#!!"#$%&'()*+,-./*0!!"#$%&'()*+,!!"#$%&'()*+,-. APACHE II 15 TISS 25!"#$%&'()*+,-.*/!!"#$%&'()*+,-. /!"# $%&'()*+,-./0!"#$%&'()*+,-./0!"#$%&!!"#$%&'(%)*+,!!"!"#$%&'(! 35.0%!"!"#$ 10.2%!"#$! 3.7%!"#$%&'()*+, p<0.001! APACHE II TISS!"!"#$%&'()%*+,-!"!"#$%&'() 161
P,%,%,% 1308 984 488 357 68 14 192 14.7 50 5.1 5 1.0 <0.001 113 8.6 18 1.8 9 1.8 <0.001 38 2.9 0 0 <0.001 9 0.7 0 0 0.001 5 0.4 0 0 0.023 101 43 4 26 2.0 1 0.1 0 <0.001 26 2.0 8 0.8 0 0.001 16 1.2 0 0 0.001 13 0.9 18 1.8 2 0.4 0.040 10 0.7 10 1.0 1 0.2 0.238 6 0.5 2 0.2 0 0.159 3 0.2 0 1 0.2 0.348 1 0.1 4 0.4 0 0.379 458 100 18 35.0 10.2 3.7 <0.001 1.p SAS 9.1 2. TISS APACHE II p=0.040 / 162
ICU APPACH TISS < 15 15 P <25 25 P 1308 641 667 368 940 % 35.0 37.1 33.0 0.116 33.4 35.6 0.450 984 600 384 397 587 % 10.2 10.3 9.9 0.825 10.6 9.9 0.722 488 264 224 149 339 % 3.7 5.3 1.8 0.040 3.4 3.8 0.796 p -1 APACHE II APACHE II < 15 15 P,%,% 10 4 4 1.52 1 0.45 0.381 0 0 0 0 0 0 6 2.27 3 1.34 0.517 4 0 0 0 0 0 0 0 0 0 1 0.38 0 1.00 0 0 2 0 0.502 1 0.38 0 1.00 14 4 0.040 1. p SAS 9.1 APACHE II 163
n=1308 n=984 n=488 1 113 35.8 26 24.8 4 17.4 2 / 105 33.2 43 41.0 8 34.8 3 59 18.7 24 22.9 6 26.1 4 / 29 9.2 4 3.8 1 4.3 5 5 1.6 6 5.7 2 8.7 6 4 1.3 0 0 7 1 0.3 2 1.9 2 8.7 316 105 23 17 4 morphine 12 8 1 fentanyl 2 morphine fentanyl 35.8% / 33.2% 18.7% 164
ICU Walker & Gillen 2006 107 98% 84% 78% 55% 12 1 2 3 RSS 4 35.0% 3.7% p<0.001 35.8% 17.4% / 9.2% 4.3% RSS APACHE II p = 0.040 APACHE II <15 14 APACHE II >15 4-1 APACHE II <15 1 18.7% 26.1% / 33.2% 34.8% 165
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.,,,...2000;2:332-341. 03. Kress JP, Hall JB. Sedation in the mechanically ventilated patient. Crit Care Med. 2006;34:2541-2546. 04.. http:// www.tjcha.org.tw 2006 6 10. 05.,,.Propofol..2001;8:52-59. 06.,.....1994:246-262. 07.,,.....1992:333-351. 08.,...1996;23:6-21. 09.,,,...2003;20:11-18. 10. 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;11:831-840. 11. Weinert CR, Chlan L, Gross C. Sedating critically ill patients: factors affecting nurses'delivery of sedative therapy. Am J Crit Care. 2001;10:156-165. 12. 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;22:338-345. 13. 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;89:697-701. 14. O'Donnell JM, Bragg k, Sell k. Procedural sedation: safety navigating the twilight zone. Nursing. 2003;33: 36-41, 44-45. 15. Willison A. How to avoid mistakes in medicine administration. Nursing Time. 1996;92:40-41. 16. Arbour R. Sedation and pain management in critically ill adults. Critical nurse. 2000;20:39-56, quiz 17-20. 17. Powers J. A sedation protocol for preventing patient self-extubation. DCCN- dimensions of critical care nursing. 1999;18:30-34. 166
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: 886-2-8792-3311 ext. 17362; E-mail: victor99@ndmctsgh.edu.tw Division of Surgical Intensive Care 1, Tri-Service General Hospital, Taiwan 167