成人危重症患者血糖管理现状及护理实践内容的田野研究

doi:10.3761/j.issn.2096-7446.2024.02.001

摘要/Abstract

摘要： 目的了解当前我国成人危重症患者血糖管理现状及护理实践内容,明确实践过程中存在的问题并给出改进建议。方法 2021年9月—2022年4月,采用田野研究方法对重庆市4所三级甲等医院ICU血糖管理实践进行了为期8个月的非参与式观察。采用ICU患者血糖管理情况表及护理人员血糖管理实践记录表收集量性资料,反复阅读田野笔记,汇总现有护理实践内容、当前血糖管理护理实践中存在的问题,进一步进行资料归类及深入分析。结果 4所田野观察地均拥有纸质版胰岛素输注方案,方案平均使用时间为（9.00±2.92）年,但方案内容存在差异;共观察60例高血糖患者,不同田野地的患者在入住ICU期间的高血糖持续时间、达到目标血糖水平所需时间及目标血糖范围的维持时间差异无统计学意义。12名护士血糖管理主要工作内容包括胰岛素输注及调整、血糖监测、患者营养管理、低血糖处理,但在血糖监测方式、胰岛素使用方式、营养支持是否伴随胰岛素输注等问题上仍与最佳证据存在差距。结论护理人员需在提升自我临床决策能力的基础上,构建并实施基于最佳证据的全面、规范且统一的成人危重症患者血糖管理实践方案,这是解决当前田野地血糖管理实践问题的主要策略。

关键词: 危重病, 血糖管理, 胰岛素输注系统, 护理实践, 田野研究

Abstract: Objective To understand the status and contents of current nursing practice in the management of blood glucose in critically ill adult patients in China. Methods From September 2021 to April 2022,an 8-month non-participatory observation of glucose management practice in the intensive care units of four tertiary care hospitals in Chongqing was conducted using field research. Quantitative data were collected using the ICU patient glucose management profile form and nursing staff glucose management practice record form. We repeatedly read the field notes and summarized existing nursing practices and existing problems in current blood glucose management nursing practices,further categorized and conducted in-depth analysis of the data. Results All four field observation sites had paper-based insulin infusion protocols,and the mean duration of the use of the protocols was（9±2.92） years,and the contents of the protocols differed across the fields. A total of 60 hyperglycemic patients were observed,and there were no statistically significant differences in the duration of hyperglycemia,the time required to reach target blood glucose level,and the maintenance of the target blood glucose range among patients from different field sites. The main tasks of the 12 nurses in glucose management included insulin infusion and adjustment,glucose monitoring,patient nutrition management,and hypoglycemia treatment. However,there was still a gap with the best evidence on blood glucose monitoring method,insulin use,whether nutritional support should be combined with insulin infusion,etc. Conclusion Nursing staff need to enhance their clinical decision-making skills,and further construct and implement a comprehensive and standardized practice plan for glucose management in critically ill adult patients based on the best evidence. This is a main solution to address current glucose management practice issues in the field sites.

Key words: Critical Illness, Glucose Management, Insulin Infusion System, Nursing Practice, Field Research

黄苗, 甘秀妮, 张传来, 周雯. 成人危重症患者血糖管理现状及护理实践内容的田野研究[J]. 中华急危重症护理杂志, 2024, 5(2): 101-107.

HUANG Miao, GAN Xiuni, ZHANG Chuanlai, ZHOU Wen. A field study of the status and contents of nursing practice in the management of blood glucose in critically ill adults[J]. Chinese Journal of Emergency and Critical Care Nursing, 2024, 5(2): 101-107.

参考文献

[1] Deane AM,Plummer MP,Ali Abdelhamid Y.Update on glucose control during and after critical illness[J]. Curr Opin Crit Care,2022,28(4):389-394.
[2] Mifsud S,Schembri EL,Gruppetta M.Stress-induced hyperglycaemia[J]. Br J Hosp Med(London),2018,79(11):634-639.
[3] American Diabetes Association Professional Practice Committee. 16. Diabetes care in the hospital:standards of medical care in diabetes-2022[J]. Diabetes Care,2022,45(Suppl 1):S244-S253.
[4] Rovida S,Bruni A,Pelaia C,et al.Nurse led protocols for control of glycaemia in critically ill patients:A systematic review[J]. Intensive Crit Care Nurs,2022,71:103247.
[5] Ilcewicz HN,Hennessey EK,Smith CB.Evaluation of the impact of an inpatient hyperglycemia protocol on glycemic control[J]. J Pharm Pharm Sci,2019,22(1):85-92.
[6] Rabinovich M,Grahl J,Durr E,et al.Risk of hypoglycemia during insulin infusion directed by paper protocol versus electronic glycemic management system in critically ill patients at a large academic medical center[J]. J Diabetes Sci Technol,2018,12(1):47-52.
[7] 王朝平,袁晓丽,赵小玲,等. 基于CiteSpace的我国重症患者血糖管理研究热点文献计量学分析[J]. 循证护理,2022,8(16):2181-2187.
Wang CP,Yuan XL,Zhao XL,et al.Bibliometric analysis of blood glucose management hotspots of severe patients in China based on CiteSpace[J]. Chin Evid Based Nurs,2022,8(16):2181-2187.
[8] 陈向明. 质的研究方法与社会科学研究[M]. 北京:教育科学出版社,2000:228-232.
Chen XM.Qualitative research in social sciences[M]. Beijing:Educational Science Publishing House,2000:228-232.
[9] 李菁菁,潘文彦,王晓容,等. ICU成人危重症患者血糖管理的最佳证据总结[J]. 护理学报,2021,28(12):21-26.
Li JJ,Pan WY,Wang XR,et al.Best evidence summary of blood glucose management for ICU adult patients[J]. J Nurs,2021,28(12):21-26.
[10] Wu ZX,Liu J,Zhang D,et al.Expert consensus on the glycemic management of critically ill patients[J]. J of Intensive Med,2022,2(3):131-145.
[11] Boutin JM,Gauthier L.Insulin infusion therapy in critically ill patients[J]. Can J Diabetes,2014,38(2):144-150.
[12] Yoo HJ,Suh EE,Shim J.Effectiveness of blood glucose control protocol for open heart surgery patients[J]. J Adv Nurs,2021,77(1):275-285.
[13] 郭彦. 护士主导的心脏手术围术期血糖管理方案的构建研究[D]. 湖州:湖州师范学院,2021.
Guo Y.Study on the construction of perioperative blood glucose management scheme led by nurses in heart surgery[D]. Huzhou:Huzhou University,2021.
[14] Krinsley JS,Preiser JC,Hirsch IB.Safety and efficacy of personalized glycemic control in critically ill patients:a 2-year before and after interventional trial[J]. Endocr Pract,2017,23(3):318-330.
[15] Cook CA,Vakayil V,Pribyl K,et al.A pharmacist-driven glycemic control protocol to reduce the rate of severe hypoglycemia in high-risk patients[J]. Hosp Pharm,2022,57(1):45-51.
[16] Dehkordi SHH,Albu J,Aziz E F,et al.Pathway for the management of hyperglycemia in the cardiac care unit[J]. Crit Pathw Cardiol,2017,16(4):119-125.
[17] Stewart KW,Pretty CG,Tomlinson H,et al.Safety,efficacy and clinical generalization of the STAR protocol:a retrospective analysis[J]. Ann Intensive Care,2016,6(1):24.
[18] Maharaj D,Perrie H,Scribante J,et al.Glycaemic control in a cardiothoracic surgical population:Exploring the protocol-practice gap[J]. South Afri J Crit Care,2017,33(1):4-10.
[19] Sun PY,Poblete RA,Nguyen PL,et al.Association between glycemic gap and in-hospital outcomes in aneurysmal subarachnoid hemorrhage[J]. Front Neurol,2021,12:714341.
[20] Neelon L,Basawil K,Whitney L,et al.Critical care nurse-led quality improvement hyperglycemia reduction initiative[J]. J Nurs Care Qual,2019,34(2):91-93.
[21] Shea KE,Gerard SO,Krinsley JS.Reducing hypoglycemia in critical care patients using a nurse-driven root cause analysis process[J]. Crit Care Nurse,2019,39(4):29-38.
[22] Rodriguez-Calero MA,Llodra EB,Cuberos MC,et al.Effectiveness of an evidence-based protocol for the control of stress-induced hyperglycaemia in critical care[J]. Enferm Intensiva(Engl Ed),2019,30(1):4-12.
[23] Compton F,Ahlborn R,Weidehoff T.Nurse-directed blood glucose management in a medical intensive care unit[J]. Crit Care Nurse,2017,37(3):30-40.
[24] Alshaya AI,Degrado JR,Lupi KE,et al.Safety and efficacy of transitioning from intravenous to subcutaneous insulin in critically ill patients[J]. Int J Clin Pharm,2022,44(1):146-152.
[25] Timmins F,Green C,Parissopoulos S,et al.Management and leadership of intensive care units for the future[J]. Nurs Crit Care,2023,28(2):149-152.
[26] 罗振吉,磨勇华,苏小妮,等. 中心静脉及动脉穿刺留置导管采血途径在危重症患者中的应用[J]. 右江医学. 2013,41(6):877-879.
Luo ZJ,Mo YH,Su XN,et al.Application of central venous and arterial indwelling catheter for blood collection in critically ill patients[J]. Youjiang Med J,2013,41(6):877-879.
[27] Huang M,Yang R,Zhang C,et al.Staff knowledge,attitudes and practices regarding glycaemic management in adult intensive care units:A national survey[J]. Nurs Crit Care,2023 28(6):931-939.
[28] 薛佳凤,戴付敏. ICU护士对重症患者血糖管理认知的质性研究分析[J]. 现代诊断与治疗,2021,32(24):4016-4017.
Xue JF,Dai FM.Qualitative study of ICU nurses' cognition of blood glucose management in critically ill patients[J]. Mod Diagn Treat,2021,32(24):4016-4017.
[29] Wabeke D,Tolich D.What are the barriers and facilitators for critical care nurse participation in a patient blood management program?[J]. Dimens Crit Care Nurs,2023,42(4):196-201.
[30] Du B,Hu X,Hou M.Critical care resources in mainland China:when more may not always be better[J]. Crit Care Med,2017,45(12):2113-2114.
[31] Chiwaula CH,Jere DL.Experiences of nurse managers and practitioners on implementation of an evidence-based practice intervention[J]. Health SA,2022,27:1597.