To Study The Effect Of Early Systematic Intestinal Irritation To Prevent Critical Ill Patients Treated By Mechanical Ventilation From Gastrointestinal Dysfunction

ObjectiveGastrointestinal tract is the trigger of the systemic inflammatory response syndrome and the beginning of the actuator is the central organ of sepsis and multiple organ dysfunction syndrome (MODS). Studies have shown that up to43.1%on the one hand the proportion of critically ill patients with significant gastrointestinal dysfunction; the other hand, the incidence of MODS and mortality of ICU patients with gastrointestinal dysfunction also significantly increased. Therefore actively seek ways to prevent critically ill patients with gastrointestinal dysfunction, is extremely important to protect patients with gastrointestinal function. There is no other than the current in the field of treatment to prevent or reduce the effective nursing interventions of the gastrointestinal tract dysfunction, this study combines a variety of single application can promote defecation measures, and the formation of a sequential implementation of the intestinal tract to stimulate the process, the proposed explore on the basis of routine treatment, intestinal irritation, the test group of mechanical ventilation in critically ill patients with early application of the preventive system to ensure that patients within3days to drain the intestinal feces, to explore the implementation of the system of mechanically ventilated patients early preventive intestinal Road stimulation to intervene, the incidence of patients with gastrointestinal dysfunction, mechanical ventilation days, MODS incidence of, ICU hospital days and other aspects of the impact.MethodPatients who admitted to the ICU and EICU of a hospital in2009-2011included in this study line the second day of enteral nutrition.Patients with contraindications will be excluded from the study. Contraindications include:patients does not allow abdominal massage(diarrhea, gastrointestinal surgery, other wound on the abdomen.), not allow be enema, with short bowel syndrome, hyperactive bowel sounds, vital signs are not stable need to rescue the patient at any time, with gastrointestinal dysfunction or MODS. The patients were randomly divided into experimental and control groups. According to the random number table, the last digit of the singular into the experimental group, the last digit of the number of pairs to the control group. As of December31,2011,two groups of patients by sex, age, primary diagnosis, APACHE Ⅱ score, constipation history matching packet. If a patient length of stay ICU less than or equal to one day, or enteral nutrition is less than three days, or automatically discharged, more then one time transferred to the ICU, failed to matching, he will be removed. The observation period for ICU length of stay is less than equl to29days of patient observation to patients with departmental rotation or death or exclusion criteria happened, more than29days and no exclusion criteria of patients observed up to29days.There are272cases of patients who met the inclusion criteria, matches successful for a total of94cases,47cases in each group. The groups of patients were diagnosed as follows:7cases of bone disease;19cases of neurological diseases; pulmonary infection, respiratory insufficiency in14cases; two cases of multiple trauma; three cases of severe acute pancreatitis; cardiopulmonary cerebral resuscitation after two cases. The two groups were gender, age, and intervention before the APACHE score, history of constipation comparable.Preparatory workBefore the study, determine the inclusion and exclusion of cases range; The preparation of "ICU patients with implementation of the intestinal stimulation informed consent", including the implementation of the indications and significance of intestinal irritation, intestinal irritation technical steps, costs, complications and sign; The establishment of the nine-member team of the ICU intestinal care, the matron headed into the responsibility of head of the night group leaders to become team members; The training of stimulate technical to intestinal tract content related to intestinal care team members; The enactment of "Intestinal intervention nursing records for ICU patients", including the daily assessment of the patient, the implementation of the measures, the patient defecation, the use of drug treatment such as mosapride, double discrimination,and so on; The enactment of "ICU patients with intestinal intervention data collection sheet", record the APACHE Ⅱ score of the time before the intervention and the end of the observation period, gastrointestinal dysfunction rate, time of occurrence, duration of mechanical ventilation, incidence of MODS and mortality. Two groups of patients in accordance with the diagnosis and treatment principle in a timely manner to control the primary disease, to maintain thehysiological functions of the heart, lung, kidney, brain and other vital organs, maintain within the bad environment is stable, both by the nasogastric tube nutrition pump continues to pump into the early enteral nutrition and oral promote gastrointestinal drugs (mosapride) and microorganisms (Bifidobacterium); Appropriate sedation with propofol, the depth of sedation was maintained at a Ramsay sedation index score of2-3points.The experimental group intervention process:The cases included in the test group, to the families informed consent and to sign in "ICU patients intestinal stimulation to informed consent". Daily after the transfer of work in the morning, if the responsibility of nurses is the one of the intestinal care team members, self-assess the patient’s basic condition; If she is not, the team leader responsible for assessing.30minutes after start eating breakfast (or the first enteral nutrition) in the morning, the assessment required to determine the patients with and without exclusion criteria of this test, if there is suspension of intervention, the end of the case; If not appear, according to the patient interventions, once a day. And fill "Intestinal intervention nursing records for ICU patients" seamless. The intervention process is as follows:after half an hour in the morning enteral nutrition in the morning, patients to be given abdominal massage(the first phase).Specific methods are:the operators stand by the ventral of the patient, the palm side according to ascending colon, transverse colon, descending colon, sigmoid colon traveling direction circular massage of abdominal with the palm side, press efforts to achieve the compression depth is appropriate for3-4cm continued15to20minutes. Need to records whether the patient defecation and the shape, quantity of stool. Stool induration, oral some Congrong purge fluid, and stool soft, not the additional processing (following defecation by processing the same as those);No bowel movement is given to the second phase of the rectum to stimulate patients with a disposable silicone gloves, for the purposes of standing in patients with ventral to clean paraffin oil lubricated index finger, middle finger, two fingers to slow probe into the anus approximately2refers to the length of the section, clockwise massage5to6laps around the intestinal wall, the rectum to stimulate the ongoing abdominal massage. Yet not offering intervention temporarily The second day repeat the above interventions, not defecation are still no long Continue to repeat the first day of the third day interventions, has not yet defecation to be the third stage of deep enema, the patient take the left lateral position and, as far as possible, elevate the patient hip, the use of disposable50ml sterile syringe enema40ml, connected disposable sterile suction tube on the12th, bolus enema air suction tube row of the net and launched a length of15cm or so little open enema lubrication suction tube head-end, lubricate the suction catheter into the rectum10cm-15cm, slow push into the open after the enema, wait10seconds or so, again, abdominal massage, focuses on massage of the left lower abdomen. Such as half an hour is not yet defecation or defecation be the fourth stage of the second deep enema, not yet defecation, then fifth stage of the hand-dug defecation.The control group interventions:Daily after the morning shift the responsibility of nurses to assess patients with defecation. If a patient is three days and more without bowel movements, to give enema40ml; If within half an hour stool giving enema40ml once again.The patients is not defecation through the day, retention enema with0.9%saline500ml and then records of "Intestinal intervention nursing records for ICU patients".The data of patients given intestinal tract intervention to be Calculated and recorded by the class of nurses, including APACHE Ⅱ score before the intervention and at the end of the observation period; the gastrointestinal dysfunction, case number, time of occurrence; with mechanical ventilation time; ICU length of stay days (Admission day is counted in and day of discharge is not included, if ICU length of stay days is longer than29days, then29days is recorded.), MODS, mortality.Data was input SPSS statistical software. Description of the measurement data using the mean±standard deviation, normality test and homogeneity of variance test, the data fit the normal distribution, homogeneity of variance of the data using independent samples t test, heterogeneity of variance correction t-test; Normally distributed data Wilcoxon test was used to count data were compared using chi-square test.Results1. APACHE Ⅱ score:Experimental group and control group at the end of the observation period were significantly different (p<0.05);The test group before the intervention and the end of the observation period were significantly different (p<0.05); the control group before the intervention and the end of the observation period, no significant difference (p>0.05).Consider the same two groups of cases, but the control group, more deaths than the experimental group, and may lead to the data analysis results show that the control group before the intervention and the end of the observation period, no significant difference, so the statistical control group survival cases of intervention before the end of the observation period APACHE Ⅱ score, showed a significant difference (p<0.05).2. Gastrointestinal dysfunction:The two groups were significantly different, and two groups of patients with history of constipation also have distinct differences.3. Gastrointestinal dysfunction, the incidence of:Experimental group and control group constipation in patients with a history of the incidence of no statistical significance (P>0.05); patients with no history of constipation incidence of significant differences (P<0.05). Control were significant differences within the group of the test group and control group (P<0.05).4. The duration of mechanical ventilation:two groups were significantly different (P<0.05).5. The days of hospitalization in the ICU, MODS incidence and mortality: between the two groups had no significant differences (P>0.05).ConclusionCare routine:The patient three days stool to give the enema to purge processing, only a passive waiting for the discharge of stool only a small amount of stool within the rectum, the majority of the fecal accumulation in the colon or more, over time, fecal stone formation.The interventions in addition to intervene correctly process, the focus is aimed at prevention, early application. After the implementation of the above-mentioned series of measures, from the beginning of the patient course of the disease, which is to ensure that patients within3days to drain the intestinal stool, avoid fecal long-term stay in the colon high, over time the formation of fecal stones, or even toxic intestinal paralysis, and to protect the patients’intestinal function, delay bowel function the purpose of the decline process.1. To intervene early in mechanically ventilated patients using the system of preventive intestinal stimulation, can be significantly reduced in patients with APACHE Ⅱ score, gastrointestinal dysfunction incidence and delayed the time of occurrence of gastrointestinal dysfunction, thus shortening the patients treated with mechanical ventilation time, shorten ICU length of stay;2. Whether constipation and a history of gastrointestinal dysfunction in critically ill patients has important implications, as a key intervention in the crowd, and emphasized that early preventive interventions;3. There is no valid evidence to prove whether critically ill patients with MODS morbidity and mortality, the days of hospitalization in the ICU can be reduced further study.