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Stroke thrombolysis can be done safely outside ICU 非ICU病房也可安全开展卒中溶栓治疗  

2013-04-01 17:10:35|  分类: 默认分类 |  标签: |举报 |字号 订阅

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檀香山——在美国心脏协会(AHA)主办的国际卒中大会上报告的一项研究结果显示,虽然急性缺血性卒中患者通常入住ICU接受静脉注射组织型纤溶酶原激活剂(TPA)治疗,但实际上没有必要。相反,这些患者可在准备充分的卒中病房安全接受静脉注射TPA治疗,临床结局极佳,并可大大节省费用。


Kisha C. Coleman
 
阿拉巴马大学伯明翰综合卒中中心的Kisha C. Coleman护士报告了迄今最大规模的系列卒中患者非ICU静脉注射TPA治疗的研究结果。这项研究纳入了2009~2011年由急诊转入9个床位的中等水平卒中病房接受静脉注射TPA治疗的302例连续患者。同期,另外31例急性缺血性卒中患者因血液动力学或呼吸不稳定由急诊转入ICU接受治疗。

卒中病房人员安排灵活,护士接受了全面的培训,能够开展静脉注射TPA治疗、输注尼卡地平以控制血压、双水平气道正压通气、非创或直接中心动脉导管和心脏监护。

患者入住卒中病房时的中位美国国立卫生研究院脑卒中量表(NIHSS)评分为9,出院时中位改良兰金量表(mRS)评分为3,10%的患者接受尼卡地平输注治疗。

结果显示,卒中病房治疗患者总症状性颅内出血率为3.3%,全身出血率为2.9%。入住卒中病房接受治疗的病例数逐年增加,由2009年的86例增至2010年的107例和2011年的109例。同时,症状性颅内出血率由第1年的4.7%下降至后2年的2.8%。Coleman认为,上述结果归功于护理效率的逐年提高。

无1例患者需要由卒中病房转至ICU接受继续治疗,也没有出现TPA相关死亡病例。中位住院时间由2009年的9.8天减少至2010年的6.4天和2011年的5.2天。

入住ICU和卒中病房患者住院时NIHSS评分、症状性颅内出血和全身性出血率以及平均住院时间均相似。

但ICU患者每天费用比卒中病房患者高出约1,200美元,即使校正护士的额外培训费用后,预计3年内患者避免入住ICU可节省362,400美元费用。研究者强调,这是一个保守的数据,真正节省的费用很可能被大幅度低估。

研究者认为,仅仅因为TPA治疗监测而入住ICU实际上是对系统资源的过度使用,并没有获得额外安全性受益。患者在卒中病房接受静脉注射TPA治疗,除大量节省费用外,另一好处是可接受连续性治疗。

研究者报告无相关利益冲突。

原文:

By: BRUCE JANCIN, Clinical Neurology News Digital Network

HONOLULU – Traditionally, acute ischemic stroke patients have been admitted to an ICU for administration of intravenous tissue plasminogen activator therapy. But it’s not necessary, according to Kisha C. Coleman.

Instead, these patients can safely undergo intravenous TPA therapy in a well-prepared stroke unit with excellent clinical outcomes – and big cost savings, said Ms. Coleman, a nurse at the University of Alabama at Birmingham comprehensive stroke center.

She presented what she and her coinvestigators said is the largest-ever series of non–ICU-managed stroke patients treated with intravenous TPA. The series consisted of 302 consecutive patients admitted from the emergency department to the university’s nine-bed intermediate-level stroke unit for intravenous TPA therapy during 2009-2011. During this 3-year period, another 31 acute ischemic stroke patients were sent from the ED to the ICU because of hemodynamic or pulmonary instability.

The stroke unit has flexible staffing, and the nurses have undergone extensive training. Their capabilities include management of intravenous TPA therapy, administration of nicardipine infusions when warranted for blood pressure control, management of bilevel positive airway pressure ventilation, and noninvasive or direct central arterial line and hardwired cardiac monitoring.

The median National Institutes of Health Stroke Scale score at admission to the stroke unit was 9, with a median modified Rankin score of 3 at discharge. Ten percent of patients received nicardipine infusions.

The overall symptomatic intracranial hemorrhage rate was 3.3%, with a systemic hemorrhage rate of 2.9%. The volume of patients admitted to the stroke unit for intravenous TPA increased over time from 86 patients in 2009 to 107 in 2010 and 109 in 2011. Meanwhile, the incidence of symptomatic intracranial hemorrhage dropped from 4.7% the first year to 2.8% in each of the next 2 years.

"We attribute that to increased nurse efficiency over time in caring for these types of patients," Ms. Coleman said at the International Stroke Conference, sponsored by the American Heart Association.

No patients required a transfer from the stroke unit to the ICU for continued management. No TPA-related deaths occurred.

Hospital length of stay decreased from a median 9.8 days in 2009 to 6.4 in 2010 and 5.2 days in 2011, she continued.

The 31 patients admitted to the ICU from the emergency department during the study period and the 302 managed in the stroke unit had similar admission NIH Stroke Scale severity scores, symptomatic intracranial hemorrhage and systemic hemorrhage rates, and average lengths of stay.

A day in the ICU costs about $1,200 more than does a day in the stroke unit, she noted. The estimated cost savings resulting from avoided ICU days during this 3-year period was $362,400, even after adjustment for the expense of the additional training for nurses. And that figure is a conservative one that probably significantly underestimates the true savings, according to Ms. Coleman.

"Use of the ICU solely for management of TPA monitoring may constitute a significant overuse of system resources at an expense that is not associated with additional safety benefit," she concluded.

Beyond the sizable cost savings, another advantage of managing intravenous TPA therapy in the stroke unit rather than the ICU is continuity of care. These patients are admitted to and discharged from the stroke unit, she noted.

Ms. Coleman reported having no relevant financial conflicts.
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