早產兒氣管內管抽吸實證照護指引發展

Development of Evidence-Based Clinical Practice Guidelines for Endotracheal Suction in Premature Infants

背景：氣管內管分泌物抽吸為插管之早產兒常見的處置，抽吸中易引起低血氧與心跳過慢等症狀可能造成腦部受損，而導致神經發展障礙的不良結果，影響早產兒未來的生活品質。目的：本文之目的乃是以實證基礎方式發展早產兒氣管內管抽吸照護指引，以提供安全且適切的早產兒氣管內管抽吸照護。方法：於南部某醫學中心新生兒加護病房成立指引發展小組、分析現有的氣管抽吸指引及建構臨床問題、依臨床問題進行系統性文獻回顧與文獻評讀、撰擬臨床建議、進行共識決策程序、外部專家審核與成效評值等七大步驟完成照護指引發展。結果：早產兒氣管內管抽吸照護指引，經17位早產兒專家進行兩回合德菲法共識問卷調查達75%以上同意共識者，共13個議題，39項建議，內容包含抽吸前評估與抽吸頻率、氧氣提供、抽吸導管選擇、感染控制、抽吸壓力設定、食鹽水管路溼潤、抽吸深度、抽吸期間與抽吸次數、寧握安撫、評估與生命徵象監測、氧氣調整、恢復時間及評估與記錄等，三位方法學專家對於指引品質，綜合評價為建議使用；四位外部專家整體評估均推薦於臨床使用；新生兒加護病房29位護理人員大部分認為指引建議內容可行且容易做到，測試指引安全性方面，五位早產兒依此指引進行氣管內管抽吸時血氧飽和濃度維持在正常範圍，未發生低血氧（血氧飽和濃度＜85%）及心跳遲緩現象（心跳＜100次／分鐘）。結論本研究發展之早產兒氣管內管抽吸照護指引整合文獻證據，具臨床專家共識與嚴謹度，推薦於臨床使用。

Background: Endotracheal suctioning (ETS) for mechanically ventilated premature infants is a routine practice in neonatal intensive care. However, ETS is associated with hypoxemia and bradycardia, which may cause brain damage and negatively affect neurodevelopmental outcomes.Purpose: This study develops a set of evidence-based clinical-practice ETS guidelines for premature infants.Methods: A multidisciplinary task group at a medical center in southern Taiwan was established. Team members analyzed current ETS practice guidelines, constructed foreground questions, reviewed each question systemically, drafted a new set of guidelines, established expert consensus, disseminated the developed guidelines within a hospital setting, and evaluated their efficacy in practice.Results: The developed ETS guidelines address 13 issues with 39 recommendations. The Delphi method found that 75% of experts agreed with all of the recommendations. Issues addressed in the ETS included pre-assessment, frequency of suctioning, pre-oxygenation, suction-tube selection, infection control, suction pressure and depth decision making, humidity with normal saline, suction duration and number, containment and comforting, assessment during and after suctioning, recovery time, and documentation. The panel of clinical and methodological experts recommended that ETS be used in practice and nurses in the neonatal intensive care unit evaluated the ETS as applicable and accessible. The cardiorespiratory responses to ETS of 5 premature infants were within normal ranges without episodes of hypoxemia (oxygen saturation ＜ 85%) or bradycardia (heart rate ＜ 100 beat/min).Conclusions: This set of evidence-based ETS guidelines for premature infants integrated recommendations from the best available literature and obtained a high consensus among clinical experts. Thus, these guidelines are recommended for clinical application.