Transcript 57000d7f8add09c4a607b0f9e9598813

台灣實證醫學學會2011學術年會海報
從實證護理角度探討冰敷對於咳血病患療效
廖翎聿 何宜美 陳素容 張佑泟
行政院衛生署胸腔病院護理科 醫療科
【Introduction】
咳血為體內出血及肺部病症。指導病患勿熱食、用
力咳嗽預防出血是常見護理活動外，但臨床上也會教
導病患胸前冰敷，冰敷是骨骼肌或鼻部受傷後物理治
療之一。故本篇系統回顧目的是要探討『冰敷』對於
咳血病患在止血療效。
Main Results
Citation/s
Abdominal
Packing For
Surgically
Uncontrollable
Hemorrhage
Level of
evidence
Materials and
Methods
Results
回溯性研 39位中有9位是因為體溫過低死並達顯著性差異(36±1.2、
究，共審
p＜0.001)。(Table 7)
查 39 病患 死亡因素探討發現PH、PT/PTT異常是主要因素，其中
病歷
PT/PTT呈現正相關。(Table89)
PH與體溫成正相關(Fig1)
結論:腹部出血病患於開刀時予以腹內冰水止血，短時
間會達止血效果，但長時間相對會引發體溫過低、
PT/PTT延長、PH偏酸液容易造成死亡
Ib
【目的】
本篇系統回顧目的是要探討『冰敷』對於咳血病患在
止血療效。
【方法】
對於咳血病患是否應給予『冰敷』
Clinical Question 護理措施？
Citation/s
Clinical bottom line
冰敷使表皮血管收縮，降低微血管的通透性及出血情
況，間接減輕組織水腫（McDowell, Mc-Farland, &
Nalli, 1994）運用雖須醫囑執行，但護理可運用獨立
功能，如：在袋中放碎冰、冷凝包等達成其生理性成
果（Mariah & Ruth, 1998/2003; Michlovitz,1996）
Bronchoscopic
cryotherapy
for advanced
bronchial
carcinoma
Level of
evidence
IIb
Materials and Methods
Results
前瞻性研究，採非隨機，針 23位(70%)在cryotherapy後無論在臨床
對81位肺腺癌出血以
症狀包括咳血、肺功能都有進步(見
bronchoscopic cryotherapy進
Table3)
行治療病患
其中咳嗽與肺功能均呈現正相關(見
資料分析採Student's paired t
Figure1)
6分鐘走路與pao2成正相關(見Figure2)
test.
測量指標包括病患臨床評估: 結論:透過Bronchoscopic cryotherapy有
呼吸困難指數、咳嗽、咳血、 效改善肺腺癌病患咳血情況，相對提
喘鳴肺功能-6分鐘走路
升肺功能，改善臨床症狀。
PICO Question：
■ P：咳血病患
■ C： 無
■ I/E：冰敷
■ O： 止血
Data Sources Pub Med共5篇
Data Selection
Citation/s
包括Review及隨機對照臨床試驗、介入措施為冰敷、
冷敷或冷療及在研究測量包括溫度改變、止血等並依
CASP判讀後之等級較高且可獲得全文之英文文章。
Main Results
Citation/s
Lead author's name
Multidisciplinary Management of
Life-Threatening
Massive Hemoptysis: A 10-Year
Experience
Abdominal Packing For Surgically
Uncontrollable Hemorrhage
Bronchoscopic cryotherapy for
advanced
bronchial carcinoma
Does Cryotherapy Improve Outcomes
With
Soft Tissue Injury?
1. Did the study ask a clearly-focused
question?
2. Was this a randomised controlled trial
(RCT) and was it appropriately so?
3. Were participants appropriately
allocated to intervention and control
groups?
4. Were participants, staff and study
personnel ‘blind’ to participants’ study
group?
5. Were all of the participants who
entered the trial accounted for at its
conclusion?
6. Were the participants in all groups
followed up and data collected in the
same way?
7. Did the study have enough
participants to minimize the play of
chance?
8. How are the results presented and
what is the main result?
9. How precise are these results?
10. Were all important outcomes
considered so the results can be
applied?
Y
Multidisciplinary
Management of
cryotherapy for
Life-Threatening
Massive Hemoptysis: A
advanced
bronchial carcinoma 10-Year Experience
Bronchoscopic
Y
Y
Ia
journal
Shigemura,N., Wan,I. Y., Yu,S.
C. H. Wong,R H., Hsin,. K Y.,
Thung,H. K., Lee,T.W., Wan,S.,
Underwood,M. J.and Yim, P. C.
SHARP,K. W. and
LOCICERO,R. J.
Walsh,D. A., Maiwand, M. 0.,
Nath,A .R., Lockwood,P.,
Lloyd,M. H .and Saab, M.
Tricia J. Hubbard; Craig R.
Denegar
Pennsylvania State
J. William Myrer, PhD; Gary
Cold- and Hot-Pack Contrast Therapy:
Measom, RN, PhD; Earlene
Subcutaneous and Intramuscular
Durrant, EdD;
Temperature Change
Gilbert W. Fellingham, PhD
Abdominal
Packing For
Surgically
Uncontrollable
Hemorrhage
Cold- and
Hot-Pack
Contrast
Therapy:
Subcutaneous
and
Intramuscular
Temperature
Change
Level of
evidence
Ann Thorac Surg
SHIGEMURA ET AL
851
2009;87:849–53
Ann. SUrg. . May
1992
Materials and Methods
Results
研究設計為前瞻性實 溫度改變:顯示持續20分鐘，使用1.8公斤冰
驗性研究，採隨機取
敷袋冰敷對照組，溫度下降比實驗組來的
樣。共分2組：實驗組: 多( p = .0001) (Fig 4).
冷熱各交替至少5分鐘 實驗組小腿皮內溫度變化 8°C to14°C over
交替，對照組:冰敷20
each 5-minute interval of contrast (p < .0001),
分鐘
在20-minute ice treatment decreased
Subjects: Nine men and ntramuscular and subcutaneous temperatures
approximately 7°C and 17°C respectively (p
seven women
 Measurements:
< .0001) (Tables 1 and 2).
結論：持續冰敷才能有效降肌肉層及皮下
Subcutaneous and
組織層溫度，但必須持續20分鐘，冰敷重
intramuscular tissue
量1.8kg
temperatures
Thorax
1990;45:509-513
Journal of Athletic
Training
2004;39(3):278–279
Journal of Athletic
Training Volume 32
September 1997
Does Cryotherapy
Improve Outcomes
With Soft Tissue
Injury?
Y
Cold- and Hot-Pack
Contrast Therapy:
Subcutaneous and
Intramuscular
Temperature Change
Citation/s
Does
Cryotherapy
Improve
Outcomes
With
Soft Tissue
Injury?
Level of
evidence
Ia
Materials and Methods
Results
系統性文獻採隨機取樣， 組織受傷1-3天開始提供冰敷，於受傷
凡具實驗組和對照組研究
後一週再評估，無論在腫脹、疼痛都
設計列入收案對象，共收
有明顯改變，但對於改善活動是無限
祝改變，且持續冰敷比間接性冰敷有
錄55篇文章占 66.7
however。
效
測量軟組織主客觀資料包 結論:持續冰敷可以有效改軟組織腫脹
括疼痛、腫脹及活動功能
及疼痛
【結果】
Y
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
搜尋結果：文獻等級Ib單盲隨機控制、Ic立意取樣單組前後
測，及II b回溯性病例研究共5篇，樣本數從16至39位，測
量指標肌肉溫度變化及止血。其中一篇是將冰寶放在小腿20
分鐘後，表皮溫度下降7度C，皮下組織下17度C，及另一篇
研究是將冰水直接沖洗腹腔內出血，結果造成病患低體溫、
PH值改變，反而造成出血時間延長，兩篇均達顯著差異；最
後是肺腺癌咳血病患肺內血管直接冷療研究，咳血改善67%，
但未達顯著
【結論】
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Don’t know
Don’t know
Don’t know
Don’t know
Don’t know
Y
Y
Y
Y
Y
文獻評析結果，冰敷無法有效改善咳血，反而會使得
體溫降低，造成病患不適，增加出血風險。故經由本
篇文獻回顧結果，並不建議咳血病患於胸前冰敷。