【作者】 胡蓉芳；

【导师】 姜小鹰；

【作者基本信息】 福建医科大学 ， 老年医学， 2010， 博士

【摘要】 第一部分ICU噪光环境对人体睡眠、褪黑激素和皮质醇分泌的影响目的研究ICU环境中噪声和光照强度的实际状况,分析噪声产生的主要因素;探讨模拟ICU噪声、光照环境对健康受试者夜间睡眠、褪黑激素和皮质醇分泌及主观心理指标的影响,探讨声光防护措施的防护效果。方法24小时连续监测ICU环境中的噪声、光照强度,对ICU典型噪声进行采集录制;采用交叉设计方法,在模拟ICU噪光环境的睡眠实验室内监测14名健康受试者4晚(即适应状态、基础状态、ICU噪光刺激状态、ICU噪光刺激但受试者佩戴遮光眼罩和降噪耳塞状态)的睡眠多导图,比较不同试验状态下受试者夜间睡眠结构、尿液褪黑激素、皮质醇的分泌水平和晨起时的主观睡眠评价、情绪状态。结果1、ICU24小时噪声均在50dB(A)之上,外科ICU噪声水平最高,24小时噪声平均值为70.1dB(A),夜间噪声平均值在60dB(A)之上;各ICU之间的光照度差异较大,夜间机械通气患者视觉水平处的光照度,以外科ICU最强,上半夜患者视觉水平的光照度分别是117lux、489lux,下半夜患者视觉水平的光照度分别是60.1lux、238.6lux。2、实验室研究的结果:不同试验状态下,受试者的睡眠结构、主观睡眠质量、尿褪黑激素与皮质醇分泌水平的差异均具有统计学意义(P<0.05),但晨间受试者的焦虑水平没有显著性差异(P>0.05)。ICU噪光刺激状态下,受试者的主观睡眠质量下降,夜间多导睡眠图发生明显改变,表现为REM潜伏期延长、觉醒指数增多、REM比例减少(P<0.05),夜间褪黑激素和皮质醇分泌均受到显著影响(P<0.05)。受试者夜间有、无佩戴遮光眼罩和降噪耳塞时,其夜间的睡眠结构、主观睡眠质量、尿褪黑激素水平有显著性差异(P<0.05),尿皮质醇水平、晨间焦虑水平没有显著性差异(P>0.05)。结论ICU24小时均处于高噪声和夜间持续人工照明环境中。ICU噪光环境对健康受试者的睡眠及激素分泌存在干扰,夜间佩戴眼罩、耳塞有利于改善健康受试者的睡眠。第二部分ICU患者睡眠及非药物干预的临床研究目的评价非药物干预措施改善成人ICU患者睡眠的有效性及安全性;探讨采用声光防护配合放松音乐疗法的干预措施改善ICU患者睡眠、激素分泌的效果。方法分成两个阶段,第一阶段,采用Cochrane系统评价方法,参照Cochrane麻醉组制定的检索策略,计算机全面检索MEDLINE、EMBASE、CCTR、ISI Web of Science、PQDD、CBM-disc、CNKI等英文、中文数据库,并结合手工检索。纳入有关非药物干预改善ICU患者睡眠的随机对照试验(RCT)、半随机对照试验(quasi-RCT)和非随机对照试验(CCT),由2名评价人员共同评价所纳入的研究质量,对符合纳入标准的研究采用Rev Man 5.0软件进行分析。第二阶段采用随机、平行对照临床试验方法,在同一ICU中,将50例患者随机分成干预组25例,对照组25例。干预组给予声光防护措施配合放松音乐疗法;对照组除常规护理外无上述措施。比较两组患者术前晚、术后第一晚、第二晚8pm~8am之间的尿褪黑激素和皮质醇的分泌水平及ICU期间患者主观睡眠质量的差异。结果1、系统评价结果:纳入14个研究包括11个随机对照试验,3个非随机对照试验,共包括ICU患者965例。纳入研究的质量参差不齐,只有1个研究质量为A级。1个试验采用背部按摩和音乐放松训练,1个试验采用想象松弛训练法,3个试验采用夜间佩戴眼罩和(或)耳塞,1个试验采用ICU环境干预,1个试验采用家属三餐分段探视,1个试验采用综合行为干预,1个试验采用术前护理访视,5个试验采用不同机械通气模式。Meta分析结果:1个研究显示夜间佩戴眼罩和耳塞对患者的主观睡眠质量无影响,2个研究因无法获知计量数据的均数和标准差,无法进行合并分析,但原文献显示夜间佩戴眼罩、耳塞能够提高患者的主观睡眠质量。放松和想象松弛训练组与常规护理组的睡眠得分差异无统计学意义。ICU环境干预能够增加患者入睡的人数。三餐分段探视模式能够提高患者的每天睡眠时间。术前护理访视能够有效促进患者睡眠。夜间背部按摩能够有效提高睡眠时间、睡眠效率、REM时间。2个研究Meta分析的结果显示,50%比例辅助通气模式与高、低水平压力支持通气模式,对没有使用镇静剂患者的PSG睡眠结构的影响无统计学差异;对于使用镇静剂的患者,比例辅助通气模式与压力支持通气相比,能够提高患者的睡眠效率。有3个研究将辅助控制通气模式与压力支持通气模式比较。Meta分析结果显示,辅助控制通气时患者每小时睡眠中断的总次数少于压力支持通气的患者,具有统计学意义。辅助控制通气时患者的S1%、S2%大于压力支持通气的患者,具有统计学意义。压力支持增加设置救命通气的模式能够提高患者的睡眠效率。2、临床试验结果(1)干预组有3名患者中途退出试验,2名患者出现术后严重并发症中止试验,最后进入资料分析的数据干预组和对照组分别是20例和25例。(2)两组患者不同时间尿褪黑激素、皮质醇水平的比较:组内比较,两组患者术前晚、术后第一晚、术后第二晚尿褪黑激素水平的差异均具有统计学意义(P<0.05),术后第一晚、第二晚两组患者的尿褪黑激素水平明显低于术前晚尿褪黑激素水平;组间比较,术前晚、术后第一晚、术后第二晚两组的尿褪黑激素水平的差异均无统计学意义(P>0.05)。组内比较,两组患者术前晚、术后第一晚、术后第二晚尿皮质醇水平的差异均具有统计学意义(P<0.05),术后第一晚、第二晚两组患者的尿皮质醇水平明显高于术前晚尿皮质醇水平;组间比较,术前晚、术后第一晚、术后第二晚两组的尿皮质醇水平的差异均无统计学意义(P>0.05)。(3)主观睡眠质量的比较:干预组与对照组患者对ICU睡眠质量的评价差异具有统计学意义(P<0.05),干预组的主观睡眠质量比对照组好。结论1、目前尚无充分证据证明非药物干预措施改善ICU患者睡眠的临床有效性和安全性。今后需要大样本、高质量的随机对照试验进一步证实。2、心脏外科术后ICU患者术后第一晚、第二晚夜间尿褪黑激素和皮质醇水平显著改变,表现为夜间褪黑激素分泌水平明显降低,皮质醇分泌水平明显升高。3、采用声光防护配合放松音乐疗法的干预措施能够有效提高ICU患者的主观睡眠质量,是一项经济、简便、安全、有效的助眠措施。4、采用声光防护配合放松音乐疗法的干预措施对改善ICU患者夜间褪黑激素和皮质醇分泌水平未见显著作用。更多还原

【Abstract】 Part I Effects of a simulated ICU environment on nocturnal sleep, melatonin and cortisol in healthy subjectsObjective: To observe the noise and light condition in ICU environment and determine the physiological and psychological effects of ICU noise and light, and of earplugs and eye masks, used in these conditions in healthy subjects.Methods: ICUs noise and light were continuously monitored for 24 hours. Fourteen subjects underwent polysomnography under four conditions: adaptation, baseline, exposure to recorded ICU noise and light (NL), and NL plus use of earplugs and eye masks (NLEE). Urine was analyzed for melatonin and cortisol levels. Subjects rated their perceived sleep quality, anxiety levels and perception of environmental stimuli.Results: There were excessive noise levels in the ICUs,, with means 70.1dB(A) 24 hours and nighttime means > 60 dB(A). Nocturnal illumination in ICUs vary widely. Subjects had poorer perceived sleep quality, more light sleep, longer rapid eye movement (REM) latency, less REM sleep when exposed to simulated ICU noise and light (P<0.05). Nocturnal melatonin (P=0.007) and cortisol secretion levels (P=0.004) differed significantly by condition but anxiety levels did not (P=0.06). Use of earplugs and eye masks resulted in more REM time, shorter REM latency, less arousal (P<0.05) and elevated melatonin levels (P=0.002).Conclusions: There are excessive noise and night-time continuous artificial lighting in ICUs. Earplugs and eye masks promote sleep and hormone balance in healthy subjects exposed to simulated ICU noise and light, making their promotion in ICU patients reasonable. PartПNon-pharmacological interventions for sleep promotion in ICU patientsObjective To assess the efficacy of non-pharmacological interventions for sleep promotion in critically ill adult patients; To determine the effects of a noise and light reduction intervention combined relaxing music therapy on the sleep of adult patients in a cardiac surgery critical care unit.Methods First stage, Cochrane systematic review of randomized controlled trials (RCTs), quasi-RCTs and controlled clinical trials (CCTs) for non-pharmacological interventions for sleep promotion in ICU adult patients was performed. Clinical trials were searched in MEDLINE、EMBASE、CCTR、CBMdisc、PQDD、ISI web of science and from the reference of all include trials. The selection of studies, data extraction and assessment of quality were done independently by two reviewers. Data were processed by Rev Man 5.0 from the Cochrane collaboration. Second stage, a RCT to determine the effects of a noise and light reduction intervention combined relaxation music therapy on the sleep of adult patients in a cardiac surgery critical care unit was performed. Fifty patients were randomly assigned to intervention group (n=25) and the usual nursing care group (control group, n=25). Intervention group used earplugs and eye mask during nighttime sleep hours following a period of 15 to 30 minutes relaxing music. Urine from 8pm to 8am before surgery and first day, second day after surgery was analyzed for melatonin and cortisol levels. Partcipants rated their perceived sleep quality and perception of environmental stimuli.Results1. Fourteen trials including 965 patients met the inclusion criteria. Eleven trials were RCTs, 3 were CCTs. The quality of all trials varied, only one trial was grade A. One was about back massage and relaxation intervention, 3 were used earplugs and (or) eye masks, one was used relaxation and imagery, one was about ICU environment control, one was controlled periods for family member visit, one was used behavior intervention, one for nursing intervention before surgery, and 5 were about different ventilation mode. Meta-analysis indicated: use of earplugs and eye mask is not better than usual nursing care in term of subjective sleep quality, but two other trials showed use of earplugs and /or eye mask improved patients’subjective sleep quality. These interventions, such as back massage, ICU environment control, controlled periods for family member visit, nursing intervention before surgery improved patients subjective sleep quality effectively (P<0.05). There were significant increased fragmentation index and decreased percentage of stages 1 and 2 NREM sleep with pressure support ventilation (PSV) than with assist-control ventilation (ACV) (P<0.05). For no-sedated patients, there were no significant different in PSG sleep variables compared proportional assist ventilation (PAV) to pressure support ventilation (PSV) (P>0.05); For sedated patients, the sleep efficiency was significantly higher with PAV than with high PSV (P<0.05).2. Five patients dropped out of the study, all in intervention group. No differences were found in nocturnal urinary secretion levels of 6-MT and cortisol of three nights between the intervention and control group (P>0.05). Differences in nocturnal urinary secretion levels of 6-MT and cortisol were both significant among the three nights within two group, the levels of 6-MT were significantly decreased on the first day and second day after surgery (P<0.05), but the levels of cortisol were increased significantly (P<0.05). Subjective sleep quality were significant increased compared intervention group with control group (P<0.05).Conclusion1. There was no sufficient evidence to conclude that non-pharmacological interventions is effective or safe in sleep promotion for adult ICU patients. More randomised controlled trials with greater number of participants are needed in future study.2. ICU patients after cardiac surgery suffer from severe decrease of nocturnal melatonin and increase of cortisol.3. A noise and light reduction intervention combined relaxing music therapy resulted in better subjective sleep quality.4. A noise and light reduction intervention combined relaxing music therapy更多还原