豊島 美樹

BACKGROUND: Delirium is a common complication among patients in the intensive care unit (ICU). It is important to prevent the occurrence of delirium in critically ill patients. AIM: This review aimed to evaluate the efficacy of non-pharmacological interventions and determine what combination of these is effective in preventing delirium among Intensive Care Unit patients. STUDY DESIGN: A systematic review and meta-analysis. This review follows the guidelines of the Preferred Reporting Items for Systematic reviews and Meta Analysis statements for Network Meta-Analysis (PRISMA-NMA). Data sources included the Cumulative Index to Nursing & Allied Health Literature., MEDLINE, and Cochrane library databases. The integrated data were investigated with odds ratio (OR) and 95% confidence interval (95% CI), using the random-effects Mantel-Haenszel model. Data were considered significant when p < 0.05. Furthermore, to reveal what combination of care is effective, we performed a network meta-analysis estimated OR, 95% CI. RESULTS: We identified three randomized controlled trials and eight controlled before-after trials (11 in total, with 2549 participants). The pooled data from 11 trials of multicomponent intervention had a significant effect on delirium prevention (OR 0.58, 95% CI 0.44-0.76, p < 0.001). As a result of network meta-analysis, two bundles were effective compared to the control group in reducing the incidence of delirium: a) the combination of sleep promotion (SP), cognitive stimulation (CS), early mobilization (EM), pain control (PC), and assessment (AS) (OR 0.47, 95% CI 0.35-0.64, p < 0.002), and b) the combination of SP and CS (OR 0.46, 95% CI 0.28-0.75, p < 0.001). CONCLUSION: This study revealed that non-pharmacological interventions, particularly multicomponent interventions, helped to prevent delirium in critically ill patients. In the network meta-analysis, the most effective care combination for reducing incidence of delirium was found to be multicomponent intervention, which comprises SP-CS-EM-PC-AS, and SP-CS. RELEVANCE TO CLINICAL PRACTICE: These findings reveal an efficient combination of multicomponent interventions for preventing delirium, which may be a very important prerequisite in planning care programs in the future.

研究目的は,倫理カンファレンスにおけるタイムリーな多職種倫理コンサルテーションチーム(ECT)介入の効果と問題を明らかにすること。カンファレンス参加者9名を対象に半構成的面接調査を実施し,質的記述的に分析した。効果は【タイムリーに検討できる】【多職種の意見を把握したうえで一緒に検討できる】【症例を丁寧に客観的に検討できる】【ECTに相談の場をファシリテーションしてもらえる】【考え方や道筋が整理できる】【多様な気づきが得られる】【医療チームで患者の意向に沿った支援ができる】【医療者間で認識を統一し,支援方法を共有できる】【病院全体の総意として検討できる】【医療者が自信をもって支援できる】【医療者の心理的負担が軽減する】【新たな知見を得て,別の症例に活用できる】,問題は【倫理に関する知識不足】【ECTと対等に意見交換できない】【期待した成果が得られない】【個別性が高く,検討内容を応用できない】の全16カテゴリーが抽出された。(著者抄録)

背景:在宅で生活する乳幼児期の先天性心疾患児は,計画外に入院することがある.計画外入院を防ぐ支援を検討するためには,原因を明らかにする必要があると考え,患児数や原因などの実態を調査した.方法:A病院で5年間に入院歴のある乳幼児期の先天性心疾患児のDPCと診療記録を対象にデータ収集し分析を行った.結果:乳幼児期の先天性心疾患児の35.4%が計画外入院を要した.そのうち,0歳児は31.7%と有意に多く,染色体異常を合併する患児が多かった.主な原因は,肺炎や気管支炎などの呼吸器合併症,心不全,SpO2低下やチアノーゼ,低酸素血症などを含む呼吸状態の悪化であった.在宅酸素療法は50.3%,在宅人工呼吸療法は7.9%,在宅経管栄養療法は26.0%で使用していた.結論:先天性心疾患児の計画外入院は,0歳児が最も多く,先天性心疾患による体肺循環の障害に加え,呼吸機能と循環機能の未発達さや脆弱性による影響があった.計画外入院を防ぐためには,病院から在宅と切れ目のない支援,訪問看護などの医療職の支援が必要である.(著者抄録)

BACKGROUND: Returning to work is a serious issue that affects patients who are discharged from the intensive care unit (ICU). This study aimed to clarify the employment status and the perceived household financial status of ICU patients 12 months following ICU discharge. Additionally, we evaluated whether there exists an association between depressive symptoms and subsequent unemployment status. METHODS: This study was a subgroup analysis of the published Survey of Multicenter Assessment with Postal questionnaire for Post-Intensive Care Syndrome for Home Living Patients (the SMAP-HoPe study) in Japan. Eligible patients were those who were employed before ICU admission, stayed in the ICU for at least three nights between October 2019 and July 2020, and lived at home for 12 months after discharge. We assessed the employment status, subjective cognitive functions, household financial status, Hospital Anxiety and Depression Scale, and EuroQOL-5 dimensions of physical function at 12 months following intensive care. RESULTS: This study included 328 patients, with a median age of 64 (interquartile range [IQR], 52-72) years. Of these, 79 (24%) were unemployed 12 months after ICU discharge. The number of patients who reported worsened financial status was significantly higher in the unemployed group (p<0.01) than in the employed group. Multivariable analysis showed that higher age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.03-1.08]) and greater severity of depressive symptoms (OR, 1.13 [95% CI, 1.05-1.23]) were independent factors for unemployment status at 12 months after ICU discharge. CONCLUSIONS: We found that 24.1% of our patients who had been employed prior to ICU admission were subsequently unemployed following ICU discharge and that depressive symptoms were associated with unemployment status. The government and the local municipalities should provide medical and financial support to such patients. Additionally, community and workplace support for such patients are warranted.

小児集中治療室(PICU)に子どもが入室した親に生じる心理的状況を明らかにするために,不安,抑うつ,PTSDの既存尺度を用いた質問紙調査を行った。調査は,子どもが入室中と退室から3ヵ月後の2時点で実施し,日本国内12施設のPICUと6施設の小児が入室する成人ICUで,1回目(入室中)の質問紙に237人,2回目(退室後3ヵ月)の質問紙に142人の親(父親または母親)から回答を得た。その結果,子どもがPICUおよび成人ICUに入室した親のうち,入室中の時点で25.4～34.3%に,退室後3ヵ月の時点で11.6～20.4%に,不安,抑うつ,PTSDが生じており,子どもがPICUに入室した親は,子どもが成人ICUに入室した親よりも心理的問題が生じる度合が高かった。また,本邦においても,欧米の先行研究結果と同様に,PICU入室児の親に心理的問題が生じていた。ところで,入室中の不安,抑うつ,PTSD得点がカットオフ値以上であった親の方が,カットオフ値未満の親よりも,退室後3ヵ月の同尺度得点がカットオフ値以上であるリスクが高い一方で,退室後3ヵ月に不安,抑うつ,PTSD得点がカットオフ値以上の親には,入室中の同尺度得点がカットオフ値未満であった親が,不安で33.3%,抑うつで50.0%,PTSDで17.9%含まれていたことから,入室中に,一見問題がなさそうに見える親であっても,退室後に心理的問題が生じる可能性が示唆された。(著者抄録)