专家解读重症新冠肺炎诊疗与管理共识:早干预、整体护理、可复制

2020-02-12 杨迪 崔元苑 人民网-人民健康网

近日,华中科技大学同济医学院附属同济医院联合北京协和医院、中日友好医院、北京大学第一医院、北京大学第三医院、北京大学人民医院、北京医院等来汉支援的各家医院共同发布《重症新型冠状病毒感染肺炎诊疗与管理共识》(以下简称“共识”),力争通过经验总结,提高重症患者的治愈率,降低病死率。对此,人民网记者采访了华中科技大学同济医学院附属同济医院的三位专家,共同对共识中的亮点进行分析解读。

近日,华中科技大学同济医学院附属同济医院联合北京协和医院、中日友好医院、北京大学第一医院、北京大学第三医院、北京大学人民医院、北京医院等来汉支援的各家医院共同发布《重症新型冠状病毒感染肺炎诊疗管理共识》(以下简称“共识”),力争通过经验总结,提高重症患者的治愈率,降低病死率。对此,人民网记者采访了华中科技大学同济医学院附属同济医院的三位专家,共同对共识中的亮点进行分析解读

共识亮点:将具有高危因素的普通型患者纳入重症管理

专家解读:早干预、扼杀重症苗头或者延缓病程进展

此次“共识”提出,将新冠肺炎重症患者分为具有发展为重症的高危因素的普通型、重型和危重型。其中特别指出将符合持续高热、高龄、有严重基础疾病、前后两次对比肺部CT进展迅速任何一条高危因素的普通型患者纳入重症群体管理。

对此,华中科技大学同济医学院附属同济医院呼吸内科教授、主任医师谢俊刚表示,不能等到患者发展成了重症再想对策,要将治疗窗口前移。

谢俊刚解释,新冠肺炎进展迅速,符合以上任一条的普通型患者,都是潜在重症人群。尤其是肺部CT,能很直观地看到病情变化。一旦CT显示病情有所进展,就应视为潜在重症人群进行治疗。

华中科技大学同济医学院附属同济医院护理部主任汪晖介绍,我们从观察中发现,新冠肺炎的疾病发展进程比较快,特别是缺氧这块,年龄大的、有基础疾病的患者可能更快,这也是此次共识中普通型患者(具有发展为重症的高危因素)受关注的原因。

华中科技大学同济医学院附属同济医院医务处处长吴剑宏也指出,初期处于普通型的患者往往很快就发展成重症,等到发展成重症或危重症再收治,就会错过最佳治疗时机,所以,此次共识中加入了普通型患者(具有发展为重症的高危因素)及时收治。为的就是早干预、扼杀重症苗头或者延缓病程进展。

共识亮点:对重症患者“整体护理”进行明确指导

专家解读:不只关注疾病,还包括身体、心理、社会、精神各个层面的整体护理

“共识”中强调,对重症患者的院前评估及转运、病区的设置及管理、医疗质量的评估、如何开展多学科联合诊疗及整体护理进行了明确指导。

对于“整体护理”的内容,汪晖解读称,同济医院作为重症新冠肺炎的定点救治医院,对于重症患者要实施有别于一般护理的责任制整体护理。

汪晖介绍说,具体要点包括生命体征的监测与护理,将患者体温、呼吸、呼吸频率、深度氧饱和度等作为观察重点。发热患者要根据发热情况给予护理,通过药物或物理降温。

需要特别提醒的是,对于高热患者药物降温处理后会出现出汗较多,引起体液的变化,出现低血压的情况,要注意观察。对于呼吸困难比较重的患者,通过有创、无创呼吸机给氧,护理时要根据血氧饱和度的情况调节吸气、呼气的压力以及吸氧的浓度等参数。同时要注意的是,密闭式吸痰要做好人工气道的管理。

“疫情期间,做好心理护理特别重要。”汪晖指出,患者会有创伤心理的应激反应,如被隔离感,对疾病的不确定感,在护理方面需要评估患者的心理状态,适当的调试、干预与支持。同时,通过分享成功救治的案例,沟通疫情控制的情况,帮助他们树立战胜疾病的信心。

汪晖认为,因为疾病发展进程比较快,护理上更要重视对病情的观察。包括患者咳嗽、呼吸频率、缺氧情况、胸闷胸痛情况,各种氧疗效果的观察,血氧饱和度、缺氧改善度、呼吸情况,根据观察调整给氧流量。

“同时,由于药物治疗的复杂性,对于有基础疾病的患者,在正确及时给药的同时还要观察药物的不良反应。”汪晖强调,要加强对患者基础疾病的观察与护理。对于高血压糖尿病以及心脑疾病患者,在观察新冠肺炎的同时,还要注意护理好血压、血糖等指标。对于并发症的观察、预防和处理也要及时到位。

在生活照顾的护理方面,汪晖介绍,还要做好皮肤压力性损伤的护理。做好健康指导,从疾病的不确定感、预后、治疗配合等方面对患者进行指导,保证患者睡眠饮食的健康,减少免疫系统的伤害。要观察患者体液平衡,记录好出入量,为医嘱提供帮助。

在营养管理方面,他表示,要提供高热量、高蛋白、高维生素的食物给患者,或者肠内、肠外营养素的支持。

在康复指导方面,当患者病情稳定了、出院了,还要跟进指导,包括呼吸方式、康复训练、气道廓清训练、呼吸操、营养、放松减压等,帮助患者慢慢恢复肺功能。

“整体护理就是以人的健康为中心,不只关注疾病,还包括患者身体、心理、社会、精神各个层面的全程护理,更是包括入院、住院、出院以及出院后的康复、跟进护理。因此,更强调护理专业水平的整体性高度和协调配合能力。”汪晖如是理解,如此形成以患者需求和问题为导向,制定护理计划,实施精准的护理措施,进行护理效果评价的模式。

共识亮点:目前最为系统的针对重症新冠肺炎管理的全流程指南

专家解读:聚焦重症、更全面、更细化、可复制

共识中分别推荐了针对具有发展为重症的高危因素的普通型、重型、危重型患者的治疗意见,是目前最为系统的针对重症新冠肺炎患者管理的全流程指南。

吴剑宏解读称,救治重症就要拿出适应重症的方案。之前的诊疗指南或者方案都是全面性的,这次是专门针对重症的,焦点很清晰。

“之前是讲医学上的治疗,很专业。在这次共识中,我们谈病区建设、重症病房的支撑体系、院前评估、就医、分诊分治、组织抢救、病房建设,从治疗到出院全流程的一个方案。可以说是更全面、可复制的一个方案。”吴剑宏进一步说,如何进行人员配置、装备配置、病房管理、整体护理、多学科专家支撑、病房的质量控制和质量管理等相关操作规范、流程,甚至什么条件下应该插管、应坚持用无创呼吸机这些更具体的事项,在共识里面都说明了。

共识亮点:明确转出重症病房及危重症监护病房标准和出院标准

专家解读:出院标准按国家诊治方案执行、回家后也要单独隔离14天

共识表示,其对重症病房病区的分布、医务人员的个人防护要求、患者的安置、清洁消毒、患者的出院标准都有明确的规范。

谢俊刚提醒,出院标准是按国家诊治方案执行,按现有对新冠肺炎的认识,并不能保证达到痊愈。鉴于目前核酸检测阳性率为30%—40%,出院患者回家后也要单独隔离14天。在此期间,如没有发烧、腹泻、呼吸困难等症状,方可解除隔离。

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    2020-02-20 wxl882001

    了解一下

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=2080358, encodeId=48d3208035894, content=<a href='/topic/show?id=5c34916e9c3' target=_blank style='color:#2F92EE;'>#诊疗与管理#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=91679, encryptionId=5c34916e9c3, topicName=诊疗与管理)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=139a316, createdName=wumeihua88, createdTime=Sun Apr 26 23:56:00 CST 2020, time=2020-04-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1927424, encodeId=4ae4192e424ae, content=<a href='/topic/show?id=590220681a0' target=_blank style='color:#2F92EE;'>#专家解读#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20681, encryptionId=590220681a0, topicName=专家解读)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=80c5136, createdName=drj2003, createdTime=Wed Jul 22 04:56:00 CST 2020, time=2020-07-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=379454, encodeId=2ed33e94548d, content=了解一下, beContent=null, objectType=article, channel=null, level=null, likeNumber=82, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6KcicAVC1MwuOgo3iaicb1Imgk1yIfnvr6oXzibcAFB6puAyNJXbzWhNuLqaFYBVRWjh7rghkvFLPxMAfD5ib3nXwVD/0, createdBy=bed21972958, createdName=wxl882001, createdTime=Thu Feb 20 19:50:21 CST 2020, time=2020-02-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1579668, encodeId=ca6115e9668af, content=<a href='/topic/show?id=490795953ed' target=_blank style='color:#2F92EE;'>#重症新冠肺炎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=95953, encryptionId=490795953ed, topicName=重症新冠肺炎)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=9f4216549541, createdName=ms5439512287675881, createdTime=Fri Feb 14 06:56:00 CST 2020, time=2020-02-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=379158, encodeId=c6983e915823, content=了解一下, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6KcicAVC1MwuOgo3iaicb1Imgk1yIfnvr6oXzibcAFB6puAyNJXbzWhNuLqaFYBVRWjh7rghkvFLPxMAfD5ib3nXwVD/0, createdBy=bed21972958, createdName=wxl882001, createdTime=Wed Feb 12 19:16:05 CST 2020, time=2020-02-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1027131, encodeId=1bee102e13127, content=新冠肺炎,疫情何时才能消失, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=公卫新人, createdTime=Wed Feb 12 18:56:00 CST 2020, time=2020-02-12, status=1, ipAttribution=)]
  5. [GetPortalCommentsPageByObjectIdResponse(id=2080358, encodeId=48d3208035894, content=<a href='/topic/show?id=5c34916e9c3' target=_blank style='color:#2F92EE;'>#诊疗与管理#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=91679, encryptionId=5c34916e9c3, topicName=诊疗与管理)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=139a316, createdName=wumeihua88, createdTime=Sun Apr 26 23:56:00 CST 2020, time=2020-04-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1927424, encodeId=4ae4192e424ae, content=<a href='/topic/show?id=590220681a0' target=_blank style='color:#2F92EE;'>#专家解读#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20681, encryptionId=590220681a0, topicName=专家解读)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=80c5136, createdName=drj2003, createdTime=Wed Jul 22 04:56:00 CST 2020, time=2020-07-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=379454, encodeId=2ed33e94548d, content=了解一下, beContent=null, objectType=article, channel=null, level=null, likeNumber=82, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6KcicAVC1MwuOgo3iaicb1Imgk1yIfnvr6oXzibcAFB6puAyNJXbzWhNuLqaFYBVRWjh7rghkvFLPxMAfD5ib3nXwVD/0, createdBy=bed21972958, createdName=wxl882001, createdTime=Thu Feb 20 19:50:21 CST 2020, time=2020-02-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1579668, encodeId=ca6115e9668af, content=<a href='/topic/show?id=490795953ed' target=_blank style='color:#2F92EE;'>#重症新冠肺炎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=95953, encryptionId=490795953ed, topicName=重症新冠肺炎)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=9f4216549541, createdName=ms5439512287675881, createdTime=Fri Feb 14 06:56:00 CST 2020, time=2020-02-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=379158, encodeId=c6983e915823, content=了解一下, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6KcicAVC1MwuOgo3iaicb1Imgk1yIfnvr6oXzibcAFB6puAyNJXbzWhNuLqaFYBVRWjh7rghkvFLPxMAfD5ib3nXwVD/0, createdBy=bed21972958, createdName=wxl882001, createdTime=Wed Feb 12 19:16:05 CST 2020, time=2020-02-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1027131, encodeId=1bee102e13127, content=新冠肺炎,疫情何时才能消失, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=公卫新人, createdTime=Wed Feb 12 18:56:00 CST 2020, time=2020-02-12, status=1, ipAttribution=)]
    2020-02-12 wxl882001

    了解一下

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=2080358, encodeId=48d3208035894, content=<a href='/topic/show?id=5c34916e9c3' target=_blank style='color:#2F92EE;'>#诊疗与管理#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=91679, encryptionId=5c34916e9c3, topicName=诊疗与管理)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=139a316, createdName=wumeihua88, createdTime=Sun Apr 26 23:56:00 CST 2020, time=2020-04-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1927424, encodeId=4ae4192e424ae, content=<a href='/topic/show?id=590220681a0' target=_blank style='color:#2F92EE;'>#专家解读#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20681, encryptionId=590220681a0, topicName=专家解读)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=80c5136, createdName=drj2003, createdTime=Wed Jul 22 04:56:00 CST 2020, time=2020-07-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=379454, encodeId=2ed33e94548d, content=了解一下, beContent=null, objectType=article, channel=null, level=null, likeNumber=82, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6KcicAVC1MwuOgo3iaicb1Imgk1yIfnvr6oXzibcAFB6puAyNJXbzWhNuLqaFYBVRWjh7rghkvFLPxMAfD5ib3nXwVD/0, createdBy=bed21972958, createdName=wxl882001, createdTime=Thu Feb 20 19:50:21 CST 2020, time=2020-02-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1579668, encodeId=ca6115e9668af, content=<a href='/topic/show?id=490795953ed' target=_blank style='color:#2F92EE;'>#重症新冠肺炎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=95953, encryptionId=490795953ed, topicName=重症新冠肺炎)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=9f4216549541, createdName=ms5439512287675881, createdTime=Fri Feb 14 06:56:00 CST 2020, time=2020-02-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=379158, encodeId=c6983e915823, content=了解一下, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6KcicAVC1MwuOgo3iaicb1Imgk1yIfnvr6oXzibcAFB6puAyNJXbzWhNuLqaFYBVRWjh7rghkvFLPxMAfD5ib3nXwVD/0, createdBy=bed21972958, createdName=wxl882001, createdTime=Wed Feb 12 19:16:05 CST 2020, time=2020-02-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1027131, encodeId=1bee102e13127, content=新冠肺炎,疫情何时才能消失, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=公卫新人, createdTime=Wed Feb 12 18:56:00 CST 2020, time=2020-02-12, status=1, ipAttribution=)]
    2020-02-12 公卫新人

    新冠肺炎,疫情何时才能消失

    0