實證研究之臨床應用–使用Lidocaine jelly是否可降低鼻胃管放置的疼痛不適?Effect of application the Lidocaine jelly to alleviate pain and discomfort of nasogastric tube insertion

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2020-01-31 已刊登
新刊登 綜 整 預防/治療/介入類型

作  者

陳品熙* 林麗英 吳琬婷 陳楷勳 周美蘭 張素青

實證知識類別

B 類:實證健康照護應用

PICO

治療/預防性問題

治療/介入措施

其他 other

科別

  • 臨床指引/實證照護成效 Clinical Guidelines/Evidence Based Outcomes

中文關鍵詞

鼻胃管置入 2% Lidocaine凝膠 疼痛

英文關鍵詞

Nasogastric intubation Nasogastric tube insertion Lidocaine jelly Pain

機構名稱

高雄榮民總醫院

申請單位

護理部

中文摘要

形成臨床提問:
臨床技術常規放置鼻胃管時以水溶性凝膠(K-Y jelly),或liquid paraffin做為潤滑劑,病人常因放置鼻胃管造成鼻部或喉嚨疼痛、噁心和嘔吐等,甚至自拔鼻胃管,無法配合醫療處置。 目前許多侵入性檢查於導管置入前,如胃鏡、膀胱鏡等,常以Lidocaine凝膠做為潤滑劑,因Lidocaine凝膠可於完整的黏膜表面快速產生麻醉效果,約5分鐘就可有效降低疼痛。 因此思考若將Lidocaine凝膠運用於放置鼻胃管的病人,是否比目前使用的水溶性凝膠(K-Y Jelly)更能減少疼痛不適?期望經由文獻搜尋、嚴格文獻評讀,依實證文獻進行臨床應用,能解決病人問題,改變臨床實務,提升照護品質。
文獻搜尋的方法與分析:
確立問題並提出PICO關鍵字Intubation, Gastrointestina、Lidocaine、Jelly、Pain,以MeSH term及自然語言關鍵字(Intubation, Gastrointestina or nasogastric intubation or nasogastric tube insertion) and (Lidocaine or Xylocaine) and (Gels or Jelly) and (Pain or discomfort) 於PubMed、Cochrane Library、Trip Database、Airiti Library華藝線上圖書館等資料庫進行文獻搜尋。納入條件為消化道相關疾病的成人病人接受鼻胃管置入者。排除對象為小孩、精神障礙、懷孕、敗血症狀、自殺、心理疾患、鼻部損傷或預放置口胃管者。文獻搜尋截至2018年2月,共搜尋到50篇,排除重複(包括已納入統合分析的隨機對照試驗)及與主題不符合文獻,僅餘1篇與主題符合且最佳研究證據等級文獻,為2018年Lor, Y. C.等八人發表之「The application of lidocaine to alleviate the discomfort of nasogastric tube insertion: A systematic review and meta-analysis.」。2019年11月再次搜尋無更新文獻。
文獻的品質評讀:
以Critical Appraisal Skill Program tools for Systematic Review進行文獻嚴格評讀,實證證據等級為Level I,文獻顯示以Lidocaine凝膠作為放置鼻胃管時的潤滑劑,能有效降低疼痛;且使用最小濃度的2% Lidocaine即能有效地降低疼痛。
證據之臨床應用:
2018年3月成立實證臨床應用小組,建立執行計畫,收案地點為急診,對象為疑似腸胃道疾病病人,常規照護組為水溶性凝膠(K-Y jelly),實證應用組為臨床易取得的2% Lidocaine凝膠,兩組病人皆在放置鼻胃管完成固定後的當下及放置鼻胃管後五分鐘,由病人主觀填寫問卷,瞭解病人的不適情況,進行結果分析。
成效評值:
實證臨床應用收案共52人,常規照護組27人,實證應用組25人,以卡方及t檢定評估兩組間基本資料均p值>0.05,統計學上並無顯著差異,顯示兩組具有同質性。 兩組間,在放置鼻胃管完成後的當下,使用2% Lidocaine凝膠的病人比使用K-Y jelly的病人,在疼痛分數(p-value= 0.002)、噁心發生(p-value <0.001)均顯著較低、較少。在咳嗽、吞嚥困難、流鼻血發生及疼痛部位,兩組未達顯著差異。在鼻胃管放置後五分鐘,使用2% Lidocaine凝膠的病人在疼痛分數(p-value= -0.025)、噁心發生(p-value <0.001)、吞嚥困難發生(p-value <0.001)和有無疼痛部位(p-value= 0.015),均較使用K-Y jelly的病人顯著較低、較少。在嘔吐、咳嗽、或流鼻血發生則兩組未達顯著差異。
結論與建議:
經實證臨床應用,顯示運用2% Lidocaine凝膠做為放置鼻胃管的潤滑劑,能有效減輕病人疼痛,亦能減緩噁心、吞嚥困難或不適感發生。故將此做為護理技術常規修訂依據,推廣全院臨床運用,讓放置鼻胃管的病人得以受惠,提升醫療成果。

英文摘要

Ask an answerable question (PICO):
Although the K-Y jelly or liquid paraffin is usually regarded as the lubricant in the process of the nasogastric Tube (NGT) insertion, nasal or throat pain, nausea and vomiting are the chief complains of patients after nasogastric intubation. Patients would remove tube by themselves and could not comply with medical treatment. The lidocaine jelly is often selected as a local anesthetic gel before many invasive procedures, such as gastroscopy or cystoscopy. The lidocaine jelly can quickly produce anesthesia on the entire mucosal surfaces, and quickly reduce pain in 5 minutes. Therefore, the aim of the study was to explore whether the lidocaine jelly can reduce pain and discomfort more than water-soluble gel (K-Y jelly) in nasogastric intubation?
The Method and Analysis of Literature Review:
To identify the clinical problem and create keywords with PICO (Intubation, Gastrointestina, Lidocaine, Jelly, Pain). Also, included MeSH term and natural language keywords, such as (Intubation, Gastrointestina or nasogastric intubation or nasogastric tube insertion) and (Lidocaine or Xylocaine) and (Gels or Jelly) and (Pain or discomfort). Databases from PubMed, Cochrane Library, Trip Database, Airiti online Library were searched until on November 2019. Inclusion criteria were the patient who being related to gastrointestinal disease required NGT insertion in emergency department. The patients, such as children, mental disorders, pregnancy, sepsis, suicide, mental illness, nasal injury, or NGT intubation from mouth, were excluded. A total of 50 articles were included. Studies were excluded duplicate papers and non-compliant with themes. In the end, there is only one article -“The application of lidocaine to alleviate the discomfort of nasogastric tube insertion: A systematic review and meta-analysis.” that coincides with clinical problem.
Critical Appraisal:
The Critical Appraisal Skill Program tools for Systematic Review (2018) were used to appraise the quality of this literature. According to Oxford CEBM (2011), the level of evidence is Level I. The paper finding indicated that it is effective for NGT insertion taking Lidocaine jelly for lubricant. The result of the study suggested that the minimum concentration of 2% Lidocaine jelly could effectively reduce pain and discomfort.
Clinical Application of Evidence:
The subjects who suspected gastrointestinal disease would enroll at emergency department. In the routine care group, K-Y jelly was used. 2% lidocaine jelly was used in the experiment group. The outcomes were evaluated in the immediate time and 5-minute after the insertion.
Evaluation of Effectiveness:
In total of 52 subjects participating in the study, 27 in the routine care group and 25 in the experiment group. The Chi-square test and independent t-test were used to examine the differences of demographic data between the groups. There was no significant difference. At immediate time after the insertion, the levels of pain and nausea in the experiment group were lower than the routine care group (p-value < 0.05). After 5-minute after the insertion, the levels of pain, nausea, difficult swallow, and the part of pain in the experiment group were lower than the routine care group (p-value < 0.05).
Conclusions and Recommendations:
This study demonstrated that 2% Lidocaine was effective in the NGT insertion to reduce pain, nausea, and difficult swallow. We suggest the protocol of the nasogastric Tube (NGT) insertion skill needs to be modified in the clinical settings to improve the quality of nursing care.