急性护理中的意识障碍：CRS-R的应用及一级创伤医院的呼吸、吞咽和出院结局

文献信息

中文摘要

目的： 展示修订版昏迷恢复量表（CRS-R）在重症急性护理中的应用，并描述意识障碍（DoC）患者相关的功能和康复轨迹。尽管大多数研究强调急性期后的评估和恢复，但损伤后最初数天和数周的早期康复仍未得到探索。
设计： 回顾性观察性队列研究。
地点： 一级创伤和认证卒中中心急性护理医院。
参与者： 共68名因严重脑损伤入院的成人，初始格拉斯哥昏迷量表评分≤8。
主要结局指标： 结局评估涵盖3个领域：（1）意识，通过CRS-R评估；（2）呼吸功能，包括咳嗽分类、气管切开状态和拔管准备试验（说话瓣膜或封堵）；（3）吞咽/进食，通过功能性经口摄入量表（FOIS）和参与经口饮食推进评估来衡量。
结果： 初始CRS-R评估显示，2.9%（n=2）处于昏迷，52.9%（n=36）处于无反应觉醒综合征（UWS），27.9%（n=19）处于微意识状态减（MCS-），13.2%（n=9）处于微意识状态加（MCS+），2.9%（n=2）已脱离微意识状态。出院时，没有患者仍处于昏迷；2.9%（n=2）处于UWS，17.7%（n=12）处于MCS-，13.2%（n=9）处于MCS+，41.2%（n=28）已脱离微意识状态。在脱离微意识状态的患者中，53.6%在30天内实现。73.5%（n=50）需要气管切开；大多数在带管期间参与了封堵（72%，n=36/50）和说话瓣膜试验（88%，n=44/50），68%（n=34/50）成功拔管。42.6%（n=29）完成了仪器吞咽评估，39.7%（n=27）出院时接受经口饮食。总体而言，不到一半（39.7%，n=27）出院至专门或康复机构。
结论： 意识障碍患者在急性护理期间在意识、呼吸功能和吞咽方面表现出可证明的改善，挑战了康复潜力始于恢复轨迹后期的普遍假设。这些发现强调了早期启动结构化评估和干预以优化结局并指导出院计划的重要性。未来研究应侧重于开发和评估用于识别急性护理中意识障碍的标准化筛查方案，并检查国家筛查、评估和治疗实践。

英文摘要

OBJECTIVE: To exemplify the use of the Coma Recovery Scale-Revised (CRS-R) during critical acute care and to characterize associated functional and rehabilitative trajectories of patients with disorders of consciousness (DoC). Although most research emphasizes postacute assessment and recovery, early rehabilitation in the initial days and weeks after injury remains unexplored.
DESIGN: Retrospective, observational cohort study.
SETTING: Level 1 Trauma and Certified Stroke Center acute care hospital.
PARTICIPANTS: A total of 68 adults admitted with a severe brain injury with an initial Glasgow Coma Scale score of ≤8.
MAIN OUTCOME MEASURES: Outcomes were assessed across 3 domains: (1) consciousness, via the CRS-R; (2) respiratory function, including cough categorization, tracheostomy status, and decannulation readiness trials (speaking valve or capping); and (3) swallowing/eating, measured by the Functional Oral Intake Scale (FOIS) and engagement in evaluations for oral diet advancement.
RESULTS: Initial CRS-R assessments showed 2.9% (n=2) in coma, 52.9% (n=36) in unresponsive wakefulness syndrome (UWS), 27.9% (n=19) in minimally conscious state minus (MCS-), 13.2% (n=9) in MCS plus (MCS+), and 2.9% (n=2) emerged. By discharge, no patients remained in coma; 2.9% (n=2) were in UWS, 17.7% (n=12) MCS-, 13.2% (n=9) MCS+, and 41.2% (n=28) emerged. Among those emerging, 53.6% did so within 30 days. Tracheostomy was required in 73.5% (n=50); most participated in capping (72%, n=36/50) and speaking valve trials (88%, n=44/50) while cannulated, and 68% (n=34/50) were decannulated. Instrumental swallowing evaluations were completed in 42.6% (n=29), with 39.7% (n=27) discharged on oral diets. Overall, under half (39.7%, n=27) were discharged to specialized or rehabilitative settings.
CONCLUSION: Patients with DoC make demonstrable improvements in consciousness, respiratory function, and swallowing during acute care, challenging prevailing assumptions that rehabilitation potential begins later in the recovery trajectory. These findings underscore the importance of initiating structured assessments and interventions early to optimize outcomes and inform discharge planning. Future research should focus on the development and evaluation of standardized screening protocols for identifying DoC in acute care, as well as examining national screening, assessment, and treatment practices.