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言語的コミュニケーションが困難なICU患者の痛みのアセスメントツールの開発

山田, 章子 名古屋大学

2021.11.17

概要

集中治療室(Intensive Care Unit: 以下ICU)入室患者は、様々な痛みを体験する。痛みは、身体的・精神的ストレスとなり、混乱状態や身体状態の悪化を招くため、痛みのマネージメントは重要である。
 言語的コミュニケーションが可能な患者は、容易に痛みの強さや部位を看護師に伝えることができるが、ICU入室患者は、人工気道と持続的鎮静を使用しており会話が困難であるため、痛みを訴えることができない。近年、医療者が、言語的コミュニケーションができない患者の痛みを、患者の行動を観察して評価するCritical-Care Pain Observation Tool(CPOT)がカナダで開発された。CPOTは、国際的に高く評価され、複数の言語に翻訳されているが、日本語版はまだない。そこで本研究ではCPOT日本語版を作成し、信頼性と妥当性を検証し、有用性を評価することとした。

研究Ⅰ日本語版Critical-Care Pain Observation Tool(CPOT-J)の作成
 CPOTの原作者であるGelinasから翻訳の許可を得た後、バックトランスレーション法を用いて、CPOT-Jを作成した。逆翻訳で、原文と3か所で相違がみられ、逆翻訳版を作成者にE-Mail で送り、逆翻訳の表現を用いる許可を得た。

研究Ⅱ日本語版Critical-CarePainObservationTool(CPOT-J)の信頼性・妥当性・反応性の検証
【研究方法】
 術前に同意を得た心臓血管外科患者34名を対象に、麻酔覚醒後で人工呼吸器装着中に、研究者とICU看護師とが独立してCPOT-Jを用いて痛みを評価し、評価者間信頼性を検証した。妥当性についてはCPOT-Jの点数と、バイタルサインおよびRichmond Agitation-Sedation Scale(RASS)との関連性を検証するとともに、抜管後にインタビューし、患者自身が自覚した痛みとCPOT-Jとの値を比較した。反応性については、体位変換などの痛み刺激の直前・直後・20分後に測定、その変化を検証した。

【結果】
 評価者間信頼性については、重み付けκ係数が、0.48~0.94の範囲であった。痛み刺激前後におけるCPOT-Jの変化値は、収縮期血圧および脈圧の変化値と相関がみられ、RASSの変化値とは相関は見られなかった。抜管後に患者から報告されたNumeric Rating  Scale(NRS)とは、ρ=0.573(p=0.002)の有意な相関を認めた。反応性については、痛み刺激直後の CPOT-J の値が他の時期に比較し有意にスコアが高かった。

研究Ⅲ事例検討による限界の検討
【研究方法】
 27名の患者のうち、CPOT-Jの数値が患者から報告されたNRSと一致しているケースと、不一致であったケースの2ケースについて、痛みの違いについて検討した。

【結果】
 CPOT-Jと患者の自己報告が一致したケースは、主に胸骨中央部の創の痛みであり、一致しなかったケースは、背部の痛みであった。患者の手の届く部位であることや、痛みの強さが変動しやすいことが、CPOT-Jで正確に評価できる要件であることが示唆された。

【結論】
 CPOT-Jは、痛み刺激直後と20分後で高い評価者間信頼性が得られ、痛みの変化を把握する際に一致しやすいことが示唆された。CPOT-Jの変化値と脈圧および収縮期血圧の変化値との相関から、弱いものの基準関連妥当性が認められた。RASSと関連はなく、鎮静レベルと痛みとの弁別性は確保できると考えられたが、対象患者の中に、興奮状態の患者がいなかったため、さらなる検証が必要である。反応性については、痛み刺激の前後で有意な変化の相関から、ある程度、患者の知覚する痛みを把握することが可能であることが示唆された。ただし、痛みの種類や部位によっては、十分に把握できない可能性があり、その限界を踏まえた上での活用が望まれる。

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