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Article(id=1322168201136427708, tenantId=1146029695717560320, journalId=1220038315760373764, issueId=1322167871413796899, articleNumber=null, orderNo=null, doi=10.12102/j.issn.1009-6493.2026.03.002, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1746633600000, receivedDateStr=2025-05-08, revisedDate=1767715200000, revisedDateStr=2026-01-07, acceptedDate=null, acceptedDateStr=null, onlineDate=1793159063848, onlineDateStr=2026-10-28, pubDate=1770652800000, pubDateStr=2026-02-10, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1793159063848, onlineIssueDateStr=2026-10-28, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1793159063847, creator=13701087609, updateTime=1793159063847, updator=13701087609, issue=Issue{id=1322167871413796899, tenantId=1146029695717560320, journalId=1220038315760373764, year='2026', volume='40', issue='3', pageStart='353', pageEnd='528', issueExtLink='null', onlineDate='null', pubDate='1770652800000', pubDateStr='2026-02-10', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=null, createTime=1793158985236, creator='13701087609', updateTime=1793158985236, updator='13701087609', preIssue=null, nextIssue=null, articleTotal=null, ext=null, issueFiles=null, downloadFileDto=null}, startPage=361, endPage=367, ext={EN=ArticleExt(id=1322168201639744189, articleId=1322168201136427708, tenantId=1146029695717560320, journalId=1220038315760373764, language=EN, title=Interpretation of the version of 2025 focused update to the "Clinical practice guidelines for the prevention and management of pain, anxiety, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU", columnId=1322164987112575032, journalTitle=Chinese Nursing Research, columnName=Guideline and Consensus, runingTitle=null, highlight=null, articleAbstract=

This article interpreted the updated content of the "Clinical practice guidelines for the prevention and management of pain,anxiety,agitation/sedation,delirium,immobility,and sleep disturbances in adult patients in the ICU",to analyze potential barriers to their implementation in clinical practice by using the new Consolidated Framework for Implementation Research(CFIR 2.0) from the field of implementation science.

, authors=Lu LIU, Shan ZHANG, authorsList=Lu LIU, Shan ZHANG, authorCompany=null, correspAuthors=Shan ZHANG, authorNote=null, correspAuthorsNote=
ZHANG Shan, E-mail:
, copyrightStatement=null, copyrightOwner=null, extLink=null, articleAbsUrl=null, sourceXml=null, magXml=null, pdfUrl=null, pdf=null, pdfFileSize=null, pdfExtLink=null, richHtmlUrl=null, mobilePdfUrl=null, reviewReport=null, pdfFirstPage=null, abstractGraph=null, abstractGraphContent=null, abstractVideo=null, citation=null, cebUrl=null, magXmlContent=null, mapNumber=null, fund=null), CN=ArticleExt(id=1322168203229385408, articleId=1322168201136427708, tenantId=1146029695717560320, journalId=1220038315760373764, language=CN, title=2025版《重症监护病房成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠紊乱的预防与管理临床实践指南》更新内容的解读, columnId=1322164987414564922, journalTitle=护理研究, columnName=指南与共识, runingTitle=null, highlight=null, articleAbstract=

对《重症监护室成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠障碍的管理临床实践指南》更新内容进行解读，并参考实施科学领域中的新版实施性研究综合框架（CFIR 2.0）分析指南在实践转化过程中的潜在障碍因素。

, authors=刘璐, 张山*, *, authorsList=刘璐, 张山, authorCompany=null, correspAuthors=张山, authorNote=

刘璐，硕士研究生在读

, correspAuthorsNote=
张山，E-mail：
ZHANG Shan, E-mail:
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刘璐，硕士研究生在读

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刘璐，硕士研究生在读

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language=null, rfNumber=1, rfOrder=0, authorNames=MART M F, PUN B T, PANDHARIPANDE P, journalName=Crit Care Med, refType=null, unstructuredReference=MART M F,PUN B T,PANDHARIPANDE P,et al.ICU survivorship-the relationship of delirium,sedation,dementia,and acquired weakness[J].Crit Care Med,2021,49(8):1227-1240., articleTitle=ICU survivorship-the relationship of delirium,sedation,dementia,and acquired weakness, refAbstract=null), Reference(id=1322530194280268317, tenantId=1146029695717560320, journalId=1220038315760373764, articleId=1322168201136427708, doi=null, pmid=null, pmcid=null, year=2018, volume=46, issue=9, pageStart=e825, pageEnd=e873, url=null, language=null, rfNumber=2, rfOrder=1, authorNames=DEVLIN J W, SKROBIK Y, GÉLINAS C, journalName=Critical Care Medicine, refType=null, unstructuredReference=DEVLIN J W,SKROBIK Y,GÉLINAS C,et al.Clinical practice guidelines for the prevention and management of pain,agitation/sedation,delirium,immobility,and sleep disruption in adult 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rfNumber=40, rfOrder=39, authorNames=辜甜田, 陈伟, 李晓娟, journalName=中华急危重症护理杂志, refType=null, unstructuredReference=辜甜田,陈伟,李晓娟,等.ICU清醒患者睡眠促进策略审查指标的制订及障碍因素分析[J].中华急危重症护理杂志,2024,5(2):108-114., articleTitle=ICU清醒患者睡眠促进策略审查指标的制订及障碍因素分析, refAbstract=null), Reference(id=1322530206846403142, tenantId=1146029695717560320, journalId=1220038315760373764, articleId=1322168201136427708, doi=null, pmid=null, pmcid=null, year=2020, volume=141, issue=null, pageStart=104233, pageEnd=null, url=null, language=null, rfNumber=41, rfOrder=40, authorNames=CATHO G, CENTEMERO N S, CATHO H, journalName=Int J Med Inform, refType=null, unstructuredReference=CATHO G,CENTEMERO N S,CATHO H,et al.Factors determining the adherence to antimicrobial guidelines and the adoption of computerised decision support systems by physicians:a qualitative study in three European hospitals[J].Int J Med Inform,2020,141:104233., articleTitle=Factors determining the adherence to antimicrobial guidelines and the adoption of computerised 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journalId=1220038315760373764, articleId=1322168201136427708, language=EN, label=Table 1, caption=

Revised content of the version of 2025 focused update to the "Clinical practice guidelines for the prevention and management of pain,anxiety,agitation/sedation,delirium,immobility,and sleep disturbances in adult patients in the intensive care unit"[14]

, figureFileSmall=null, figureFileBig=null, tableContent=
主题2025版指南2018版指南
推荐意见修订推荐强度/干预倾向/证据质量推荐意见推荐强度/干预倾向/证据质量
焦虑（新增）针对重症监护病房成年焦虑病人，现有证据不足以支持使用苯二氮䓬类药物进行治疗无推荐意见
无可获得证据		无关于焦虑的建议
躁动/镇静在需要优先实现轻度镇静和/或减少谵妄的重症监护病房中，针对机械通气的病人，建议使用右美托咪定而非丙泊酚进行镇静有条件推荐
支持实施干预
中等确定性		针对机械通气的成年危重症病人，建议使用丙泊酚或右美托咪定而非苯二氮䓬类药物进行镇静有条件推荐
低质量
谵妄针对重症监护病房成年谵妄病人，现有证据不足以支持或反对使用抗精神病药物替代常规的治疗有条件推荐
利弊不明
低确定性		建议不要常规使用氟哌啶醇或非典型抗精神病药物来治疗谵妄有条件推荐
低质量
活动受限对于重症监护病房成年病人，建议提供强化活动/康复治疗替代常规活动训练/康复治疗（心脏外科手术后病人除外）有条件推荐
支持实施干预
中等确定性		建议对危重症成年病人实施康复治疗或活动训练有条件推荐
低质量
睡眠紊乱对于重症监护病房成年病人，建议给予褪黑素进行治疗有条件推荐
支持实施干预
低确定性		现有证据无法支持使用褪黑素来改善成年危重症病人的睡眠情况无推荐
极低质量
), ArticleFig(id=1322530193718231579, tenantId=1146029695717560320, journalId=1220038315760373764, articleId=1322168201136427708, language=CN, label=表1, caption=

2025版《重症监护病房成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠障碍的预防与管理临床实践指南》指南修订内容[14]

, figureFileSmall=null, figureFileBig=null, tableContent=
主题2025版指南2018版指南
推荐意见修订推荐强度/干预倾向/证据质量推荐意见推荐强度/干预倾向/证据质量
焦虑（新增）针对重症监护病房成年焦虑病人，现有证据不足以支持使用苯二氮䓬类药物进行治疗无推荐意见
无可获得证据		无关于焦虑的建议
躁动/镇静在需要优先实现轻度镇静和/或减少谵妄的重症监护病房中，针对机械通气的病人，建议使用右美托咪定而非丙泊酚进行镇静有条件推荐
支持实施干预
中等确定性		针对机械通气的成年危重症病人，建议使用丙泊酚或右美托咪定而非苯二氮䓬类药物进行镇静有条件推荐
低质量
谵妄针对重症监护病房成年谵妄病人，现有证据不足以支持或反对使用抗精神病药物替代常规的治疗有条件推荐
利弊不明
低确定性		建议不要常规使用氟哌啶醇或非典型抗精神病药物来治疗谵妄有条件推荐
低质量
活动受限对于重症监护病房成年病人，建议提供强化活动/康复治疗替代常规活动训练/康复治疗（心脏外科手术后病人除外）有条件推荐
支持实施干预
中等确定性		建议对危重症成年病人实施康复治疗或活动训练有条件推荐
低质量
睡眠紊乱对于重症监护病房成年病人，建议给予褪黑素进行治疗有条件推荐
支持实施干预
低确定性		现有证据无法支持使用褪黑素来改善成年危重症病人的睡眠情况无推荐
极低质量
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2025版《重症监护病房成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠紊乱的预防与管理临床实践指南》更新内容的解读
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刘璐 , 张山 *, *
护理研究 | 指南与共识 2026,40(3): 361-367
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护理研究 |指南与共识 2026 , 40 (3) : 361 -367
2025版《重症监护病房成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠紊乱的预防与管理临床实践指南》更新内容的解读
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刘璐，硕士研究生在读

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刘璐，硕士研究生在读

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刘璐, 张山*, *
作者信息
  • 1首都医科大学护理学院，北京 100063
通讯作者:
张山，E-mail：
ZHANG Shan, E-mail:
作者简介:

刘璐，硕士研究生在读

Interpretation of the version of 2025 focused update to the "Clinical practice guidelines for the prevention and management of pain, anxiety, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU"
Lu LIU, Shan ZHANG
Affiliations
  • 1Capital Medical University School of Nursing, Beijing 100063 China
    • Corresponding Author:
    ZHANG Shan, E-mail:
出版时间: 2026-02-10 doi: 10.12102/j.issn.1009-6493.2026.03.002
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摘要
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对《重症监护室成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠障碍的管理临床实践指南》更新内容进行解读，并参考实施科学领域中的新版实施性研究综合框架（CFIR 2.0）分析指南在实践转化过程中的潜在障碍因素。

重症监护病房  /  成年人  /  疼痛  /  焦虑  /  躁动  /  镇静  /  谵妄  /  活动受限  /  睡眠紊乱  /  临床实践指南  /  指南解读

This article interpreted the updated content of the "Clinical practice guidelines for the prevention and management of pain,anxiety,agitation/sedation,delirium,immobility,and sleep disturbances in adult patients in the ICU",to analyze potential barriers to their implementation in clinical practice by using the new Consolidated Framework for Implementation Research(CFIR 2.0) from the field of implementation science.

intensive care unite,ICU  /  adult  /  pain  /  anxiety  /  agitation  /  sedation  /  delirium  /  immobility  /  sleep disruption  /  clinical practice guidelines  /  guideline interpretation
刘璐, 张山. 2025版《重症监护病房成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠紊乱的预防与管理临床实践指南》更新内容的解读. 护理研究, 2026 , 40 (3) : 361 -367 . DOI: 10.12102/j.issn.1009-6493.2026.03.002
Lu LIU, Shan ZHANG. Interpretation of the version of 2025 focused update to the "Clinical practice guidelines for the prevention and management of pain, anxiety, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU"[J]. Chinese Nursing Research, 2026 , 40 (3) : 361 -367 . DOI: 10.12102/j.issn.1009-6493.2026.03.002
正文
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重症监护病房（intensive care unite，ICU）病人经常因疾病侵扰、有创治疗及操作、物理环境刺激、语言表达障碍等因素产生疼痛、焦虑、睡眠紊乱等不适症状[1]。超过50%的重症监护病房病人在休息或治疗过程经历中至重度疼痛[2-3]。而镇静镇痛有利于减轻病人的应激负荷，保护器官的储备功能，并且可以改善病人睡眠以及缓解焦虑，是重症监护病房病人的常规治疗措施[4]。然而，研究表明，镇静镇痛可能引起呼吸抑制、循环紊乱、肌力减弱以及诱发谵妄等不良后果，不仅会加重原有病情，增加病人院内死亡风险[5-6]，还会对病人出院后造成远期的心理、生理和认知损害[1,7]。因此，为系统管理上述症状，美国重症医学会（Society of Critical Care Medicine，SCCM）发布了2013版《重症监护病房成年病人疼痛、躁动/镇静、谵妄的预防与管理临床实践指南》[8]和2018版《重症监护病房成年病人疼痛、躁动/镇静、谵妄、活动受限和睡眠紊乱的管理临床实践指南》[2]。研究表明，针对2013版《重症监护病房成年病人疼痛、躁动、谵妄的预防与管理临床实践指南》/2018版《重症监护病房成年病人疼痛、躁动/镇静、谵妄、活动受限和睡眠紊乱的管理临床实践指南》中2个及以上要素的综合干预方法可以缩短机械通气持续时间和重症监护病房住院时长[9]。因此，2013版《重症监护病房成年病人疼痛、躁动/镇静、谵妄的预防与管理临床实践指南》/2018版《重症监护病房成年病人疼痛、躁动/镇静、谵妄、活动受限和睡眠紊乱的管理临床实践指南》对综合管理重症监护病房病人具有重要的指导意义。
研究表明，在2013版《重症监护病房成年病人疼痛、躁动、谵妄的预防与管理临床实践指南》/2018版《重症监护病房成年病人疼痛、躁动/镇静、谵妄、活动受限和睡眠紊乱的管理临床实践指南》的质量评价中，其应用性得分最低[10-11]。除此之外，医护人员对指南的认知及执行尚不充分[12-13]。2025年3月，美国重症医学会汇总新的证据，发布了2025版《重症监护病房成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠障碍的预防与管理临床实践指南》的重点更新版本[14]。因此，本研究为促进2025版《重症监护病房成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠障碍的预防与管理临床实践指南》指南的有效实施，对指南更新内容进行解读，并参考实施科学领域中的实施性研究综合框架（Consolidated Framework for Implementation Research，CFIR）分析2018版《重症监护病房成年病人疼痛、躁动/镇静、谵妄、活动受限和睡眠紊乱的管理临床实践指南》及2025版更新内容实施的潜在障碍，为临床医护人员提供参考。本研究解读参照指南解读类文献的报告规范“RIGHT for INT”[15]。
1　指南制订方法
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2025版《重症监护病房成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠障碍的预防与管理临床实践指南》制订工作组成员共24人，包括学科专家、临床医师、护士、药剂师、物理治疗师、心理学家、重症监护病房幸存者以及重症领域指南开发方法学专家。工作组全体成员定期参加视频会议并在美国重症医学会年度大会上进行面对面会议，共同确定指南的范围与核心临床问题。证据总结基于严格的系统评价和Meta分析，并依据GRADE证据-决策（evidence-to-decision，EtD）框架形成推荐意见。专家通过匿名投票，确保每项推荐意见的回复率≥70%、共识率≥80%。2025版《重症监护病房成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠障碍的预防与管理临床实践指南》指南共修订5条推荐意见，其分级、证据质量和推荐意见与2018版指南的比较见表1。
2　2025版《重症监护病房成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠障碍的预防与管理临床实践指南》更新内容解读
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2.1　重症监护病房病人的焦虑管理
焦虑是2025版《重症监护病房成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠障碍的预防与管理临床实践指南》的新增主题。研究表明，在重症监护病房住院的7 d内，病人焦虑的发生率约为25%，尽管发生率相较于疼痛、气短等不适症状低，但对重症监护病房病人造成的痛苦更大[16]。因此，重症监护病房焦虑的规范化管理亟待完善。苯二氮䓬类药物常用于重症监护病房急性焦虑的治疗，但证明其有效性的证据不足[15]。因此，2025版《重症监护病房成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠障碍的预防与管理临床实践指南》未能给出明确的推荐意见，但因慢性焦虑而长期服用苯二氮䓬类药物的病人突然停药可能会出现急性戒断反应，应考虑维持苯二氮䓬类药物的治疗[15]。此外，苯二氮䓬类药物的使用是可改变的谵妄发生的危险因素之一[2]。因此，在重症监护病房焦虑的治疗中应重视非药物干预措施的作用。目前，音乐疗法、芳香疗法、重症监护病房日记以及虚拟现实技术等非药物干预措施在缓解重症监护病房焦虑方面均有一定效果，并且可以提高苯二氮䓬类药物减停的成功率[17-18]。未来，需要开展高质量的随机对照试验，以探索重症监护病房焦虑的综合干预方案。除此之外，面部焦虑量表、视觉模拟量表等焦虑测量工具可用于重症监护病房焦虑评估，但不同测量工具的评估结果可能具有异质性，需要对上述量表在重症监护病房中的应用进行一致性评价，并评估其敏感性和特异性，以促进重症监护病房焦虑评估的标准化[15]。
2.2　重症监护病房病人的镇静治疗
针对需要轻度镇静和减少谵妄发生的重症监护病房机械通气病人，2025版《重症监护病房成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠障碍的预防与管理临床实践指南》建议使用右美托咪定替代丙泊酚进行镇静，但对于需要深度镇静或存在心动过缓高风险的重症监护病房病人，应考虑使用其他镇静剂[15]。右美托咪定能够延长目标镇静的维持时间以及减少需要补充镇痛剂的比例[19-20]。对于谵妄高风险的重症监护病房病人，相较于丙泊酚，右美托咪定能够预防谵妄的发生，缩短谵妄持续时间，并且在心动过缓、低血压等不良反应的发生率方面无明显差异[20-21]。除此之外，研究表明，右美托咪定的使用与无机械通气时间延长[HR=2.7，95%CI（0.7，4.8）]和重症监护病房住院时间缩短[HR=-2.6，95%CI（-4.4，-0.9）]有关，但在RASS镇静程度评分表（Richmond Agitation Sedation Scale，RASS）评分<2分的病人中，可能增加90 d重症监护病房病死率[HR=2.35，95%CI（1.27，4.36）][20]。未来研究需要明确右美托咪定在深度镇静病人中的作用，以及在不同年龄人群中的疗效差异。
2.3　重症监护病房病人的谵妄管理
与常规治疗相比，对于是否使用抗精神病药物治疗重症监护病房成年谵妄病人，2025版《重症监护病房成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠障碍的预防与管理临床实践指南》未能给出明确的推荐意见。2018版《重症监护病房成年病人疼痛、躁动/镇静、谵妄、活动受限和睡眠紊乱的管理临床实践指南》建议不要常规使用氟哌啶醇或非典型抗精神病药物预防或治疗谵妄[2]。抗精神病药物对谵妄治疗的益处、风险以及作用机制尚不明确。研究表明，与安慰剂相比，抗精神病药物（如氟哌啶醇）的使用不会延长重症监护病房病人无谵妄或无昏迷的时间，对认知功能、心理和生活质量无明显改善[22-23]，在死亡率、机械通气持续时间、重症监护病房住院时长以及不良事件（如QT间期延长、锥体外系反应）方面无明显差异。此外，典型与非典型抗精神病药物的使用对重症监护病房谵妄的影响也无明显差异[22]。未来需要在更大范围、不同类型的谵妄人群中进一步开展研究，并且评估抗精神病药物对病人长期认知功能的影响。
2.4　重症监护病房活动受限病人的康复训练
2025版《重症监护病房成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠障碍的预防与管理临床实践指南》建议，除心脏手术后的病人，应在常规康复训练的基础上，为重症监护病房病人提供强化康复训练[15]。2025版《重症监护病房成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠障碍的预防与管理临床实践指南》将强化康复训练定义为：超出该科室常规活动/康复训练的任何额外干预措施，例如，蹬车训练、踏步训练等强度更大的活动或更早期开始、更长时间的训练等[15]。重症监护病房获得性衰弱是重症监护病房病人在住院期间常见的神经肌肉功能障碍，发生率约为43%，是重症监护病房和住院死亡、机械通气时间延长以及气管插管拔管失败的独立危险因素，并且与病人出院后生活质量以及5年生存率更低有关[24]。综合康复训练能够缩短重症监护病房病人机械通气时长、镇静及镇痛时间，改善病人重症监护病房转出前的肌力水平、活动能力及认知能力，但个别案例可能出现血流动力学变化、呼吸急促等不良反应[25-26]。因此，在康复训练前应谨慎评估病人情况，并在训练过程中严密监测各项生理指标的变化。康复活动是多学科团队参与的复杂干预措施，在不同类型重症监护病房中开始的时机、方法、强度、频率以及持续时间等有待未来研究探索。
2.5　重症监护病房病人的睡眠紊乱治疗
2025版《重症监护病房成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠障碍的预防与管理临床实践指南》建议，使用褪黑素改善重症监护病房病人的睡眠情况[15]。褪黑素能够提高病人的睡眠质量，降低谵妄的发生率，以及缩短重症监护病房住院时长，但对睡眠总时长、谵妄的持续时间、机械通气时间和住院总时长影响尚无证据[15]。对焦虑、躁动、重症监护病房后认知功能、应激障碍以及重症监护病房死亡率等结局影响的证据尚不充足。三分之二的重症监护病房病人存在睡眠障碍，与死亡、谵妄等不良预后发生风险增高密切相关[27]。昼夜节律紊乱和情绪压力是导致重症监护病房病人睡眠障碍的重要因素[28]。研究发现，重症监护病房镇静病人血清褪黑素水平降低，可能是引起昼夜节律紊乱的机制之一[29]。因此，褪黑素替代疗法对改善重症监护病房病人的睡眠质量可能有益。然而，褪黑素制剂目前属于膳食补充剂范围，质量可能参差不齐。因此，未来研究需要对褪黑素使用剂量、频率和时长进一步评估。
3　2025版《重症监护病房成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠障碍的预防与管理临床实践指南》实施的潜在障碍因素
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3.1　分析方法
2009年，Damschroder等[30]开发了CFIR框架，帮助卫生服务研究者探索创新实施过程中潜在的影响因素，推动实施科学发展。CFIR是一套多理论整合的实施因素“元理论框架”[31]。Balas等[32]使用该框架对2018版《重症监护病房成年病人疼痛、躁动/镇静、谵妄、活动受限和睡眠紊乱的管理临床实践指南》实施潜在障碍因素进行解读，以促进指南策略的有效应用。2022年，Damschroder等[33]根据CFIR应用相关文献的系统评价和334名文章通讯作者的深度反馈，更新了框架维度及构成要素，形成CFIR 2.0版本。新版CFIR框架涵盖创新（innovation）、外部环境（outer setting）、内部环境（inner setting）、个体特征（individuals）、实施过程（implementation process）5个维度，包括48个构成要素及19个亚构成要素[34]。刘莹等[31,34]于2023年对CFIR 2.0进行了翻译、解读，为框架在国内的应用提供了理论支持。
3.2　指南实施的潜在障碍因素
2025版《重症监护病房成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠障碍的预防与管理临床实践指南》是对2018版《重症监护病房成年病人疼痛、躁动/镇静、谵妄、活动受限和睡眠紊乱的管理临床实践指南》部分内容的更新，未更新的推荐意见与旧版本一致。因此，本研究基于CFIR 2.0框架讨论2018版《重症监护病房成年病人疼痛、躁动/镇静、谵妄、活动受限和睡眠紊乱的管理临床实践指南》及更新内容实施的潜在障碍。此外，实施过程维度与其他几个维度的内容高度关联，因此与其他几个维度合并讨论。
3.2.1　创新
3.2.1.1　证据基础要素
在创新的证据基础要素方面，由于缺乏高质量的随机对照试验，2018版《重症监护病房成年病人疼痛、躁动/镇静、谵妄、活动受限和睡眠紊乱的管理临床实践指南》包含大量低质量推荐意见，尽管更新指南在个别意见上的证据确定性等级有所提升，但整体推荐意见的可靠性较为不足。由于研究的缺乏、数据质量低以及干预的利弊未明等因素，指南的推荐意见几乎均为在特定条件下的推荐。因此，医护人员在使用指南时，需要结合具体情况，考虑更多因素权衡临床实践的利弊，增加了临床决策的复杂性以及实践的异质性，医护人员的指南依从性也会显著降低[35]。
3.2.1.2　复杂性和设计要素
在创新的复杂性和设计要素方面，2018版《重症监护病房成年病人疼痛、躁动/镇静、谵妄、活动受限和睡眠紊乱的管理临床实践指南》推荐的干预方案包含较多的多因素非药物干预措施，如2018版《重症监护病房成年病人疼痛、躁动/镇静、谵妄、活动受限和睡眠紊乱的管理临床实践指南》推荐的ABCDE集束化干预以及更新版指南推荐的强化康复训练，上述综合干预措施包含的步骤多，需要跨学科团队合作。因此，实施的复杂性较高。除此之外，一些干预措施可能需要引进新的设备，如康复训练的辅助仪器，这些措施可能因成本限制以及超出医保报销范围而无法开展[12]。在适用人群方面，2018版《重症监护病房成年病人疼痛、躁动/镇静、谵妄、活动受限和睡眠紊乱的管理临床实践指南》及更新版本对不同亚组的讨论尚不充分，一些特殊人群的适用性有待研究。
3.2.2　环境
3.2.2.1　工作基础要素
在工作基础要素方面，人力资源不足是阻碍医护人员指南实施的常见因素[36]。在物质基础要素方面，环境的基础结构对重症监护病房病人的预后有重要的影响。研究表明，在增加了动态照明系统的改良重症监护病房以及单人间病房中，病人的谵妄发生风险更低[37-38]。然而，病房基础设施通常不易改变，或者改造成本高昂，相关推荐意见的开展可能受到限制。在可用资源、激励制度以及知识和信息可及性要素方面，医疗组织是否提供了必要的指南实施所需的材料和设备、与指南实践相关的指导和培训，以及组织内的监管机制是否完善均与医护人员的指南依从性有关[36]。
3.2.2.2　沟通与协作要素
在沟通与协作要素方面，睡眠、谵妄以及康复训练等照护领域涉及多学科集束化干预措施。因此，跨专业团队人员配置不足以及团队协调能力缺乏，如未形成跨学科干预小组、专业人员缺失、专业人员参与度不足以及沟通不畅等，都有可能阻碍指南的有效实施[39]。组织的文化模式要素对医护人员的沟通与协作亦有影响，如不平等的合作文化、榜样的缺失以及循证理念不足等，是指南实施的潜在障碍[36]。
3.2.2.3　兼容性要素
在兼容性要素方面，应考虑指南实施策略是否符合现有的工作流程、系统和过程。制订指南实施策略时应充分考虑实践场所现有的条件和工作模式，对指南实施的促进及阻碍因素进行审查，尽量避免与现有工作流程冲突以及增加医护人员的工作负担，导致实践成本增加和工作开展受阻[40]。
3.2.3　个体特征
不同角色在创新实践中所处的位置不同，影响着指南实施的不同环节。高层领导决定实施的优先级、制订奖惩制度、协调内外部环境的资源。因此，高层领导支持不足，实践难以成功开展；中层领导上传下达，在高层战略的指导下整合指南与实践资源，影响着信息的传播和指南实施的维持；专家实践内容和性质，同行意见则可以通过其代表性以及其他成员的信任度影响组织成员的价值观和行为[34]。一项质性研究显示，尽管实践可能会偏离指南要求，初级医护人员的实践行为最终由上级医护人员的决策而定[41]。实施领导是具体实践的带头人，协调团队资源、人员配合，推动指南的落实，实施成员是具体的实践者[34]。带头人的领导力不足、对指南实施的支持度不足，实施成员的态度不积极、知识与技能缺乏，是影响指南最终落实效果的不利因素[36]。
4　启示
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4.1　指南对临床的指导意义
2018版《重症监护病房成年病人疼痛、躁动/镇静、谵妄、活动受限和睡眠紊乱的管理临床实践指南》及2025版《重症监护病房成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠障碍的预防与管理临床实践指南》更新内容遵循科学严谨的方法学制订，并且在指南制订工作组中纳入了重症监护病房病人代表，该人群在临床问题建立、主题优先级排序以及推荐意见形成等多个关键步骤中发挥作用，与重症专家及临床实践者共同推动以病人为中心的重症指南的完善。此外，指南不仅关注药物治疗，也强调非药物干预措施的作用，并且考虑了干预对病人短期和长期结局的影响。在实用性和可操作性方面，2018版《重症监护病房成年病人疼痛、躁动/镇静、谵妄、活动受限和睡眠紊乱的管理临床实践指南》提供了具体的操作建议，2025版《重症监护病房成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠障碍的预防与管理临床实践指南》则对推荐意见进行了干预倾向的评估，对一些特殊情况也做了考量，为重症监护病房病人常见症状的综合管理提供了科学、有效的参考框架。
4.2　指南的传播与实施策略
在指南实施之前，应从实施策略、构成人员特征以及组织环境等多个维度全面评估指南实施的促进和阻碍因素，拟定清晰、可行以及符合实施场所现实情况的实施方案，设置实施标准及反思与评价机制，促进指南有效融入日常临床工作[39]。在指南实施过程中，管理者应识别并提供必要的材料及设备，定期组织团队会议收集指南实施过程中的问题，设置质量改进联络员及时给予问题反馈；组织应提供领导力培训及指南实施相关的知识和技能培训；优化指南知识的呈现方式，如适当引入智能化决策支持系统，减少实践成员的认知负荷，提高指南推进效率。在指南阶段性实施后，应分析效果检验指标的达成情况，动态调整实施策略，做好下一阶段的推进计划。除此之外，针对指南中尚未解决的问题，应鼓励科研创新，促进科研人员与实践团队的合作，探索符合本土情况的干预方案，共同促进重症监护病房综合管理指南的进一步完善。
5　小结
收起
2025版《重症监护病房成年病人疼痛、焦虑、躁动/镇静、谵妄、活动受限和睡眠障碍的预防与管理临床实践指南》在2018版《重症监护病房成年病人疼痛、躁动/镇静、谵妄、活动受限和睡眠紊乱的管理临床实践指南》的基础上新增了“焦虑”主题，并对镇静、谵妄、活动受限和睡眠紊乱管理的推荐意见进行了更新，进一步增加了以病人为中心的重症领域综合管理指南的全面性。然而，多数推荐意见的证据质量较低、强度不足，需要临床医护人员结合病人的个体情况、现实条件权衡利弊后进行决策。此外，指南实施面临多学科协作不足、实施资源有限等挑战，需通过领导支持、优化知识传播方式及持续质量改进等策略推动落地。未来需要开展更多高质量研究，尤其是针对本土化方案的探索，以提升指南的临床适用性，改善重症监护病房病人的短期与长期预后。

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doi: 10.12102/j.issn.1009-6493.2026.03.002
  • 接收时间：2025-05-08
  • 首发时间：2026-10-28
  • 出版时间：2026-02-10
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  • 收稿日期：2025-05-08
  • 修回日期：2026-01-07
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    1首都医科大学护理学院，北京 100063

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2种不同金属材料的力学参数
科
Family		 属数
Number of
genus		 种数
Number of
species		 占总种数比例
Percentage of
total species (%)		 属
Genus		 种数
Number of
species		 占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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