- 學位論文
術中低血壓預防及術後肺部併發症的風險因子分析和吞嚥困難相關性之統合分析
Intraoperative Hypotension Prevention, Risk Factors for Postoperative Pulmonary Complications, and a Meta-analysis of the Correlation with Dysphagia
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摘要
背景：本博士論文共分為三個研究計畫。三個計畫的共通點在於具有共通的目標，通過尋找方法或是風險因子分析改善圍術期（術前、術中和術後）的術後併發症。第一個計畫背景為目前文獻使用低血壓預測指數指引是否能減少術中低血壓的持續時間與嚴重程度以及術後併發症的效果不明。第二個計畫為目前在口腔癌切除併重建手術的病人術後肺部併發症的發生率以及風險因子尚無完整術前術中的資料。第三個計畫為目前對於主觀問卷和客觀的吞嚥攝影診斷之間的相關性尚無定論。 目的：第一個計畫目的為探討低血壓預測指數指引是否可以減少術中低血壓發生的持續時間與嚴重程度與術後併發症的發生。第二個計畫目的為探討接受口腔癌切除併重建手術的病人術後肺部併發症之發生率與風險因子。第三個計畫目的為探討主觀問卷和吞嚥攝影之間的相關性。 方法：第一個計畫為使用低血壓預測指數指引執行一個60人隨機對照試驗。其中一組30人接受低血壓預測指數指引(實驗組)，另外30人一組沒有接受低血壓預測指數指引(控制組)。主要測量結果為時間加權平均動脈壓小於65mmHg，並追蹤術後30天的併發症，包含消化道、心臟神經等器官。第二個計畫為使用臺大醫整庫、電子麻單以及病歷資料，做一回顧觀察性研究，回顧過去十年接受口腔癌切除併重建手術的病人術後肺部併發症發生率以及風險因子。第三個計畫為使用相關性統合分析探討主觀問卷和客觀吞嚥攝影的相關性。 結果：第一個計畫的結果為受試者實驗組有30位，控制組有30位。年齡中位數為62歲，其中48位為男性。手術的中位持續時間為490分鐘。實驗組之時間加權平均動脈壓小於65 mmHg 中位數顯著低於對照組(median [Q1, Q3]: 0.02 [0.003, 0.08] vs. 0.37 [0.20, 0.58], P < 0.001）。術後併發症除了消化道併發症在實驗組發生人數顯著比控制組少，其餘器官併發症兩組沒有差異。第二個計畫的結果為術後肺部併發症的觀察性研究中共納入993名患者，術後肺部併發症發生率為25.8%。年齡越大（OR：1.0；p < 0.001）、麻醉風險越高(分級>2；OR：1.4；p = 0.020)以及腫瘤分期越高（第I期：Reference；第II期 [OR]: 3.3, p = 0.019；第III期：4.4, p = 0.002；第IV期：4.8, p = 0.002）為術後肺部併發症的風險因子。第三個研究結果為問卷及吞嚥攝影的統合分析納入了5篇使用Eating Assessment Tool-10的研究，共856名患者，以及1項使用雪梨吞嚥問卷的研究，共27名患者。結果顯示，主觀問卷與吞嚥攝影檢查之間存在中等相關性（r = 0.35，95% CI [0.20, 0.48]）。 結論：第一個計畫結論為使用低血壓預測指數指引可以減少術中低血壓發生的持續時間與嚴重程度，但對於術後併發症的效果仍需更多研究。第二個計畫結論為口腔癌切除併重建手術的病人，術後肺部併發症的發生率為25.8%，風險因子包含腫瘤期數、年齡以及麻醉風險等級大於2。第三個計畫結論為主觀問卷與吞嚥攝影檢查之間存在中等相關性。主觀問卷可作為護士和居家護理人員的輔助工具，用於早期評估患者吞嚥困難的風險。
並列摘要
Backgrounds: This thesis consists of three research projects. The commonality among these projects lies in their shared objective: to improve perioperative (preoperative, intraoperative, and postoperative) complications through intraoperative monitoring management or risk factor analysis. This thesis is divided into three research projects. The first project investigates the effectiveness of using the Hypotension Prediction Index (HPI) to reduce the duration and severity of intraoperative hypotension and postoperative complications, an area that remains unclear. The second project addresses the lack of comprehensive preoperative and intraoperative data on the incidence and risk factors for postoperative pulmonary complications (PPCs) in patients undergoing oral cancer resection and free flap reconstruction. The third project explores the correlation between subjective questionnaires and videofluoroscopy in patients with dysphagia, for which no definitive conclusions have been established. Aims: The purpose of the first project is to investigate whether guidance using the HPI can reduce the duration and severity of intraoperative hypotension and postoperative complications. The second project aims to examine the incidence and risk factors of postoperative pulmonary complications in patients undergoing oral cancer resection and reconstruction. The third project seeks to explore the correlation between subjective questionnaires and videofluoroscopy. Methods: The first project involves conducting a randomized controlled trial with 60 participants using HPI guidance. Thirty patients will receive HPI-guidance (intervention group), while the other 30 will not (control group). The primary outcome measure is the time-weighted average of mean arterial pressure (TWA MAP) below 65 mmHg, with a 30-day postoperative follow-up on complications. The second project is a retrospective observational study utilizing data from National Taiwan University Hospital to review the incidence and risk factors of PPCs in patients undergoing oral cancer resection with reconstruction over the past decade. The third project uses a correlation meta-analysis to examine the relationship between subjective questionnaires and videofluoroscopy. Results: The results of the first project show 30 patients in the intervention group and 30 in the control group, with a median age of 62 years, and 48 patients were male. The median duration of surgery was 490 minutes. The median TWA MAP < 65 mmHg was significantly lower in the experimental group than in the control group (0.02 [0.003, 0.08] vs. 0.37 [0.20, 0.58], P < 0.001). In terms of postoperative complications, the experimental group had significantly fewer gastrointestinal complications compared to the control group, while other organ complications showed no difference between the groups. The second project’s results from the observational study of PPCs included 993 patients, with an incidence rate of 25.8%. Increased age (OR: 1.0; p < 0.001), higher American Society of Anesthesiologists Classification (grade >2; OR: 1.4; p = 0.020), and advanced tumor stage (stage I: reference; stage II [OR]: 3.3, p = 0.019; stage III: 4.4, p = 0.002; stage IV: 4.8, p = 0.002) were identified as risk factors. The results of the third project’s meta-analysis included five studies using the Eating Assessment Tool-10, totaling 856 patients, and one study using the Sydney Swallow Questionnaire with 27 patients. The findings indicated a moderate correlation between subjective questionnaires and videofluoroscopy (r = 0.35, 95% CI [0.20, 0.48]). Conclusions: The conclusion of the first project is that HPI guidance can reduce the intraoperative hypotension, though its effect on postoperative complications requires further study. The second project concludes that the PPC incidence is 25.8%, with risk factors including tumor stages, age, and higher anesthetic risks. The third project concludes that there is a moderate correlation between subjective questionnaires and videofluoroscopic swallowing studies.
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