- 學位論文
經溫控治療之非可電擊心律心臟驟停病人預後分析
The evaluation and analysis about the possible affecting factors of the neurologic outcomes of resuscitated cardiac arrest patients after target temperature management
摘要
背景介紹 心臟停止病人通常其神經學預後與死亡率皆高，尤其是起始心率為非可電擊心律之病人。雖然復甦後照護標準與流程的建立與目標體溫控制治療（Target temperature management, TTM）的進步與發展多年，值至今日，臨床醫師依然對與哪些心臟停止病人可以對這些治療有良好反應依然沒有一定的定論。藉由分析病人發生心臟停止前之狀況、心臟停止時的急救復甦過程與恢復自發性循環後的治療等過程當中的各項參數與預後的關係，嘗試找出與良好預後相關的參數，吾人相信可以協助臨床醫師預測該病人是否經過積極治療後能有良好的預後，以幫助臨床醫師進行治療方向之擬訂。本研究利用台灣本土資料登記庫—台灣心臟停止病人進行目標體溫控制治療登錄網絡（TaIwan Network of Targeted Temperature ManagEment for CARDiac Arrest registry, 簡稱TIMECARD資料庫）內的登錄資料分析，嘗試找出相關的參數，並對於結果進行分析討論。 研究方法 本研究利用TIMECARD資料庫，並且篩選出心臟停止時之起始心律為非可電擊心率，亦即無收縮性心搏停止（Asystole）或是無收縮性心電氣活動（Pulseless Electrical Activity，PEA）之病人，以及選定符合研究目的參數變項進行敘述性統計與分析統計。主要結果設定為出院時為良好神經學預後，亦及大腦表現分類（Cerebral performance category）分數為1或2分。進行單變項分析後，再挑選具意義的參數變項進入多變項二元邏輯回歸分析。此外，次要結果分析中，也設定病人為目擊倒地事件與否的比較，以及PEA與Asystole病人之比較。進一步將非目擊倒地病人篩選出來，針對良好神經學預後進行次族群分析。 研究結果 共332位起始心率為非可電擊心率病人之心臟停止病人被篩選出來進行進一步的分析。其中，共109位病人最終存活（32.8%），且當中有38位病人最終出院時為良好神經學預後（11.4%）。經過單變項分析後發現，良好神經學預後組相對於不良神經學預後組有統計顯著差異的參數變項包含心臟停止前CPC、院內心臟停止事件、起始心率為PEA、旁觀者有無提供心肺復甦術（Cardiopulmonary resuscitation, CPR）、CPR持續時間、恢復自發性循環時的收縮壓與舒張壓、有無併發癲癇、是否曾經有過低血鉀與是否接受過經皮冠狀動脈介入術。多變項分析結果發現，起始心率為PEA、較高的收縮壓與舒張壓、沒有併發癲癇、曾經有過低血鉀等四個變項針對良好神經學預後則仍具有統計學顯著意義。在非目擊心臟停止事件之病人中，與良好神經學預後有相關之參數，則僅剩起始心率為PEA。針對其他次要結果指標之分析結果也有數個心臟停止前病人狀態、心臟停止急救時相關參數以及恢復自發性循環後的狀態與復甦後照顧等各有部分因子達到統計顯著差異。 結論 在TIMECARD資料庫當中，針對起始心率為分可電擊心率之心臟停止病人，其接受目標體溫控制治療後，有數個變項與良好神經學預後有統計學顯著意義，而這些參數與病人之心臟停止前病史與身體狀態、CPR急救時的狀況與恢復心跳後的情況及併發症有相關，此些參數可提供臨床醫師作為病人預後預測之參考。
並列摘要
Background Patients who suffered from cardiac arrest, especially those who had initial non-shockable rhythm, often turned to be poor neurologic outcomes and to have high mortality rates. Though target temperature management (TTM) and protocolized post-cardiac arrest care has been developed for years, clinicians still wondered which kind of patients would be benefit from these management in the real daily practice. To recognize the possible impact factors that are correlated with the outcomes of cardiac arrest patients would help the clinicians to estimate the patients’ outcomes and make clinical decisions. Methods The TaIwan Network of Targeted Temperature ManagEment for CARDiac Arrest (TIMECARD) registry was established and included patients who suffered from cardiac arrest with successful resuscitation and received TTM therapy in Taiwan. We utilized the registry and selected patients with initial non-shockable rhythm as study group. The primary outcome was a favorable neurologic outcome, defined as a CPC scale of 1 or 2 at discharge. Univariate and multivariate analyses were performed to identify significant variables. Furthermore, sub-group analysis about the difference between patients who were witnessed and those who were non-witnessed were completed. Similarly, analysis of the difference between initial rhythm of PEA and asystole were also completed. Results A total 332 patients with initial non-shockable rhythm was selected. Among them, 109 patients survived (32.8%) and 38 patients belonged to the favorable neurologic outcomes (11.4%). The factors significantly affecting the neurologic outcome (p < 0.05) were the pre-arrest CPC 1, in-hospital cardiac arrest event, the presence of an initial rhythm of pulseless electric activity (PEA), received bystander cardiopulmonary resuscitation (CPR), a shorter CPR duration, a higher systolic blood pressure (SBP) at return of spontaneous circulation (ROSC), a higher diastolic blood pressure (DBP) at ROSC, without new-onset seizure, experience of hypokalemia, and received percutaneous coronary intervention. The results of multivariate analysis revealed that patients with initial rhythm of PEA, higher DBP, without new-onset seizure and experience of hypokalemia were correlated with better neurologic outcomes. In the subgroup analysis of un-witnessed cardiac arrest patients with initial non-shockable rhythm, we analyzed 75 patients, and only initial rhythm of PEA was correlated with the favorable neurologic outcomes. The analysis of secondary outcomes also revealed multiple variables were correlated with the favorable neurologic outcomes. Conclusions In the TIMECARD registry, initial non-shockable cardiac arrest patients who had initial rhythm of PEA, higher DBP at ROSC, without new-onset seizure and hypokalemia during management were correlated with better neurologic outcomes statistically significant.