內科加護病房非計劃性拔管之探討

The Exploration of Unplanned Extubation in a Medical Intensive Care Unit

陳欽明(Chin-Ming Chen) ； 曾桂玲(Kuei-Ling Tseng) ； 黃佩珍(Pei-Chen Huang) ； 鄭高珍(Kuo-Chen Cheng)

《中華民國急救加護醫學會雜誌》 17卷1期 (2006/03) Pp. 13-23

https://doi.org/10.30018/JECCM.200603.0002

摘要

目的：非計劃性拔管(unplanned extubation, UE)是使用氣管內管插管常見之併發症，會增加加護病房(intensive care unit, ICU)住院天數及醫療費用，同時也是重要的醫療品質指標。我們試著了解93年度南部某醫學中心一內科ICU，其UE比率是否較往年改善，以了解醫療及護理介入後之成效；同時探討UE失敗（48小時內重新再插管）的預後以及其預測因子，以改善醫療品質，減少醫療資源浪費。
方法：回溯性研究93年度UE病人的各項臨床及實驗資料，並比較成功及失敗之差異。同時搜集近三年來之UE概況，以了解護理措施介入之改善情形。
結果：93年度內科ICU共有21人次（19位）UE病人，佔該ICU所有使用呼吸器病人的4.61% (21/456)，較往年下降［最近3年為97人次，比率為7.98% (97/1215)］；而失敗者有12人次，佔所有UE之比率為57.14% (12/21)，也較往年低［最近3年為75人次，比率為77.32% (75/97)］。改善原因可能與呼吸器脫離計劃施行、鎮定劑使用指引之應用、有效率之約束（以乒乓球手套取代手腳約束）、加強與病患之溝通以及護理人員之再教育有關。UE失敗者之預後為（與成功者之比較）：ICU平均住院天數較長(15.08 vs. 8.11, P=0.034)、平均住院費用較高（50.72萬 vs. 18.75萬，p=0.023）以及死亡率較高(41.67% vs. 0%, p=0.039)。而UE失敗者之預測因子為：年齡較低(56.75 vs. 69.44, p=0.034)、TISS(Therapeutic Intervention Scoring System)指數較高(31.17 vs. 25. 00, p=0.007)以及平均動脈壓(mean aterial pressure, MAP)較低(92.75 vs. 107.33, p=0.018);但將年齡、TISS及MAP做多變項分析，只有MAP具統計學上意義(p=0.038, odds ratio=0.911, 95% confidence interval=0.834-0.995)。
結論：UE人數與比率的下降，與呼吸器脫離計劃施行、鎮定劑使用指引之應用、有效率之約束（以乒乓球手套取代手腳約束）、加強與病患之溝通以及護理人員之再教育有關。UE失敗者最重要之預測因子則為MAP，其預後明顯較差（死亡率高及醫療成本提高）。若能事前多一些防範，減少不必要之UE，不幸發生UE之後，針對可能的高危險群病人予以嚴格監控，相信必可改善醫療品質，減少醫療資源浪費。

關鍵字

氣管內插管 ； 非計劃性拔管 ； 重新再插管 ； 呼吸器

並列摘要

Purpose: Unplanned extubation (UE) is a frequent event that complicates endotracheal intubation. It increases morbidity in the intensive care unit (ICU) resulting in prolonged hospital stays and increased costs and it also presents as an important predictor of care quality. We attempt here to investigate the incidence of UE in relation to the outcomes and predictive factors for failed UE (reitubation within 48 hours) at a medical ICU of a medical center in southern Taiwan during 2004. We also try to evaluate the impact of medical intervention on UE in order to improve care quality.
Methods: We retrospectively studied the clinical features and the differences between successful and failed UE in 2004. We also collected similar data over the three years previous to this in order to evaluate the effect of medical and nursing intervention on UE.
Results: Twenty one episodes of UE in nineteen patients occurred during the study period making up 4.61% (21/456) of all endotracheal intubations. The incidence had decreased compared with to the previous three years (7.89% with 97 episodes out of 1215 intubations). There were 12 episodes of failed UE (57.14% of all UEs) in 2004, a decrease compared to the previous 3 years (75 episodes, 77.32% of all 97 UE). The reasons for the improvement may be attributed to the implement of a weaning protocol, to a sedation protocol, to the use of effective physical restrains, to intensive communication with intubated patients and to nursing education. The outcome of failed UE (as compared with successful EU) was the following: a longer mean ICU period (15.08 vs.. 8.11, p=0.034), higher mean hospital costs (507158 vs.. 187479 NTD) and a higher mortality rate (41.67% vs.. 0%). The predictors of failed UE are a lower age (56.75 vs.. 69.44, p=0.034), a higher TISS score (31.17 vs.. 25.00, p=0.007) and a lower mean arterial pressure (MAP) (92.75 vs.. 107.33, p=0.018). In multiple logistic analysis, the only significant predictor is MAP (p=0.038, odds ratio=0.911, 95% CI=0.834~0.995).
Conclusions: Medical intervention resulted in a decline in UE episodes and incidence. The most important predictor of failed UE is MAP. Failed UE results in a poorer prognosis with a higher mortality and an increased hospital costs.

並列關鍵字

endotracheal intubation ； unplanned extubation ； reintubation ； mechanical ventilation