Factors Affecting Occurrence and Outcome of Unplanned Extubation among Patients in the Intensive Care Unit

影響加護病房病人非計畫性拔管發生的原因及結果

黃奕智(Yi-Chih Huang) ； 黃湘喻(Hsiang-Yu Huang) ； 藍冑進(Chou-Chin Lan) ； 楊美貞(Mei-Chen Yang) ； 黃俊耀(Chun-Yao Huang) ； 吳燿光(Yao-Kuang Wu)

《胸腔醫學》 30卷6期 (2015/12) Pp. 337-346

摘要

背景：在加護病房中，使用呼吸器的病人發生非計畫性拔管是一個常見的併發症而且常常造成死亡率增加。本研究探討加護病房病人非計畫性拔管的機率，以及造成非計畫性拔管失敗（拔管後48小時內再插管）的危險因子，可能的結果及對醫療支出的影響。方法：本研究利用病例對照研究法，自2007年1月至2011年12月共納入193位病人及579位對照組。結果：非計畫性拔管共發生193次，比率約為每使用100天呼吸器發生0.25次。非計畫性拔管失敗比率為42%（81/193），死亡率為29.5%（57/193）。經多變量分析後發現，高疾病嚴重度（APACHE II score），插管時間較長，意識狀況不佳以及充分呼吸器支持（full ventilator support）的病人在非計畫性拔管後容易失敗。同時，非計畫性拔管失敗的病人預後最差，死亡率最高，使用呼吸器的時間最久而且醫療支出最高。結論：和對照組及非計畫性拔管成功的族群相比，非計畫性拔管失敗的病人預後最差且醫療花費最高。針對不須充分呼吸器支持且使用較低氧氣分壓的病人，應更積極設法脫離避免非計畫性拔管。針對暫時無法脫離，高疾病嚴重度且意識狀況不佳的病人則應適當約束以免非計畫性拔管失敗造成死亡率上升及更多醫療支出花費。

關鍵字

重症加護照顧 ； 機械通氣 ； 再插管 ； 非計畫性拔管

並列摘要

Background: Unplanned extubation (UE) is a frequent severe complication of mechanical ventilation in critically ill patients in the intensive care unit (ICU) and may be associated with increased morbidity and mortality. This study investigated the incidence, predictive factors, outcomes, and expenditures of patients with failed UE (re-intubation within 48 hours) in adult ICUs. Methods: This case-control study included 193 cases and 579 controls (case-control ratio of 1:3) for the period covering January 1, 2007 to December 31, 2011. Results: There were 193 episodes of UE, with a density of 0.25 per 100 ventilated days. The failed UE rate was 42.0% (81/193), and the hospital mortality rate was 29.5% (57/193). In multivariable analysis, higher APACHE II score (odds ratio [OR] 0.946), longer duration from intubation to UE (OR 0.940), lower consciousness level (OR 1.208), and full ventilator support (OR 3.868) were factors predictive of failed UE. The failed UE group had the worst outcomes, the most ventilator days, and the highest costs. They also had higher hospital mortality rates (54.3%) and lower hospital discharge rates (33.3%) than the controls. Conclusion: Patients with failed UE had worse outcomes and higher costs in the ICU than the controls and those with successful UE. Aggressive weaning may be recommended for patients under partial ventilator support with low FiO2. Adequate restraint should be provided to prevent any failed UE in patients with a higher APACHE II score, more intubation days, and lower consciousness level, and those on full ventilator support.

並列關鍵字

intensive care ； mechanical ventilation ； reintubation ； unplanned extubation