早期介入討論不施行心肺復甦術與醫療資源耗用在急救後恢復自發性循環病人之回溯性分析

Retrospective Study of Early DNR Discussion and Health- Care Waste in Patients with Returns of Spontaneous Circulation after Resuscitation

馬瑞菊(Jui-Chu Ma) ； 林佩璇(Pei-Xuan Lin) ； 李孟君(Meng-Chun Li) ； 吳珮菁(Pei-Ching Wu) ； 潘宥妤(Yu-Yu Pan) ； 李佳欣(Chin-Hsin Li) ； 鄭婉如(Wan-Ju Cheng) ； 蕭嘉瑩(Chia-Ying Hsiao) ； 蘇珉一(Min-I Su)

《北市醫學雜誌》 15卷2期 (2018/06) Pp. 81-90

https://doi.org/10.6200/TCMJ.201806_15(2).0009

摘要

目的：探討心跳停止急救後恢復自發性循環(ROSC)病人早期介入不施行心肺復甦術(DNR)討論之現況。方法：採電子病歷回溯性調查設計，以2012年1月1日至2015年12月31日(共4年)急救後恢復自發性循環且在此次住院中死亡個案213位進行分析。結果：ROSC後24小時內有DNR討論(Early DNR Discussion)之個案共106位(佔49.8%)，無24小時內DNR討論者(Delayed DNR Discussion)共107位(佔50.2%)。Early DNR Discussion之個案其在住院中再次發生CPR的比率較Delayed DNR Discussion者為低(12.3% vs. 44.9%；P＜ 0.001)，且在CPR的總時間(15.2+12.1 vs. 22.9+20.6分鐘；P ＜ 0.001)、平均住院天數(6.6天+ 11.7vs. 16.0+43.9天；P = 0.035 )、加護病房住院天數(4.8天+ 8.9vs. 8.6+12.0天；P = 0.01 )、呼吸器使用天數(4.4+8.5 vs. 12.9+43.0天；P =0.048)皆較短，醫療支出(93168.4+133511.4 vs. 147162.4+151544.6元；P = 0.007)較少。而DNR討論時間無論早晚仍有超過一半的病人臨終前24小時接受維生醫療處置（血管升壓藥物72.3%、急救藥物61%、心外按摩52.1%、侵入性血壓生命跡象監視治療53.1%、呼吸器使用94.4%、氣管內管或氣切96.7%、抗生素治療75.6%、中心靜脈導管64.8%、抽血檢查84%、鼻胃管灌食97.4%等）但臨終前緩和鎮靜藥物的使用僅有8人(3.8%)。結論：早期介入DNR討論可以降低CPR時間、再次CPR比率及醫療資源如平均住院天數、加護病房住院天數、呼吸器使用天數、醫療支出之耗用，因此教育醫療人員對於急救後恢復自發性循環病人需早期介入不施行心肺復甦術討論，改善生命末期照護品質。

關鍵字

恢復自發性循環 ； 不施行心肺復甦術 ； 早期介入心肺復甦術討論 ； 醫療資源耗用 ； 緩和醫療

並列摘要

Objective: To study the impact of early DNR discussion in ROSC patients after cardiac arrest. Methods: The survey was based on the review of e-anamnesis. A retrospective study was performed on the records of consecutive ROSC patients who expired in hospital from January 1st 2012 to December 31st 2015. Results: A total of 106 cases (49.8%) had early DNR discussion within 24 hours after ROSC, while the other 107 cases (50.2%) had no early DNR discussion within 24 hours after ROSC. Cases with early DNR discussion had significantly lower rate of re- CPR (12.3% vs 44.9%; P＜0.001), CPR total time duration (15.2+12.1 vs. 22.9+20.6 minutes; P ＜ 0.001), average hospitalization (6.6 days + 11.7 vs. 16.0+43.9 days; P = 0.035), ICU days (4.8 days + 8.9 vs. 8.6+12.0 days; P = 0.01), mechanical ventilation days (4.4+8.5 vs. 12.9+43.0 days; P =0.048), and medical expenditure (93168.4+133511.4 vs. 147162.4+151544.6 NT dollars; P = 0.007) compared to cases with delayed DNR discussion. Regardless of the time of DNR discussion, still, more than half patients were given ineffective medical attention 24 hours before their death (vasopressors 72.3%, inotropes 61%, CPR 52.1%, intrusive blood pressure monitoring 53.1%, mechanical ventilation 94.4%, endotracheal intubation or tracheotomy 96.7%, antibiotic drugs 75.6%, central venous catheter 64.8%, blood test 84%, NG tube feeding 97.4%) while only 8 people (3.8%) applied palliative care with sedatives. Conclusion: Early DNR discussion can help reduce CPR duration, rate of re-CPR, and medical resource utilization, e.g., hospitalization, ICU days, mechanical ventilation days, and medical expenditure. Thus, it is recommended that medical personnel should address early DNR discussion to ROSC patients to help improve the life quality at final stage.

並列關鍵字

return of spontaneous circulation ； do not resuscitation ； DNR discussion ； medical resources utilization ； palliative care