使用體外膜氧合術之心因性休克病患 七十二小時內死亡預測因子探討

Predictors of motality within 72 hours in cardiogenic shock patients using extracorporeal membrane oxygenation

梁秀雯(Hsiu-Wen Liang)

指導教授 ： 鄭綺

臺北醫學大學/護理學院/護理學研究所/碩士(2012年)

https://doi.org/10.6831/TMU.2012.00011

摘要

論文名稱：使用體外膜氧合術之心因性休克病患七十二小時內死亡
預測因子探討
研究所名稱：臺北醫學大學護理學研究所
研究生姓名：梁秀雯
畢業時間：一○○年第一學期
指導教授：鄭綺 臺北醫學大學護理學研究所教授
體外膜氧合術（Extracorporeal membrane oxygenation, ECMO）應用於急性心肺衰竭的重症病人，是一個資源消耗高的侵入性治療。本研究目的在探討心因性休克病患，使用ECMO七十二小時內死亡之預測因子，提高ECMO治療成功的機率，減少醫療浪費，避免資源耗損。
研究方法採探索性，橫斷面（Cross-sectional）調查法。主要依「台大醫ECMO登錄病歷」（NTUH ECMO Demography），擷取本研究所需相關資料登錄於「ECMO登錄表」，以作為資料收集之工具。資料來源為某醫學中心於2000-2010年，因心因性休克而裝置ECMO之個案。研究資料以百分比、平均值、標準差呈現描述性資料，再以Wilcoxon rank sum test、Chi-squares test、Logistic regression進行檢定。
結果顯示，裝置ECMO72小時內死亡者較存活者年齡較高且於裝置ECMO時強心劑使用當量、動脈氣體分析中PaCO2、Lactic acid、Total bilirubin皆較高；心跳、舒張壓、平均血壓、動脈氣體分析中pH值、ECMO前1小時尿量、意識程度（GCS）皆較低；診斷別與72小時內是否存活有關；裝置ECMO時同步有執行CPR者死亡率較高。迴歸模式分析結果顯示，在控制了72小時內併發症發生的因素後，年齡（OR=1.054；95%信賴區間：1.029, 1.079）表示年齡每增加1歲，裝置ECMO72小時死亡的勝算比提高1.054倍、ECMO前乳酸值表示裝置ECMO前乳酸值每增加1mmoL，72小時內死亡的勝算比提高1.072倍（p=0.005）、病人診斷為其它者（OR=6.445；95%信賴區間：1.609, 25.812)，表示病人診斷為其它者，包括診斷主動脈剝離（10人）、心律不整（5人）、到院死亡（1人）、左心房黏液瘤（1人）、辦膜疾病（4人）與先天性心臟疾病（5人），於裝置ECMO 72小時內死亡的勝算比較開心手術者72小時內死亡的勝算比為6.445倍（p=0.008）。裝置ECMO前意識程度為重度昏迷者（OR= 2.070；95%信賴區間：1.174, 3.649），72小時內死亡的勝算比為輕度昏迷者的2.070倍。裝置ECMO前1小時尿量（OR=.993；95%信賴區間：0.987, 1.000），表示ECMO前1小時尿量每增加1ml，則72小時內死亡的勝算比將減為0.993倍（p＝0.039）。裝置ECMO過程有急救（OR=2.307；95%信賴區間：1.184, 4.496），72小時內死亡的勝算比將較無CPR者提高2.307倍（p=0.014）。所得之迴歸預測模式為-5.77＋0.052（年齡)＋0.07（ECMO前乳酸值）－0.466（急性心肌炎＝1，以外者＝0）－0.395（急性心肌梗塞＝1，以外者＝0）－0.043（心肌病變＝1，以外者＝0）－0.865（肺動脈栓塞與高壓＝1，以外者＝0）＋1.863（其它＝1，以外者＝0）＋0.515（中度昏迷）＋0.727（重度昏迷）－0.007（ECMO前1小時尿量）＋0.836（裝置ECMO過程CPR）。
本文裝置ECMO個案數為456人，調整過R2 （Nagelkerke R平方）為0.335，ROC面積為75%，經ROC曲線算出之死亡與72小時存活（Y）的切點為-1.51。經由此切點估算本預測模式之正確預測率達70%。
本研究結果可提供臨床裝置ECMO前之評估參考。

關鍵字：體外膜氧合術、死亡預測因子

關鍵字

體外膜氧合術 ； 死亡預測因子

並列摘要

Abstract

Paper Title: Predictors of motality within 72 hours in cardiogenic shock patients using extracorporeal membrane oxygenation
Institute Name: Institute of Nursing, Taipei Medical University
Graduate Name: Hsiu-Wen Liang
Graduation time: One hundred years of the first semester
Advisor: Chii Jeng, PhD, Professor,

Extracorporeal membrane oxygenation (ECMO) used in critically ill patients with acute cardiopulmonary failure is a highly resource-consumptive invasive treatment. This study aimed to explore the mortality predictors of the cardiogenic shock patients treated ECMO within 72 hours to improve the chances of successful ECMO therapy and reduce medical waste.
The exploratory research method with cross-sectional survey was used in this study. The design of “ECMO registry table”, which was the instrument of data collection in this study, mainly referred to the “National Taiwan University Hospital ECMO registry records” (NTUH ECMO Demography). The cases with ECMO device due to cardiogenic shock was collected from a medical center from 2000 to 2010. The descriptive data of percentage, mean, standard deviation were examined by using Wilcoxon rank sum test, Chi-squares test, and Logistic regression.
The results show that the average age of cases installed with ECMO died within 72 hours is greater than those with ECMO who survives. Furthermore, the inotropic drugs dose equivalent, PaCO2, lactic acid, total bilirubin are higher during ECMO installation. However, heart rate, diastolic blood pressure, mean blood pressure, the PH value, the urine amount 1 hour before ECMO, and the Glasgow Coma Scale (GCS) are lower in the subjects with ECMO died within 72 hours. An association between diagnosis and whether survival or not within 72 hours after ECMO installation was observed. Those having CPR performed when installing ECMOdevice have higher mortality rate. Regression model analysis showed that 1 year increased in age enhances 1.054 times of the odds ratio of mortality of ECMO installation within 72 hours with the factor of complications occured within 72 hours under controlled. (OR = 1.054; 95% CI: 1.029, 1.079); 1mmoL increased in the lactic acid value before ECMO installation enhances 1.072 times (p = 0.005) of the odds ratio of mortality within 72 hours. Patients diagnosed as others (OR = 6.445; 95% CI: 1.609, 25.812 ) included aortic dissection (n=10), arrhythmia (n=5), to the hospital death (n=1), left atrial myxoma (n=1), vavular disease (n=4) congenital heart disease (n=5). The odds ratio of mortality of ECMO installation within 72 hours is 6.445 times more than that of open heart surgery within 72 hours (p = 0.008). The odds ratio of mortality within 72 hours of deep coma patients before ECMO installation is 2.070 times more than that of mild coma patients (OR = 2.070; 95% CI: 1.174, 3.649). 1 ml increased in the urine amount 1 hour before ECMO installation decreases the odds ration of mortality within 72 hours to 0.993 times. (OR =. 993; 95% CI: 0.987, 1.000) (p = 0.039). The odds ratio of mortality within 72 hours of patiens received CPR during ECMO installation is 2.307 times more than that of those without CPR. (OR = 2.307; 95% CI: 1.184, 4.496) (p = 0.014). Based on the above data, the regression model is: -5.77 +.052 (age) +0.07 (the lactic acid value before ECMO) -0.466 (acute myocarditis=1, otherwise=0) -0.395 (acute myocardial infarction=1, otherwise=0) -0.043 (cardiomyopathy=1, otherwise=0) -0.865 (pulmonary embolism and hypertension=1, otherwise=0) +1.863 (Other=1, otherwise=0) +0.515 (moderate coma) +0.727 (deep coma) -0.007 (urine amount 1 hour before ECMO) +0.836 (CPR during ECMO installation).
The amount of cases with ECMO in this study is 456. The adjusted R2 (Nagelkerke R squared) is 0.335; ROC area is 75%. The cut point of mortality and survival rate (Y) calculated through the ROC curve is of -1.51. The prediction accuracy of this model calculated through the cut point reaches 70%.
The findings may provide clinical assessment reference before ECMO installation.

Key ward: Extracorporeal membrane oxygenation, predictors of death

並列關鍵字

Extracorporeal membrane oxygenation

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