以疾病特質分析成人葉克膜處置的發生率、基本特質及預後之探討

The study of Incidence, Basic Characteristics and Outcomes of Extracorporeal Membrane Oxygenation with Disease Characteristics in Adult

傅姿瑛(Tzu-Ying Fu)

指導教授 ： 李顯章

臺北醫學大學/公共衛生暨營養學院/醫務管理學研究所/碩士(2012年)

https://doi.org/10.6831/TMU.2012.00084

摘要

背景與目的
心臟停止給予心肺復甦無效時，選擇(Extracorporeal membrane oxygenation; ECMO)是一種最簡易的體外心肺輔助裝置，健保於2002年12月開始給付ECMO及後續醫療費用之後，ECMO成為三大高額醫療資源項目之一，除了伴隨的高額醫療費用之外，患者預後存活結果受到相當的重視；傳統上利用全民健保資料庫於ECMO的研究中，都以整體ECMO族群為研究對象，本研究針對呼吸性衰竭與心因性休克兩種疾病特質的差異，對於ECMO處置的預後結果進行詳盡的分析。
研究方法
本研究資料來自國家衛生研究院申請之｢全民健康保險資料庫｣的特殊需求檔進行回溯性分析，收集2009年01月01日至2010年12月31日曾經受ECMO處置病患之住院醫療紀錄，有65家醫院共2,299人接受ECMO處置；研究中藉由疾病特質，探討病人特質、就醫醫院特質中，各個變項對預後存活產生的影響，及住院中死亡的影響因子。並以τ檢定、χ2檢定、Log-rank test、Cox proportion hazard model進行邏輯斯迴歸分析。
研究結果
疾病特質中，年齡是增加死亡風險的顯著因子，40歲~49歲相較未滿30歲的住院死亡勝算比為1.753，50歲~59歲相較未滿30歲的住院死亡勝算比為1.629，60歲~69歲相較未滿30歲的住院死亡勝算比為1.752，70歲~79歲相較未滿30歲的住院死亡勝算比為2.969， 80歲相較未滿30歲的住院死亡勝算比為3.352；心因性休克的就醫科別為外科照護時，存活率顯著高於其他科別；週末住院與否並不是增加死亡風險的顯著因子；住院期間洗腎相較於未洗腎者的住院死亡勝算比為2.281，具有顯著意義；當住院天數≧30天~60天時，相較＜30天的住院死亡勝算比為1.156，而住院天數≧60天相較＜30天的住院死亡勝算比為2.148；既有疾病對心因性休克的死亡具有顯著意義；既有疾病別中，肝臟疾病、腎衰竭、心瓣膜疾病、糖尿病、高血壓、心律不整、嚴重精神病等，相較未罹病者的住院死亡勝算比分別為2.261、1.988、0.677、0.593、0.386、0.349、0.112。
就醫醫院特質中，區域醫院相較於醫學中心的住院死亡勝算比為0.501，醫師專科別中胸腔專科相較於心臟內科的住院死亡勝算比為0.281，則具有顯著意義。
研究結論
國人ECMO處置的成人以心因性休克為主，整體存活率約為45%，疾病別存活率中，呼吸性衰竭約為42%，而心因性休克約為46%，與ELSO統計34%及29%相較下，國內有較豐富的臨床照護經驗，不論整體或疾病別存活率都有較佳的預後結果。

關鍵字

呼吸性衰竭 ； 心因性休克 ； 葉克膜 ； 心肺復甦急救 ； 葉克膜於心肺復甦急救 ； 共病、既有疾病

並列摘要

Background：
Extracorporeal membrane oxygenation (ECMO) is a resource consuming and highly invasive treatment. Typically used for life threatening pulmonary failure or cardiogenic shock (or both). In recent years, ECMO to become the three major medical resource projects in Taiwan. Therefore to monitor the incidence, changing in hospital care or prognosis of ECMO is important. Currently, there is no publication concerning the Disease characteristics of pulmonary failure and cardiogenic shock, and even ECMO as a whole in our country. The purpose of this study is to investigate the incidence, patient characteristics and hospital characteristics in-hospital prognosis of ECMO.
Methods：
Between January 2009 and December 2010, there were 2,299 ECMO cases (older than 18 years old) from National Health Insurance Database provided by National Health Research Institute in Taiwan. The variables included disease characteristics, patient characteristics, hospital characteristics and in-hospital prognosis of ECMO. Used for Chi-square test to categorical variables and t-test for continuous variables were used to test the significance of difference in prognostic factors between the survivors and nonsurvivors. A P value less than 0.05 was considered statistically significant. Multivariate logistic regression analysis was performed to identify independent predictors of mortality.
Result：
During the study period, there were 570 cases of pulmonary failure and 1,729 cases of cardiogenic shock in total, which represent 24.79% and 75.21% of all ECMO cases respectively. Multivariate logistic regression analysis with a stepwise forward method was performed. The following patient characteristics were found significantly different between survivors and nonsurvivors by univariate analysis：age, dialysis, comorbidity and length of stay. Among the complications, the following were significant factors contributing to difference in mortality rate：liver disease, renal failure, valvular disease, diabetes mellitus, Hypertension, arrhythmia were increasing over the study period.Characteristics of the hospital the following factors were identified as independent predictors of mortality：hospital level and physician specialty were increasing over the study period.
Conclusion and suggestion：
The overall incidence of ECMO in Taiwan was mainly due to the growing incidence of cardiogenic shock. Our study found that pulmonary failure and cardiogenic shock in-hospital survival rate of ECMO was higher than ELSO (41.93% VS 34%, 45.86% VS 29%).Compared with other countries, our country institution has relatively extensive experience in adult patients. The findings derived from this study should help to utilize ECMO more effectively for adult patients in the future.

並列關鍵字

ECMO ； pulmonary failure ； cardiogenic shock ； CPR ； ECPR ； comorbidity

參考文獻

朱育增、吳肖琪(2010)。回顧與探討次級資料適用之共病測量方法. 臺灣公共衛生雜誌, 29(1), 8-21.

朱育增、吳肖琪、李玉春、賴美淑、譚醒朝(2010)。探討共病測量方法於健保次級資料之應用. 臺灣公共衛生雜誌, 29(3), 191-200.

李麗惠、薛亞聖、楊長興(2006)。週末假日就醫與治療結果之相關探討. 臺灣公共衛生雜誌, 25(2), 107-114.

施美秀、桑潁潁、胡勝川(2006)。2005年版美國心臟學會之心肺復甦術重大改變. 榮總護理, 23(1), 103-108.

柯文哲(2008)。無心16天　ECOMO引發的倫理問題. 健康世界(269), 38-40.