住院病患在病房發生心跳停止影響急救預後之急救前因子

Pre-arrest factors influencing survival after in-hospital cardiopulmonary resuscitation on the general wards

龔嘉德(Chia-Te Kung)

指導教授 ： 莊弘毅

高雄醫學大學/健康科學院/公共衛生學研究所/碩士(2011年)

摘要

研究主題:住院病患在病房發生心跳停止影響急救預後之急救前因子
原始假設：住院病患在病房發生心跳停止，並進行心肺復甦術後之預後，可由住院時之合併症及其他急救前因子進行預測。
背景：住院病患發生心跳停止而進行急救後的結果是不好的。研究指出在急救後有40%-60%的病患可恢復自發性循環(return of spontaneous circulation)，但只有3%-30%病患在接受心肺復甦術急救後，可以存活離開醫院。
住院病患進行心肺復甦術時會耗費非常多的醫療資源，心肺復甦術的執行應該是被認為是有效及有助益的，而且是無害的。所以在執行心肺復甦術前最好是可以考慮到急救後可能存活的機率。如果可以在入住醫院時或者急救前就可以精確的預測急救後不好的預後因子，應該可以避免無效的急救，而這也可以做為協助醫師及家屬是否提早簽立在醫院時不急救(do-not-resuscitate, DNR)醫囑的依據，以減少病患的痛苦，家屬的傷心及醫療的浪費。但是之前的研究因為病患的多樣性以及東西方疾病型態的不同，所以一直無法精確預測住院病患心跳停止經急救後的預後。
先前針對住院病患心跳停止的研究，主要的重點大多是著重在〝急救時〞的相關因子分析，如急救團隊到達時間，和發生時的心律等因素的分析。但是，這些〝急救時〞的急救措施大多受限於各機構間進行心肺復甦術的品質不同以及急救當時不良的記錄品質，因此大多數無法做前瞻性的研究設計及控制。我們認為，根據病患入院時的病患特質、病患之合併症等急救前因子(pre-arrest factors)可以較精確的預測住院病患發生心跳停止經急救後的存活預後分析，經由這些急救前因子的分析也可以幫助我們擬訂進一步的治療計劃。而且，在以往的研究中其所包含的研究範圍皆同時包括了不同的急救區域(如急診、一般病房及加護病房)，在不同設備及照護品質的情況下如再加上病患本身的多樣性，也導致了無法用一個模式來解釋所有的狀況，特別是無法產生一個在臨床上快速而有效的風險評估流程。
目的：本研究的目的是要探討主要急救前的相關因子，並建立一套在一般病房發生心跳停止進行急救後有效的預後因子評估。
研究方法：此研究為一回溯型研究， 針對某醫學中心2007~2010年間於一般病房住院之成人病患發生心跳停止進行急救之病歷回顧分析。
結果：總共有544名於一般病房住院之成人病患發生心跳停止進行急救被納入研究，其中218位(40.1%) 病患於急救過程中有恢復自主循環，最後出院時僅有28位(5.1%)病患存活出院，有6位(1.1%)病患出院時有良好的意識狀態。14.8%病患入院時有冠狀動脈病史，急救時第一時間發現是心室頻脈及心室顫動的比率是3.9%。90.6%病患是經由急診入院。高Charlson合併症指數(≧9) (OR 0.251, 95% CI 0.098-0.646)，住院前有心臟疾病之合併症(OR 0.612, 95% CI 0.401-0.933)，住院前有惡性腫瘤轉移(OR 0.485, 95% CI 0.282-0.835)、大夜班時發生的心跳停止(OR 0.403, 95% CI 0.252-0.642)及急救時啟動急救小組(OR 0.278, 95% CI 0.119-0.648)的急救病患，有較少的機率在急救時可以恢復自主循環。急救的病患中，如果入院前患有糖尿病(OR 0.409, 95% CI 0.175- 0.959)，及在急救開始時所發現的第一個心率是心室頻脈或是心室顫動者(OR 0.143, 95% CI 0.032-0.647)，病患有較高存活出院的機率，但是，在病情持續惡化的病患(OR 3.922, 95% CI 1.601-9.611)，其急救結果可存活出院的機率則是較低的。
結論及建議：我們的研究是臺灣地區第一個針對一般病房發生心跳停止進行的預後分析。我們的結果顯示在病房急救成功存活的機率是很低的。冠狀動脈疾病的盛行率以及發生心室頻脈及心室顫動的機率也比西方的報告低。高Charlson合併症指數(≧9)是一個可靠的預後預測因子，住院前有心臟疾病之合併症會減少在病房急救成功的機率。在病情持續惡化的病患，其急救後可存活出院的機率則是較低的。加護病房計及心臟監視系統的不足會影響在醫院急救的存活率。影響心跳停止病患在病房是否存活的機轉是由多重因子決定，可能包括了病患在病房時不同的生物條件差異，也牽涉到醫療照護人員及醫院運作的因素。我們的研究結果建議針對醫院急救系統及流程進行通盤檢討，以改善病房病患發生心跳停止事件時的急救照護品質。

關鍵字

住院心肺復甦 ； 普通病房 ； 心跳停止前併發症 ； 預後

並列摘要

Background:
The outcome after in-hospital cardiac arrest (IHCA) on general wards continues to be poor with a sustained return of spontaneous circulation (ROSC) of only about 40% to 60%. Only between 3% and 30% of patients who receive cardiopulmonary resuscitation (CPR) following a cardiopulmonary arrest (CPA) in a hospital environment will survive to be discharged.
In-hospital CPR will consume substantial healthcare resources, CPR should be applied only if it is considered to be effective and useful as well as not harmful. Accurate identification of poor prognostic factors on admission or before resuscitation could potentially prevent ineffective and useless CPR. This may also assist physicians to formulate a do-not-resuscitate order, which could reduce patient suffering, minimize family trauma and limit health care costs. However, prior studies have been undertaken to accurate estimate of IHCA prognoses were difficult and compounded by area and patient heterogeneity, such as the incidence of coronary artery disease and ventricular dysrhythmias as the initial rhythm in IHCA patients was low in oriental countries. The influence of different disease patterns in different areas on the results of IHCA has not been studied.
Most prior efforts to model CPA survival focused on intra-arrest rather than pre-arrest factors. However , intra-arrest interventions (characterizations of care such as warning system of arrest call, response time, medical emergency team activation and on site resuscitation efforts), as they could not be applied prospectively for advance care planning and because they have limitations (e.g. unknown CPR quality and poor record quality). The survival probability after IHCA may be more accurately estimated by the occurrence in time of the pre-arrest morbidity of patients. Therefore, improved understanding of pre-arrest factors associated with mortality could help advance care planning. In addition, most studies enrolled different areas or different facilities (like monitored and non-monitored setting , intensive care units ,general wards and emergency department) of IHCA patients simultaneously, that is, coupled with patient heterogeneity, makes it hard for one model to perform well on all cardiac arrest patients, especially to generate a rapid and standardized risk stratification protocol.
Objective: The aim of this study was to investigate the key pre-arrest factors to predict post-cardiopulmonary arrest outcome in adult patients with in-hospital cardiopulmonary resuscitation on the general wards.
Material and methods: We conducted a retrospective chart review by examining medical records of all adult patients who underwent in-hospital cardiopulmonary resuscitation from January 2007 to December 2010 at the Kaohsiung Chang Gung Memorial Hospital.
Results: A total of 544 patients on the general wards were analyzed for the event variables and resuscitation results. The rate of establishing a ROSC was 40.1%, the rate of survival to discharge was 5.1% and only 0.4% of the studied populations were discharged with good neurologic function. 14.8% of the patients resuscitated had coronary artery disease. ventricular tachycardia or ventricular fibrillation(VT/VF) was the initial rhythm in only 3.9% patients. Most of the patients (90.6%) came from emergency department. Pre-arrest factors including high Charlson Comorbidity Index(≧9) (OR 0.251, 95% CI 0.098-0.646), cardiac comorbidity before admission(OR 0.612, 95% CI 0.401-0.933), Metastatic malignancy(OR 0.485, 95% CI 0.282-0.835) , arrest time on midnight shift(OR 0.403, 95% CI 0.252-0.642), activation of medical emergency teams on resuscitation event(OR 0.278, 95% CI 0.119-0.648) were independently associated with low possibility of sustained ROSC. Diabetes as comorbidity before admission (OR 0.409, 95% CI 0.175-0.959) and VT/VF as initial presenting pulseless rhythm(OR 0.143, 95% CI 0.032-0.647) were independently associated with high survival, whereas deteriorated disease course was independently associated with low survival(OR 3.922, 95% CI 1.601-9.611).
Conclusions: The results of our study demonstrated a low survival rate of cardiopulmonary resuscitation on general wards in a medical center. Charlson Comorbidity Index was a more reliable pre-arrest indicator for outcome prediction after IHCA on the general wards. Cardiac comorbidity before admission was not a positive predictor for ROSC or survival to hospital discharge on the general wards. Delayed activating of medical emergency teams was related to poor outcome of ROSC in this study. Deficiency of intensive care unit beds and inadequate cardiac monitoring contribute to the lower survival rate on general wards. The mechanism for the poor survival in CPA events of general wards is likely multifactorial, potentially including biological differences in patients as well as health care staff and hospital staffing and operational factors. These data suggests the need to focus on hospital-wide resuscitation system processes of care that can potentially improve patient safety and survival following cardiac arrest on the general wards.

並列關鍵字

In-hospital cardiopulmonary resuscitation ； General wards ； Pre-arrest morbidity ； Outcome

參考文獻

1.Murphy DJ, BurrowsD, Santilli S, et al. The influence of the probability of survival on patients’ preferences regarding cardiopulmonary resuscitation. N Engl J Med 1994; 330:545–9.

2.Adams BD, Zeiler K, Jackson WO, et al. Emergency medicine residents effectively direct inhospital cardiac arrest teams. Am J Emerg Med 2005; 23:304-10.

3.Schultz SC, Cullinane DC, Pasquale MD, et al. Predicting in-hospital mortality during cardiopulmonary resuscitation. Resuscitation 1996; 33:13-7.

4.Huang CH, Chen WJ, Ma MH, et al. Factors influencing the outcomes after in-hospital resuscitation in Taiwan. Resuscitation 2002; 53:265-70.

5.Dumot JA, Burval DJ, Sprung J,et al. Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of "limited" resuscitations. Arch Intern Med 2001; 161:1751-8.