探討加護病房末期腎臟疾病合併呼吸衰竭病人計畫性拔管失敗之影響因子

Exprole Impact Factors Associated with Planned Extubation Failure among ESRD Patients with Respiratory Failure in Intensive Care Units

何孟修(MENG-HSIU HO)

指導教授 ： 許心恬

高雄醫學大學/護理學院/護理學系碩士班/碩士(2018年)

摘要

背景：台灣擁有世界最高的末期腎臟疾病(end-stage renal disease；ESRD)之發生率與盛行率，此疾病俱有的風險，若再併存呼吸衰竭對病人有極高的風險。過往較少探討ESRD合併呼吸衰竭病人在計畫性拔管失敗之影響因子及成功與失敗組預後成果之比較，故本研究探討之。
研究方法：追蹤某南部醫學中心於2015年1月1日至2017年6月30日期間，所有ESRD合併呼吸衰竭且屬計畫性拔管者，皆納入病歷、胸腔科電腦登錄資料庫回溯性的資料分析，分析變項包含人口學特性[年齡、性別、身體質量指數(Body Mass Index，BMI)]、疾病特性[昏迷指數(Glasgow Coma Scale，GCS)、疾病嚴重度(Acute Physiology and Chronic Health Evaluation，APACHE II)、造成呼吸衰竭原因]、脫離呼吸器指標(Rapid Shallow Breathing Index，RSBI；Maximal Inspiratory Pressure，MIP；Maximal Expiratory Pressure，MEP；Cuff leak test)、抽血指標(Hemoglobin，Hb；Blood Urea Nitrogen
BUN；Creatinine，Cr；Kalemia，K；Albumin)等變項，來探討加護病房患有ESRD影響計畫性拔管失敗之主要因子，並分析計畫性拔管成功與失敗兩組在預後成果(住加護病房天數、住院總天數、住院耗費醫療支出、死亡率)之差異。
研究結果：共納入336名ESRD合併呼吸衰竭計畫性拔管者，其中因資料重複、氣切插管者共排除24名，剩餘312名為計畫性拔管者，整體計畫性拔管失敗率約6%，計畫性拔管成功組有294名，其中有35名死亡，成功組死亡率為11.9%；而計畫性拔管失敗組有18名，其中有11名死亡，失敗組死亡率高達61.1%；經二元邏輯式迴歸分析發現，此加護病房ESRD合併呼吸衰竭病人計畫性拔管失敗主要影響因子為BMI、GCS、BUN、Albumin。BMI數值每增加一個單位則計畫性拔管失敗風險勝算增加1.288倍(OR=1.288,p= .046)；GCS意識昏迷指數每減少一個單位則計畫性拔管失敗風險勝算增加1.45倍(OR=0.688,p= .003)；BUN抽血指標每增加一個單位則計畫性拔管失敗風險勝算增加1.037倍(OR=1.037,p= .019)；Albumin抽血指標每減少一個單位則計畫性拔管失敗風險勝算增加15.4倍(OR=0.065，p= .001)，其上述四項變項為重要預測因子，在ESRD計畫性拔管失敗佔有顯著性的影響成效，因此在臨床上可針對此四項數值進行改善。此外，針對預後成果指標，計畫性拔管失敗組較成功組在住加護病房天數明顯較長(p= .007)及死亡率明顯偏高(p= .001)。
臨床運用：建議ESRD在呼吸訓練當中，控制病人BMI在適當範圍，選擇較佳GCS昏迷指數來進行拔管，及補足營養功能提高Albumin值，因BUN值ESRD病人已普遍偏高，可建議在洗腎日當天洗完腎，將身體毒素與水份排除體外，再評估及進行計畫性拔管。

關鍵字

加護病房 ； 末期腎臟疾病 ； 呼吸衰竭 ； 計畫性拔管失敗 ； 影響因子

並列摘要

Background：The incidence and prevalence rate of end-stage renal disease (ESRD) in Taiwan are the highest among the world. It poses extremely high risk to patients who have both ESRD and respiratory failure. In the past studies, the factors that affect planned extubation failure for patients who have ESRD combined with respiratory failure are seldom discussed. In addition, less comparison about prognosis outcome between patients who had successful planned extubation and those who failed planned extubation were investigated. As a result, this study aims to examine the influential factors of planned extubation and the prognosis outcome. Method: A retrospective data analysis is conducted to trace all ESRD patients in a medical center of Southern Taiwan between Jan. 1st, 2015 to Jun. 30th, 2017, whom are all complicated with respiratory failure under planned extubation, incorporating medical history and database of chest medicine. Variables being analyzed include: characteristics of demography [age, sex, and body mass index (BMI)], characteristics of disease [Glasgow coma scale (GCS), Acute Physiology and Chronic Health Evaluation (APACHE II), and causes of respiratory failure], weaning indicators [RSBI, MIP, MEP, and Cuff leak test], and blood test indicators (Hb, BUN, Cr, K, and albumin), etc., all of which are used to discuss the main factors attributing to planned extubation failure of patients with ESRD in intensive care unit, and the differences of the prognosis results (number of days staying in ICU, total days of hospitalization, expenses of hospitalization, and mortality rate) between the groups of successful planned extubation and failed planned extubation are analyzed.
Results: A total of 336 ESRD patients complicated with respiratory failure under planned extubation are recruited into the study. Of which, 24 patients are excluded due to repetitive data and endotracheal intubation; 312 patients under planned extubation remain, and the overall failure rate of planned extubation is approximately 6%. Two hundred ninety-four patients are in the success group of planned extubation, of which 35 patients died, with the mortality rate of the success group being 11.9%; 18 patients are in the failure group of planned extubation, of which 11 patients died, with the mortality rate being up to 61.1%. Through binary logistic regression analysis, the main factors attributing to planned extubation failure of patients in ICU are BMI, GCS, BUN, and albumin. For BMI, in which each added one unit will increase the risk of planned extubation failure by 1.288 times (OR = 1.288, p = .046); for GCS, each reduced one unit will increase the risk of planned extubation failure by 1.45 times (OR = 0.688, p = .003); for BUN indicator in blood test, each added one unit will increase the risk of planned extubation failure by 1.037 times (OR = 1.037, p = .019); for albumin indicator in blood test, each reduced one unit will increase the risk of planned extubation failure by 15.4 times (OR = 0.065, p = .001). These 4 variables are important predictors, which have significant contributing effects on the planned extubation failure. Therefore, 4 variables can be improved clinically. In addition, in terms of prognosis results, patients in the failure group of planned extubation has significantly longer days of staying in ICU (p = .007) and a significantly higher mortality rate (p = .001) when compared with those in the successful planned extubation group.
Clinical application: it is suggested that BMI of the ESRD patients should be controlled within an appropriate range during the respiratory training. Extubation should be conducted under a better GCS, and nutrition should be supplemented to increase albumin value. Due to the fact that ESRD patients have higher BUN value, it is suggested that planned extubation should be evaluated and conducted after the completion of hemodialysis for the day, when toxins and water have been expelled from the body.

並列關鍵字

Intensive care unit ； end-stage renal disease ； respiratory failure ； planned extubation failure ； effect factor

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