- 學位論文
冠狀動脈繞道手術使用三種不同侵襲性血液動力學衛材的臨床效果評估
The Clinical Outcome of Three Invasive Hemodynamic Monitoring Materials in Coronary Artery Bypass Graft
摘要
研究目的：在論病例計酬的冠狀動脈繞道手術中，爲了監測評估心臟血流動力之功能，常採用的侵襲性血液動力學衛材分別為中央靜脈導管、肺動脈導管、光纖肺動脈導管。本研究擬探討選擇不同衛材的依據並進行臨床效果分析。 研究方法：本研究為體外循環冠狀動脈繞道手術病例調查研究，總計收集某區域教學醫院從民國89年至92年共110例之病歷記錄與健保申報資料，以及自民國87年至91年全民健康保險研究資料庫，使用SAS統計分析，比較不同衛材之患者其總住院費用、總住院天數、加護病房天數、住院死亡率及14天內再住院率。 研究結果：1.顯示三種不同血液動力學衛材在不同病患特質間之使用，無明顯相關。 2.某區域醫院放置中央靜脈導管組的病患及病患在術前有急性心肌梗塞者，確實會有較高的住院死亡風險（odds ratio分別為4.66，9.38）。3.全國年份的變化可看到肺動脈導管由1998年68.89%一路下滑至2002年的32.79%，取而帶之的卻是由中央靜脈導管及光纖肺動脈導管兩者平分（30.60% and 36.61%）。區域醫院的中央靜脈導管與肺動脈導管的住院死亡率分別為6.25%及3.57%，比醫學中心低；公立醫院的光纖肺動脈導管死亡率為3.08%，比起肺動脈導管的12.62%及中央靜脈導管的20.37%明顯的少很多（p=0.013）；財團法人醫院暨私立醫院在中央靜脈導管這組的死亡率最低，只有5.45%，光纖肺動脈導管最高有17.95%，三者的差異是有明顯差別（p=0.0179）。 結論： 由本研究資料顯示，三種血液動力學衛材皆可運用在冠狀動脈繞道手術，其選擇是由麻醉醫師和心臟血管外科醫師的專業能力及醫院整體作業環境來做決定。財團法人暨私立醫院在中央靜脈導管組的住院死亡率低，總住院費用也低，在論病例計酬下是一個好的成本效果；相對的全國公立醫院及某區域醫院在中央靜脈導管組有較高的住院死亡率，應做討論。
並列摘要
OBJECTIVES: The purpose of this study is to analyze the usage of three invasive hemodynamic monitoring devices in patients receiving coronary artery bypass graft (CABG), to understand the decision-making and clinical outcome in choosing among Central Venous Pressure catheter（CVP）, Pulmonary Artery Catheter（PAC）, and Fiberoptic Pulmonary Artery Catheter. METHODS: Records of 116 CAD patients who received CABG in a regional teaching hospital from Jan. 2000 to Dec 2003, and records of 662 CABG cases from sampling of National Health Insurance Research Database were retrieved. Variables such as the demographic data, disease severity, co-morbidity, hemodynamic monitoring devices, medical cost and length of stay in each admission, length of stay in Intensive Care Unit (ICU), mortality rate during admission, and readmission rate within 14 days were analyzed. RESULTS: In the regional hospital no significant correlation of patients attributes to the choice of monitoring device was noted, the odds ratio of death in admission were higher among patients on CVP (4.66) or with preoperative acute myocardial infarction events (9.38 ). There was a down hill trend of usage of PAC with surge in usage of both CVP and fiberoptic PAC. The private hospital perform good clinical outcome in CVP group with lower mortality and low total hospital fee in case payment CABG. CONCLUSION: The usage of three invasive hemodynamic monitoring devices in CABG surgery is safe. It is up to the professional training background and personal preference of the anesthesiologists and cardiac surgeons. This study indicates that the regional hospital and public hospital should restrain from usage of CVP for hemodynamic monitoring in CABG till there is new evidence available to make change.
參考文獻
延伸閱讀
- 許碧峰（2009）。冠狀動脈繞道手術量與療效關係之實證研究。台灣公共衛生雜誌，28(1)，69-77。https://doi.org/10.6288/TJPH2009-28-01-07
- 賴珊珊（2005）。接受不同經皮冠狀動脈介入性治療術病患之處置後三年醫療資源使用以及療效之探討〔碩士論文，高雄醫學大學〕。華藝線上圖書館。https://www.airitilibrary.com/Article/Detail?DocID=U0011-2903200614040368
- Chang, J. K., Lin, C. C., Hwang, D. C., & Hsieh, K. S. (2008). 以三度空間實時間彩色超音波心圖監測發紺先天性心臟病合併大血管轉位症嬰幼兒執行心房中隔氣球造口術之臨床應用分析. 重症醫學雜誌, 9(3), 150-155. https://doi.org/10.30035/TCCM.200809.0001
- Lee, C. H. (2008). 嵌入先驗之三維區域單元競爭演算法：多切面電腦斷層掃描冠狀動脈粥樣硬化影像分割與分析 [master's thesis, National Taiwan University]. Airiti Library. https://doi.org/10.6342/NTU.2008.01092
- Wu, Y. S., Hsieh, S. R., Wei, H. J., Hsu, C. Y., & Tsai, C. L. (2019). Long-Term Outcomes in Coronary Artery Bypass Graft Patients Using Internal Thoracic Artery with Ipsilateral Arteriovenous Shunt for Hemodialysis. Acta Cardiologica Sinica, 35(4), 387-393. https://doi.org/10.6515/ACS.201907_35(4).20181208A