- 學位論文
老人脊髓麻醉風險模型發展研究
A Study of Elderly Spinal Anesthesia Risk Model Development
摘要
摘 要 人口老化是全球醫療照護政策的重點，脊髓麻醉是較為被建議用在老人的麻醉方式，至2007年止，台灣老年人口數為2,312,359人,占人口數的10.09%;預估在20年後會佔人口數的21.45%以上。未來台灣老年人口接受麻醉及手術人口數的增加，也將是趨勢;隨年齡增加，每十年增加1.42倍的風險，其多重危險因素包括麻醉藥物動力學因素、藥物血液動力學因素，身體狀態及既有疾病及手術因素等。 脊髓等半身麻醉雖是較為被建議的麻醉方式，但仍有許多麻醉不良事件或意外發生，本研究綜合國外脊髓麻醉不良事件研究結果，發生率約在7.5-46.8%。以醫療錯誤或事件的型態而言，這些數字只是活動性錯誤的部份，也是問題呈現的一小部份而已，Webster等學者對麻醉高風險提出作業安全的建議，應與核電廠類似;麻醉的風險管理必須實現在組織的各個面向，強調先前的準備(如何做、做什麼)以達成預防不良事件及最小化之的目標。 研究方法與作法:將老人脊髓麻醉臨床評估與處置流程，包括術前評估、麻醉前準備、預防性的麻醉期間處置，提出系統設計的模式;在本研究的模式設計中，以老人脊髓麻醉發生之心跳過低及血壓下降，做為風險嚴重度的(結果)依變項，繪製出安全的臨床評估與處置路徑，共59條，並以臨床老人脊髓麻醉病歷記錄結果做比對，以確認其可行性。最後以SPSS軟體，進行描述性分析、主成份分析以檢測本設計之可行性，並抽取出影響的主要因子。 結果:以335位接受脊髓麻醉的老人做比對，結果有277例個案符合本設計，吻合率為82.7%。所有的個案進行主成份分析，結果取用三個主要成份，重新命名:第一個成份為「給藥的考量」--是由麻醉高度與時間需求、用藥量及營養狀態組成。第二個成份為「老人生理狀態的考量」--是由年齡及ASA生理狀態分類組成，第三個是「麻醉前的給水」。三個主要成份因素，可做為臨床預應式及回應式的處置決策參考，降低不良事件及幾近失誤的頻率，進而減少意外、損傷及嚴重的事件發生。
並列摘要
Abstract The aging of population is a focus of global medical care policy. The use of spinal anesthesia in elderly patients has been advocated. In Taiwan, there are 2,312,359 elderly people that occupy 10.09% of the total population. This number is expected to go beyond 21.45% in 2 decades. There appear to be a future trend in the rise of number of elderly patients receiving anesthesia and surgery. Aging increases the risk by 1.42 folds per decade. The multiple risk factors include the influence of aging on drug pharmacokinetics, hemodynamics, physiological status and history of diseases. Although spinal anesthesia and central neuraxial blockade in elderly patients have been advocated, there are still incidences of adverse events or accidents during spinal anesthesia. A review of foreign literature suggests that the incidence rate falls between 7.5-46.8%.In terms of medical errors or types of adverse events, these numbers are a part of active errors, and only present a small component of the system problems. Webster et al suggested that the nuclear power industry is a good analogy for safety in high risk anesthesia practices. Risk management program in anesthesia must be materialized in all aspects of the organization and emphasize the creation of optimum conditions of the “what” and the “how” of anesthesia practice and optimum preparation, in order to minimize the adverse events in anesthesia care. Methods: The clinical assessment and intervention workflow of spinal anesthesia in the elderly, including preparation of anesthesia and risk assessment, and intervention during spinal anesthesia, are proposed by presenting a model of system design. The dependent variables of risk severity of this design were bradycardia and hypotention during elderly spinal anesthesia. Risk assessment and intervention pathway of safety was depicted, and a total of 59 intervention pathways were found. Finally, compare the intervention pathways with records of elderly spinal anesthesia to confirm the approval. SPSS software was applied to perform descriptive analysis, principal components analysis to examine the feasibility of the design, and to find out the principal components. Results: A total of 335 elderly patients were recruited into the study, and 277 patients were found to match the pathway, with a matching rate of 82.7%. After a principal component analysis of all the cases, three principal components appeared that were redefined as: The first component was medication consideration, which included nerve block height, need of operation time and nutrition condition. The second component was elderly physical status consideration, which included aging and ASA status. The third component was preloading of fluid. The three principal component factors could act as references for decision-making of proactive and reactive intervention for anesthetic practice during elderly spinal anesthesia, in order to minimize adverse events and frequency of near miss in anesthesia care, leading to a decrease in accidents, harm, and incidents.