重症病患之血糖與C-反應蛋白值對呼吸器脫離的影響

The impact of blood glucose and C-reactive protein levels on ventilator weaning in critically ill patients

黃惠敏(Hui-Min Huang)

指導教授 ： 許國堂

中山醫學大學/醫學院/醫學研究所/碩士(2014年)

https://doi.org/10.6834/CSMU.2014.00041

摘要

研究目的:台灣因為醫療之進步、全民健康保險普及以及人口老化，呼吸器依賴患者逐年增加。如何協助呼吸器依賴病患成功脫離呼吸器的議題，是呼吸照護團隊的重要挑戰。影響呼吸器依賴病患脫離呼吸器的影響因素甚多，其中常伴隨各種合併症，而導致延長使用呼吸器。呼吸器可用以協助病患暫時克服呼吸衰竭問題，讓病患擁有更多接受醫療處置的時間。然而，呼吸器的使用仍不利於病患的健康，尤其加護病房屬於稀少性的醫療資源，若能協助加護病房的病患早日脫離呼吸器，不僅可提高加護病床的使用週轉率還能減少重症病患因呼吸器使用所產生的感染問題。
血糖控制對於重症病人死亡率有明顯影響；C-反應蛋白 (C-reactive protein, CRP)是目前臨床上應用最普遍的一種炎症反應蛋白，對於重症病人死亡率亦有相關影響.本研究希望能找出血糖與C-反應蛋白與呼吸器脫離相關性，以提供臨床呼吸治療師在評估呼吸器脫離前的一項參考指標。
研究方法：故本研究以病歷回顧的方法，收集中部地區某醫學中心內科與外科加護病房呼吸器使用超過三天之病患為研究對象，使用呼吸器的病人共213人，其中脫離呼吸器成功107 人；脫離呼吸器失敗106 人，並且統計分析血糖與C-反應蛋白與呼吸器脫離相關性分析。資料分析以百分比、中位數四分位差排序呈現描述性資料，再以t-test、Chi-Square、Pearson correlation進行檢定。
研究結果：呼吸器脫離成功組使用呼吸器當天平均血糖值 164，失敗組為 160，兩組間無顯著差異(P = 0.08)；呼吸器脫離成功組使用呼吸器當天平均CRP值為9.495，失敗組為 6.415，兩組間有顯著差異(P = 0.05)；呼吸器脫離成功與失敗的生理指標: APACHEⅡ(<24小時內) 呼吸器脫離成功組平均測量值為19，失敗組為22 兩組間有顯著差異(P = 0.0042)，APACHEⅡ(>24小時) 呼吸器脫離成功組平均測量值為 16，失敗組為19兩組間有顯著差異(P<0.001)
討論：血糖值與呼吸器脫離並無統計學上的意義，可能是因為病患皆有血糖控制。而C-反應蛋白在成功脫離組明顯高於脫離失敗組可能是因為感染或發炎有得到改善；且可知病人疾病嚴重度亦是影響呼吸器脫離重大的考慮因素。

關鍵字

血糖 ； C-反應蛋白 ； 呼吸器 ； 重症病人

並列摘要

Purpose:
Due to the development of medical technology, implementation of National Health insurance (NHI) program and population aging, the amount of ventilator-dependent patients are significantly increasing within these years. Although mechanical ventilators are important for the patients with respiratory failure, ventilator support should be withdrawn when no longer necessary thus to reduce the possible nosocomial complications and costs. The issue of how to assist ventilation-dependent patients to succeed in weaning from ventilator is an important challenge to the professional health team. There are many variables that influencing ventilation- dependent patients to wean from ventilator,which usually accompanying with complications and resulted in prolong usage of ventilator. Mechanical ventilation (MV) has substantial risks, that including airway injury, ventilator-associated pneumonia, barotrauma, and increased mortality as the duration of MV increases. Therefore, it is desirable to wean a patient from a ventilator as soon as possible.
Glucose control for critically ill patients is associated with mortality rate. C-reactive protein (CRP), a biomarker of inflammation, associated with mortality in respiratory failure and in the critically ill patients.This study examined the relationship between CRP, Blood glucose level, and their correlations with mechanical ventilation weaning outcome in critically ill patients.
Methods and Materials:
This study enrolled the patients with mechanical ventilation support more than three days and a retrospective chart-review study was performed. We collected a total of 213 patients, data from a medical-surgical intensive care unit that located in centrol Taiwan. Data were collected from May 2013 to September 2013. The window version of SPSS 18.0 statistical analysis software was used to estimate the percentage, Chi-Square test, median (IQR) and Pearson correlation coefficient.
Patients who were able to successfully weaning from a mechanical ventilator were assigned to the successful group (N=107), and failure weaning from a mechanical ventilator were in the control group (N=106). Data of medication history, APACHEⅡ, PiMax, PeMax, Minute ventilation, RSBI, Blood glucose, C-Reactive Protein, Albumin, Physiological and biochemical markers were collected.
Results:
Blood Glucose level (mg/dL)1 of successfully weaning from a mechanical ventilator were 164 (median), failure weaning from a mechanical ventilator were 160 (median) with no statistical significance (P = 0.08)；CRP (mg/dL)1 of successfully weaning from a mechanical ventilator were 9.495, failure weaning from a mechanical ventilator were 6.415, with a statistical significance (P = 0.05)； APACHEⅡ (<24hrs) of successfully weaning from a mechanical ventilator were 19, failure weaning from a mechanical ventilator were 22, with a statistical significance (P=0.0042); APACHEⅡ(>24 hrs) of successfully weaning from a mechanical ventilator were 16, failure weaning from a mechanical ventilator were 19, have a statistical significance (P<0.001) .
Conclusion and Suggestion:
Blood Glucose in critically ill patients has no statistical significance for mechanical ventilation weaning outcome. C-reactive protein and Acute physiology and chronic health evaluation II (APACHE II) score have higher correlation with ventilator weaning.

並列關鍵字

Blood glucose ； C-reactive protein (CRP) ； Mechanical ventilation ； Critically ill patients

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