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  • 學位論文

住院病人心臟驟停與早期預警徵象和心肺復甦成效之探討

Improving outcome in cardiopulmonary resuscitation for hospital inpatients: systems to prevent cardiac arrests through recognition of early warning signs and timely intervention

指導教授 : 許玫琪

摘要


院內或院外急救在病人危急時是非常重要,然而往往忽視了在院內的心肺停止發生前的危險因子,本研究目的為探討高雄市某區域教學醫院院內住院病人心臟驟停與早期預警徵象和心肺復甦成效之探討。 採病歷回溯性研究,於西元2013年1月1日至西元2014年12月31日分析發生院內心跳停止施行心肺復甦的病患資料,問卷回收後,進行資料編碼及登錄,以SAS 9.4版本之統計軟體來進行資料分析。 本研究共查閱310本病歷,研究結果顯示病人基本資料,例如:年齡與性別與急救成功並無統計學上顯著差異;內科發生心臟驟停居多,但依然沒有達到統計上的顯著差異;病人的過去疾病史,例如:心衰竭、呼吸衰竭、癌症等也無顯著差異。在急救處置上、發生急救之初始呼吸變化與急救成效達到統計上的差異。心臟驟停前預警徵象、包含體溫、心跳次數、呼吸次數、脈搏次數、收縮壓、舒張壓、血氧濃度、疼痛分數會隨著時間達到顯著性的變化,從分析中發現,(1)前一小時的預警徵象變化中呼吸次數(P =0.01)、血氧濃度(P =0.01)及疼痛分數有顯著差異(P =0.002);(2).前二小時預警徵象統計在體溫(P=0.008)、呼吸次數(P =0.001)、脈搏次數(P =0.03)、血氧濃度(P =0.01)有顯著差異;(3)前三小時預警徵象在血氧濃度(P =0.03)有顯著差異(4)前四小時預警徵象中呼吸次數(P=0.03)有顯著差異;(5)前五小時預警徵象心跳次數(P =0.036)、呼吸次數(P =0.013) 、脈搏(P =0.029)、收縮壓(P=0.005)均達到統計上的顯著差異。 初始心律為心室纖維性顫動 (ventricular flutter,VF)與無脈搏心室心搏過速(ventricular tachycardia,VT)共266人次,即時執行去顫術人次為26人次(9.8%),發生心室顫動(VF)/無脈搏頻脈(VT)至執行去顫術時間≤3分鐘為3人次(1.1%),發現心臟驟停時為VF/VT心律存活出院為31人次(11.7%)。 急救無脈搏心跳死亡病人269人次中,有簽署拒絕心肺復甦術(Do not resuscitate,DNR)宣告或撤除維生設備只有39人次(14.5%);停止CPR原因包含無救治希望89人次(28.7%),死亡50人次(16.1%),急救後家屬要求簽屬DNR同意書39人(12.6%),家屬要求停止急救17人次(5.5%),和急救後回復自發性循環Return of Spontaneous Circulation 149人次(41.6%)。本研究結果也發現心肺復甦前預警徵象和第一時間電擊對存活率有正面的影響。 期待本研究結果能協助醫院改善病人心臟驟停與早期預警徵象的評估,讓住院病人心臟驟停的發生率降低、且提升心肺復甦之成功率和存活率,減少心臟驟停後所引發的身心傷害與住院天數延長。

並列摘要


It is often ignored to recognize early signs of sudden cardiac arrest and risk factors of clinical deterioration, when rapid assessment and resuscitation of critical conditions in in-hospital or out-of-hospital may need to be carried out. The study aim was to investigate the relationship and outcomes of cardiac arrest, early warning signs and cardiopulmonary resuscitation in hospital inpatients. The is a retrospective chart review study by reviewing clinical data of patients who experienced sudden cardiac arrest and cardiopulmonary resuscitation. The patients’ medical records in hospital data bank dated from January 2013 to December 2014 were collected from a large mental hospital in southern Taiwan. The data were analyzed by applying SAS 9.4 full version. A total of 310 patients met entry criteria. Results showed that demographic variables such as age and sex were not significantly correlated with success in first aid management. Internal Medicine had more cases of cardiac arrest, although it did not reach statistically significant difference. The past history of diseases such as heart failure, respiratory failure and cancers was shown to be non- statistically significant correlated for first aid management. Initial respiration changes when emergency occurs and success in first aid management were statistically significant correlated. Early warning signs such as temperature, heart rates, pulse rates, systolic pressure, diastolic pressure, blood oxygen saturation and pain scores showed significant differences over time. A number of results were found: (1). patients had significant changes in respiratory rates (P =0.01), blood oxygen saturation (P =0.01) and pain scores (P =0.002) within first monitored one hour of the warning signs. (2). Significant changes in temperature (P=0.008), respiratory rates (P =0.001), pulse rates (P =0.03) and blood oxygen saturation (P =0.01) in the monitored second hour of the warning signs. (3). Significant changes in blood oxygen saturation (P =0.03) in the monitored third hour of the warning signs. (4). Significant changes in respiratory rates (P =0.03) in the monitored fourth hour of the warning signs. (5). Changes of heart rates (P =0.036), respiratory rates (P =0.013), pulse rates (P =0.029), and systolic pressure (P=0.005) were all reached statistical significance in the monitored fifth hour of the warning signs. A total of 266 inpatients showed first monitored rhythm as ventricular flutter (VF) and pulseless ventricular tachycardia (VT). Twenty-six patients (9.8%) received prompt defibrillation. Three inpatients’ defibrillation (1.1%) after the appearance of VT/VF is within three minutes. A rate of survival from cardiac arrest was associated with VT and VF to 31 inpatients (11.7%) There are a total of 39 inpatients (14.5%) who signed do not resuscitate (DNR) or removed life support system in 269 pulseless and no heartbeat deaths after first aid management. Reasons of cessation of CPR include patients with a hopeless prognosis (N=89, 28.7%), death (N=50, 16.1%), family signed DNR after first aid management (N=39, 12.6%), requests from family to end CPR (N=17, 5.5%), and return of spontaneous circulation after first aid management (N=149, 41.6%). The study also found that early warning signs and prompt defibrillation is beneficial to rate of survival. Hopefully, this study could help to improve the assessments of in-hospital cardiac arrest and early warning signs in order to decrease the incidences of cardiac arrest of inpatients, increase the success of cardiopulmonary resuscitation and inpatients’ survival rates, and decrease the physiological and psychological impacts and admission days.

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