全身麻醉使用肌肉鬆弛劑拮抗劑Sugammadex的成本效益分析

目的：在手術完成而肌肉鬆弛劑作用無法完全消失時，會造成手術時間延宕；若劑量殘留，則會延遲恢復，甚至增加死亡率風險。而新型肌肉鬆弛劑拮抗劑Sugammadex具有廣大適應症與快速恢復及無逆轉作用的優勢。因此藉由方法論與成本效益理論深入剖析，希望可以為病患、醫護人員、醫院及社會創造四贏的局面。方法：藉由方法論與成本效益策略，建構全身麻醉使用Sugammadex之成本計算模型。提出以病人的角度：比較全身麻醉後重新插管併發症的發生率；以醫院的角度：分析自費醫療收入的成本效益、分析病人術後滿意度；及以醫療資源的角度：分析減少術後重插管所可能降低的醫療資源耗用。結果：收集2016年1月至2018年10月行氣管內插管全身麻醉病患，共有44,328人，其中有2,951人使用新型肌肉鬆弛劑拮抗劑Sugammadex，發生重插管為0人。無使用Sugammadex拮抗劑有41,377人，發生重插管為19人，發生率為0.045%；重插管後轉入加護病房照護率為100%、重插管後死亡個案為 2/19 佔10.53%、成本效益的淨效益現值部分，為新台幣1,656,903.60元；益本比1.08，符合成本效益。在滿意度調查部分，新型肌肉鬆弛劑拮抗劑Sugammadex非常滿意的病患數，遠高於無使用的病患數，甚至於使用傳統肌肉鬆弛劑拮抗劑Neostigmine的病患有一位不滿意。在醫療資源耗用部分，重插管病患平均入住加護病房的花費為新台幣11,334元/人、每人每天的生產力損失為新台幣1,570.2元/人。沒有使用新型肌肉鬆弛劑拮抗劑Sugammadex所導致的社會成本增加每人為新台幣2,902.3元，但是Sugammadex自費為新台幣6,000元，因此施打新型肌肉鬆弛劑拮抗劑Sugammaderx對病人而言未符合成本效益，但是就滿意度而言是有達成病患期望的。結論：就全人照護的醫療的角度而言，使用肌肉鬆弛劑拮抗劑Sugammadex的效益成果，具有減少合併症的發生、降低住院天數、減低佔床率、減輕家屬與醫護人員的照護時程、減少醫療資源的浪費與提升醫療品質等優點。

關鍵字

肌肉鬆弛劑拮抗劑；成本效益分析

並列摘要

Background. Neuromuscular blocking agents such as rocuronium are widely used to maintain patient immobilization and facilitate mechanical ventilation support during general anesthesia. Therefore, the recovery of voluntary muscle power is essential during the emergence and recovery phases of anesthesia for the return of adequate spontaneous respiration, cough reflex and motor function. Development of respiratory failure due to residual muscle relaxation effect increases risk of re-intubation of endotracheal tube and requires prolonged ventilatory support, leading to serious post-anesthesia complications, even death. Sugammedex is a modified cyclodextrin that encapsulates rocuronium molecules, and thus rapidly inactivates the neuromuscular blockade effect of rocuronium. Unlike the classic reversal agents, sugammedex is associated with less systemic adverse reaction due to the lack of the antimuscarinic and anticholinergic effect. This research project aimed to analyze the cost-benefit of sugammedex in perioperative care. Methods. This study retrospectively analyzed the medical records of patients received endotracheal tube intubation general anesthesia (ETGA) from August 2016 to August 2018. Patients who admitted to intensive care unit (ICU) after operation or extubated of the endotracheal tube outside the operation room (OR) were excluded. The development of acute respiratory failure after removal of endotracheal tube in the OR and required re-intubation in OR or at postanesthetisa care unit (PACU) were recorded for the agents used for reversing neuromuscular blockade and the clinical outcomes of individual patient. The increased length of hospital-stay and extraneous medical expense due to failure of extubation was calculated according the xxx model. Results. A total of 44328 patients were included in this analysis, including 2951 (6.6%) of these patients received sugammedex for reversal of neuromuscular blockade at the end of operation. There were 19 cases developed acute respiratory distress who required re-intubation during the study period. Compared with sugammedex treatment group, the incidence of re-intubation was higher in the conventional reversal group (0% vs 0.045%, respectively; P=0.633 Fisher Exact test), as all the acute respiratory failure cases did not receive sugammedex for muscle relaxant reversal. The relative risk of reintubation for conventional reversal use was 2.78 (95% CI 0.17-46.09; P=0.475). All the cases required re-intubation was transferred to ICU for postoperative care and 2 patients (10.53%) eventually expired after the event. The average per person medical care expense in the ICU and labor productivity loss was NT$ 11334 and NT$1570.2, respectively, resulting in an overall social cost of NT$ 2902.3 for a newly developed case of acute respiratory failure after extubation. However, the increase in social costs caused by not using Sugammadex is 2902.3 yuan per person, but Sugammadex is 6,000 yuan at its own expense, so it is not cost-effective for the patient to use Sugammaderx for money, but the feeling of satisfaction is cost-effective. The net benefit of the cost-benefit analysis is 1,560,906.60, and the cost-to-book ratio is 1.08, which is cost-effective. Conclusion. Based on the holistic health care principle, use of sugammedex as the reversal agent for neuromuscular blockade during recovery of anesthesia provides high cost-effectiven -ess in prevention of acute respiratory failure after extubation, reduction of extra medical expe -nse and labor productivity loss for unplanned intensive care, and enhancement of medical car -e quality. Furthermore, the avoidance of postoperative complications may potentially prohibit the unnecessary medical dispute between the health providers and the patients.