第五章 討論
第四節 未來發展
預後，包括神經學預後（cerebral performance categories）及長期存活預後41。 然而，在本研究囊括的病例中均沒有接受低體溫治療。也許，因此造成本研究
出台灣本地針對院內心跳停止病人的預防及治療策略。
(2) 研究生物標記的變化，是否與院內心跳停止病人的死因有關。
(3) 針對院內心因性心跳停止病人，利用臨床特徵及生命徵象變化建立預測模型。
第五節第五節 第五節第五節 結論結論結論結論
心因性院內心跳停止病人的心跳停止前預兆-生命徵象的變化比起非心因性的病 人，往往較不明顯，在臨床上，可能會錯過早期介入的時機。我們可以利用病人 本身的臨床特徵，早期預判可能較易發生心因性院內心跳停止的病人，改變監測 策略，進而提昇院內心跳停止病人的預後。
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Table 1a : Baseline characteristics (Hospital Settings) of study participants, specified by cardiogenic and non-cardiac status
Non-cardiogenic
Values are N (%) or Standard deviation (SD) as indicated
Department: med. = medical department; Weekend: 23:00, Friday~ 07:00, Monday;
Season: Spring (Mar, Apr, May); Summer (Jun, Jul, Aug); Autumn (Sep, Oct, Nov); Winter (Dec, Jan, Feb);
LOS: Length of stay at ED; DNR: Do not resuscitative
Medical worry, min: medical worry time, time from medical worry to death
Table 1b : Baseline characteristics (Clinical Settings) of study participants, specified by cardiogenic and non-cardiac status
Non-cardiogenic
Values are N (%) as indicated
SOB: Shortness of breath; Con’s change: Conscious change; GI bleeding: Gastrointestinal bleeding;
HLP: Hyperlipidemia; VHD: Valvular heart disease; DCM: Dilated cardiomyopathy; CVA:
Cerebrovascular accident; COPD: Chronic obstructive pulmonary disease;
ROSC: Return of spontaneous circulation; CPC: Cerebral performance categories, good means CPC1-2
Table 1c : Baseline characteristics (Laboratory Settings) of study participants, specified by cardiogenic and non-cardiac status
Non-cardiogenic
Arrest Rhythm <0.001
Asystole 27 (24.8) 11 (23.9)
Values are N (%) or Standard deviation (SD) as indicated
NSR: Normal sinus rhythm; Af: Atrial fibrillation; LBBB: Left bundle branch block;
RBBB: Right bundle branch block; VPCs: Ventricular premature contractions;
ST change: ST segment changes including ST elevation, T wave inversion, ST segment depression;
PEA: Pulseless electrical activity; Vf: Ventricular fibrillation, VT: Ventricular tachycardia;
WBC: White blood cell count; Hgb: Hemoglobin, Na: Sodium, K: Potassium.
Table 2 Comparison between cardiac and non-cardiac causes with regard to vital signs and time period in the study
Total Non-cardiac IHCA Cardiac IHCA
N Mean SD Mean SD p-value
0.5-1 hr antecedents
Temp. (℃) 155 36.3 ±1.82 36.1 ±1.11 0.44
1-4 hr antecedents
Temp. (℃) 140 36.4 ±1.78 36.0 ±1.16 0.11
4-8 hr antecedents
Temp. (℃) 82 36.6 ±1.59 36.1 ±1.35 0.23
>8 hr antecedents
Temp. (℃) 53 36.4 ±1.43 36.0 ±0.87 0.31
Temp., body tympanic temperature; HR, heart rate; RR, respiratory rat; BP, blood pressure; SaO2, Peripheral oxygen saturation; GCS, Glasgow coma scale; hr, hours.
Table 3a. Prediction of IHCA Cause by patient and hospital variables OR indicates odds ratio; 95%CI: 95% Confidence interval
SOB: Shortness of breath; Con’s change: Conscious change; GI bleeding: Gastrointestinal bleeding;
HLP: Hyperlipidemia; VHD: Valvular heart disease; DCM: Dilated cardiomyopathy; CVA: Cerebrovascular accident; COPD: Chronic obstructive pulmonary disease;
Table 3b. Prediction of IHCA Cause by arrest and clinical variables
Crude OR 95% CI Adjusted
OR*
95% CI
Weekend 1.71 (0.80, 3.68)
Day (07:00-22:59) 0.95 (0.45, 2.01)
Arrest rhythm, Vf/VT 9.81 (2.56, 37.7) 6.04 (1.27, 28.8) Initial ECG
NSR 1.24 (0.55, 2.83)
Sinus bradycardia 1.61 (0.26, 9.95) Sinus tachycardia 0.33 (0.15, 0.72)
Af 2.29 (1.00, 5.27)
ST change 4.33 (1.88, 9.96) 4.17 (1.50, 11.6)
LBBB 2.40 (0.15, 39.2)
RBBB 0.94 (0.28, 3.18)
VPCs 1.61 (0.26, 9.95)
OR indicates odds ratio; 95%CI: 95% Confidence interval
NSR: Normal sinus rhythm; Af: Atrial fibrillation; LBBB: Left bundle branch block; RBBB: Right bundle branch block; VPCs: Ventricular premature contractions;
ST change: ST segment changes including ST elevation, T wave inversion, ST segment depression;
Vf: Ventricular fibrillation, VT: Ventricular tachycardia; CI: Confidence interval;
*Adjusted for Age, Sex, Weekend, Day, Triage, Chief complaints, Medical history, Initial ECG and Arrest rhythm with stepwise regression
Table 4a. Prediction of IHCA Cause by vital sign using logistic regression analysis
OR indicates odds ratio; 95%CI: 95% Confidence interval
Temp., body tympanic temperature; HR, heart rate; RR, respiratory rat; BP, blood pressure; SaO2, Peripheral oxygen saturation; GCS, Glasgow coma scale; CI: Confidence interval.
*Adjusted for age, sex, DNR status, previous medical history, triage status, department, length of stay, medical worry.
Table 4b. Prediction of IHCA Cause by vital sign using logistic regression analysis ( 1 - 4 hours before IHCA)
Temp., body tympanic temperature; HR, heart rate; RR, respiratory rat; BP, blood pressure; SaO2, Peripheral oxygen saturation; GCS, Glasgow coma scale; CI: Confidence interval.
* Adjusted for age, sex, DNR status, previous medical history, triage status, department, length of stay, medical worry.
Table 4c. Prediction of IHCA Cause by vital sign using logistic regression analysis
Temp., body tympanic temperature; HR, heart rate; RR, respiratory rat; BP, blood pressure; SaO2, Peripheral oxygen saturation; GCS, Glasgow coma scale; CI: Confidence interval.
* Adjusted for age, sex, DNR status, previous medical history, triage status, department, length of stay, medical worry.
Table 4d. Prediction of IHCA Cause by vital sign using logistic regression analysis ( > 8 hours before IHCA)
Temp., body tympanic temperature; HR, heart rate; RR, respiratory rat; BP, blood pressure; SaO2, Peripheral oxygen saturation; GCS, Glasgow coma scale; CI: Confidence interval.
* Adjusted for age, sex, DNR status, previous medical history, triage status, department, length of stay, medical worry.
Table 5. Survival outcome in all patients, by major categories of variables for IHCA
ROSC Survival to hospital Survival to discharge CPC, good Adjusted
OR* 95% CI Adjusted
OR 95% CI Adjuste
d OR 95% CI Adjusted
OR 95% CI
Patient variables
DNR 0.02 (0.003, 0.18)
Conscious change 0.30 (0.10, 0.90)
Hospital variables
-
Arrest variables
Cardiac IHCA 0.53 (0.19, 1.47) 2.76 (1.10, 6.96) 0.65 (0.09, 4.56) 0.35 (0.03, 4.17)
Arrest rhythm, VF/VT 5.81 (1.26, 26.8) 25.6 (2.77, 236) 16.9 (1.31, 218)
OR indicates odds ratio; 95%CI: 95% Confidence interval
DNR: Do-not-resuscitation; VF: Ventricular fibrillation; VT: Ventricular tachycardia.
*Adjusted for Age, Sex, Triage, Chief complaints, previous medical history, length of stay, medical worry, Initial ECG, and Arrest rhythm with stepwise regression.
Figure 1. Patients inclusions chart
Enrolled IHCA patients (N=155)
The Patient were died within 30 minutes (N= 35)
Previous cardiac arrest (N=1) All IHCA patients
from 2011-2012 (N=206)
ED IHCA patients (N=202)
Adult IHCA (N=200)
IHCA patients with complete
data (N=191)
The patients who was died outside ER (N = 4)
Aged < 20 years (N = 2)
Incomplete data (N = 9)
Figure 2. Major categories of variables for IHCA (In-Hospital Cardiac Arrest)
分級級數 類別 項目
Fig 3. Triage guideline for emergency department patients in Taiwan. (Publication by Department of Health, Executive Yuan, R.O.C., Taiwan)
Fig 4a. Changes of body temperature in cardiac and non-cardiac IHCA. The values above the lines are the mean value in each time duration before IHCA
Fig 4b. Changes of heart rates in cardiac and non-cardiac IHCA. The values above the lines are the mean value in each time duration before IHCA
Fig 4c. Changes of respiratory rates in cardiac and non-cardiac IHCA. The values above the lines are the mean value in each time duration before IHCA
Fig 4d. Changes of systolic blood pressure in cardiac and non-cardiac IHCA. The values above the lines are the mean value in each time duration before IHCA
Fig 4e. Changes of diastolic blood pressure in cardiac and non-cardiac IHCA. The values above the lines are the mean value in each time duration before IHCA
Fig 4f. Changes of oxygen saturation in cardiac and non-cardiac IHCA. The values above the lines are the mean value in each time duration before IHCA
Fig 4g. Changes of mental status in cardiac and non-cardiac IHCA. The values above the lines are the mean value in each time duration before IHCA