探討重症系統性乏力對加護病房存活病患一年內功能表現之影響

Abstract

背景：重症系統性乏力（ICU-Acquired Weakness, ICUAW）為「重症加護後症候群」（Post-Intensive Care Syndrome, PICS）主要的身體層面障礙，與長期的生理、認知及日常生活功能缺損有關。然而，ICUAW 對台灣加護病房（ICU）存活者一年功能軌跡仍缺乏深入探討。 目的：探討有無ICUAW之ICU存活者一年內功能軌跡；辨識第十二個月日常生活活動能力（Activities of Daily Living, ADL）之預測因子，並評估轉出ICU時的握力（Handgrip Strength, HGS）及最大吸氣壓力（Maximal Inspiratory Pressure, MIP）作為ICUAW篩檢替代工具之可行性。 方法：本研究採次級分析，使用臺灣一所大學附設醫學中心六個內科 ICU 既有之前瞻性世代研究資料。成年ICU存活者於五個時間點：ICU轉出後（T1）、第1個月（T2）、第3個月（T3）、第6個月（T4）及第12個月（T5）接受評估，包含: 生理功能（HGS、MIP）、認知功能（MMSE）及日常生活功能（Barthel Index）。ICUAW以醫學研究委員會（Medical Research Council, MRC）總分進行定義。以廣義估計方程式（Generalized Estimating Equations, GEE）分析一年內五個時間點的功能軌跡；以階層迴歸分析第十二個月ADL表現的預測因子；ROC (Receiver Operating Characteristic）曲線法評估HGS與MIP作為 ICUAW 篩檢工具之區辨力。 結果：275位完成MRC測試的ICU存活者中，男性佔65.8%，中位數年齡70.0歲，22.5% (n=62)於ICU轉出時篩檢出有ICUAW。整體而言，ICUAW 組在各時間點之功能表現均顯著低於非 ICUAW 組。HGS (以常模百分比表示)在ICUAW組由T1的35.7%上升至T5的常模的45.7%；非ICUAW組則由常模的72.1%進步至90.0%。MIP在ICUAW組由T1的常模14.7%提升至T5的32.0%；非ICUAW組則由36.7%提升至56.6%。HGS 與 MIP 軌跡分析顯示，兩組皆隨時間改善且呈平行趨勢，但 ICUAW 組於追蹤期間的表現始終較差。MMSE分數在ICUAW組由16.4分提升至22.2分；非ICUAW組由24.6分提升至27.4分。日常生活功能（ADL）軌跡顯示，ICUAW組由入ICU前（T0）的75.1分，於轉出後一個月時驟降至27.7分，隨後緩慢回升至十二個月時的52.3分；非ICUAW組則從93.5分下降至77.2分，之後恢復至87.0分，但兩組至 12 個月時之獨立程度皆未恢復至入 ICU 前的水準。為評估存活者偏差的潛在影響，針對完成 12 個月追蹤者（n=113）進行敏感度分析，結果顯示軌跡方向一致。最終階層迴歸模型之平均調整後R²為0.422，顯示入ICU前的ADL每增加 1 分，12 個月 ADL 平均增加 0.390 分（95% CI，0.2–0.6）；有 ICUAW 者的 12 個月 ADL 平均較無 ICUAW 者低 28.1 分（95% CI，−40.3 至 −16.0）。ROC曲線分析指出HGS（切點10.9 kg）與MIP（切點22.5 cmH₂O）具良好區辨力（AUC > 0.80）。 結論/實務應用：患有ICUAW與轉出ICU後的功能恢復較差有關。儘管HGS與MIP之功能軌跡呈平行趨勢，患有ICUAW之ICU存活者在追蹤期間仍明顯較弱，且日常生活功能獨立程度於第12個月時亦未能回復至入ICU前的基準。入ICU前的日常生活功能及是否患有ICUAW為預測第12個月ADL獨立功能預後的重要指標。研究結果支持臨床人員常規追蹤ICU存活者之功能狀態，並及早制定個別化之復健照護計畫。HGS與MIP可作為重症患者轉出ICU時之床邊快速且客觀的ICUAW篩檢工具，提供簡便且標準化的評估方式，有助於建立ICUAW常規篩檢流程。

Background： ICU‐acquired weakness (ICUAW) is a common post‐intensive care syndrome (PICS)-related complication associated with persistent deficits in physical function, cognition, and ADL. However, evidence on one-year functional trajectories in Taiwan is limited. Purpose： To investigate one-year functional trajectories in ICU survivors with and without ICUAW, identify predictors of 12-month Activities of Daily Living (ADL) outcomes, and evaluate handgrip strength (HGS) and maximal inspiratory pressure (MIP) as alternative screening tools for ICUAW. Methods： Secondary analysis was performed using prospectively collected cohort data from six medical ICUs in Taiwan. Participants underwent serial assessments at ICU discharge and during follow-up at 1, 3, 6, and 12 months (T1–T5), including HGS and MIP, MMSE, and the Barthel Index. ICUAW was defined based on the Medical Research Council (MRC) sum score. Generalized estimating equations (GEE) were used to model trajectories, while hierarchical regression examined predictors of 12-month ADL, and ROC analyses evaluated HGS and MIP for ICUAW screening. Results： Of 275 ICU survivors who completed MRC testing (65.8% male; median age 70.0 years), 22.5% had ICUAW at ICU discharge. Across five follow-up time points, the ICUAW group demonstrated significantly poorer performance in muscle strength, cognitive function, and ADL than the non-ICUAW group. HGS increased from 35.7% of norm at T1 to 45.7% of norm at T5 in the ICUAW group, versus 72.1% of norm to 90.0% of norm in the non-ICUAW group. MIP increased from 14.7% of norm at T1 to 32.0% of norm at T5 in the ICUAW group, compared with 36.7% of norm to 56.6% of norm in the non‐ICUAW group. Trajectory analyses of age- and sex-normalized HGS and MIP showed improvement over time in both groups with parallel patterns, while ICUAW survivors remained consistently weaker throughout follow-up. MMSE improved from 16.4 to 22.2 in the ICUAW group and from 24.6 to 27.4 in the non‐ICUAW group. ADL trajectories showed that the ICUAW group declined from 75.1 points (pre-ICU) to 27.7 points at 1 month, then gradually recovered to 52.3 points at 12 months. The non-ICUAW group declined from 93.5 points to 77.2 points, then recovered to 87.0 points. Neither group returned to pre-ICU functional levels by 12 months. Sensitivity analysis restricted to 12-month survivors (n=113) showed consistent trajectory patterns. In the final hierarchical regression model, the mean adjusted R² was 0.422. 12-month ADL increased by 0.390 points per 1-point higher pre-ICU ADL (95% CI 0.2–0.6); and was 28.1 points lower in patients with ICUAW (95% CI −40.3 to −16.0). ROC analyses identified HGS (cut‐off 10.9 kg) and MIP (cut‐off 22.5 cmH₂O) as effective tools for detecting ICUAW, both with good discriminatory ability (AUC > 0.80). Conclusion / Implication： ICUAW was associated with persistently poorer post-ICU recovery. Despite parallel HGS and MIP trajectories, ICUAW survivors remained markedly weaker, and ADL did not return to pre-ICU levels at 12 months. These findings support routine post-ICU functional monitoring and early, individualized rehabilitation, with pre-ICU ADL and ICUAW status aiding risk stratification and follow-up planning. HGS and MIP are feasible bedside measures to support routine ICUAW screening.