外科加護病房病患首次接受連續性腎臟替代療法預後狀況之相關因素探討

Abstract

【背景】醫院病患發生急性腎衰竭比率約20％至67％，死亡率約26％，其會提升後續醫療成本。本研究針對加護單位首次接受連續性腎臟替代療法(CRRT)病患的臨床現況、相關因素及預後進行探討，以做將來臨床醫療照護決策的參考。 【目的】了解外科加護病房病患急性腎損傷�衰竭發生率及預後；了解CRRT病患之基本屬性及疾病特性；分析治療狀態與預後之關係；及探討預後之影響因素。 【研究方法】本研究是屬於描述性、相關性、回溯性研究設計，研究對象為中部某醫學中心外科加護病房(SICU)首次接受連續性腎臟替代療法(CRRT)之病患，查閱2012年01月01日至2013年12月31日期間所有研究對象之病歷，採用結構式個案病歷資料調查表收集資料，以描述性統計及推論性統計進行分析。 【結果】本研究對象共251例，此單位發生CRRT比例為6.4％；SICU住院日數1-73天，離開此單位時53％是死亡；118例存活轉出SICU時，27例(23％)需要依賴血液透析，77％可脫離透析治療。男性、年齡≧70歲及腸胃外科病患發生急性腎損傷�衰竭之機率高。比較存活者與死亡者發現：入SICU時血清肌酸酐(3.2 vs. 2.1)，RIFLE分級屬RIF等級比例(80% vs. 51%)；入SICU至CRRT間距天數(4.8 vs. 6.7)；CRRT前血清肌酸酐(3.7 vs. 2.9)，未發生休克比例(33% vs. 20%)，無使用呼吸器比例(15% vs. 5%)；兩組皆具顯著差異。比較透析脫離者與依賴者發現：入SICU時血清肌酸酐(2.9 vs. 4.0)，RIFLE分級屬IF等級比例(47% vs. 85%)；入SICU至CRRT間距天數(3.9 vs. 7.9)；CRRT前血清肌酸酐(3.4 vs. 4.7)，未發生休克比例(25% vs. 59%)；兩組皆具顯著差異。入SICU時之血清肌酸酐異常者、入SICU至CRRT間距天數≦2者、CRRT前無使用呼吸器者之存活率皆較高。 【結論】調查於SICU首次執行CRRT之病患，發現男性、年長者、入SICU時APACHEⅡ≧20分者，具有較高急性腎損傷�衰竭之危險性。完整評估病患之臨床狀況及適時介入連續性腎臟替代療法，可使存活者有較高的機會恢復腎臟功能並脫離血液透析。

Background: Acute renal injury/failure was a common complication among patients who admitted to surgical intensive care unit (SICU). The incidence rate was 20% to 67% and mortality rate was 26%. There was a huge medical cost and spending for follow-up health care. The study focused at related factors and prognosis of SICU patients who first-time receiving continuous renal replacement therapy (CRRT). Objective: To understand the incidence and prognosis of acute renal injury/failure; to understand the characteristics of demographic and disease in patients with CRRT; to analyze the relation between clinical situation and prognosis in patients with CRRT; to explore the related factors of prognosis in patients with CRRT. Method: This study was a retrospective and descriptive correlational design in which data were retrieved from medical charts of patients who first-time receiving CRRT at a medical center SICU in central Taiwan. Data was collected from January 1st, 2012 to December 31st, 2013 by using a self-designed chart-record sheet. The data was analyzed by descriptive statistics and inferential statistics. Results: The incidence rate of CRRT was 6.4% and 251cases were recruited. When the subjects discharged from SICU after 1-73days staying, there were 118 survivals and the mortality rate was 53％. Among survivals, becoming hemodialysis-depended patients were 27 (23％) and the others (77%) were free from dialysis therapy. Male, age≧70 years old and gastro-intestinal surgical patients, they had higher risk to acute renal injury/failure. Comparing the two groups (survivals vs. deaths) in the serum creatinine at SICU admitted (3.2 vs. 2.1 mg/dL), the percentage of belonging RIF levels in RIFLE criteria (80% vs. 51%), the interval of SICU admitted to on-CRRT (4.8 vs. 6.7 days), the serum creatinine at pre on-CRRT (3.7 vs. 2.9 mg/dL), the percentage of non-shock (33% vs. 20%), the percentage of non-using mechanical ventilator (15% vs. 5%). The results showed significant differences between the two groups. The abnormal serum creatinine while admitted to SICU, the interval of SICU admitted to on-CRRT ≦2 days and no mechanical ventilator using at pre on-CRRT, they had higher survival rate. Conclusion: The study found that elder male patients and APACHEⅡscore≧20 had higher risk to acute renal injury/failure. Evaluating patients comprehensively and implementing CRRT at the right moment were important in clinical practice, and then allowed survivors have a higher chance of recovering renal function.