動脈導管置入在創傷後復甦的效益研究

Abstract

研究目的 台灣事故傷害為十大死因之一，其中交通事故及高處墜落佔七成。失血性休克為創傷患者常見且可預防的死亡原因，因此「黃金一小時」內準確的血壓評估和介入性治療對存活率至關重要。然而，現行的非侵入間歇性血壓監測(Non-invasive blood pressure monitoring)存在準確性及即時性不足的問題，可能延誤低血壓的辨識與處置。相比之下，動脈導管提供即時、連續的血壓監測，但其在急診創傷患者中的應用證據有限。本研究以前瞻性的前後期(before-after study)比較設計來探討動脈導管對創傷患者辨識低血壓及重大復甦事件(Major resuscitative event)的效益。

研究方法 本研究為前後對照研究，前期（2020年1月1號到12月31號）收集以非侵入性血壓監測之創傷患者資料；後期（2023年1月1號到2024年12月31號）則於雲林台大急診部，針對創傷患者置入動脈導管進行連續血壓監測。納入條件為年滿18歲且符合院內創傷啟動標準之患者，此啟動標準為急診科與創傷科共同訂⽴之標準，包含了⽣命徵象、創傷機轉、傷病部位和特殊病患狀況等四項指標，若有符合上述任⼀之狀況，則啟動創傷⼩組及創傷科醫師進⾏評估並納⼊研究收案。排除條件包含年齡小於18歲、孕婦、不願參與或無法取得知情同意，以及到院前創傷性心肺停止者。本研究之主要研究目標為探討創傷患者於急診暫留過程中，在置入動脈導管前後之重大復甦事件的偵測率，其定義如下：低血壓(收縮壓 < 90毫米汞柱)、任何升壓劑的使用、心肺停止、休克指數 (心跳/收縮壓) > 1，次要研究目標包含了：延長加護病房住院 (定義為大於6天)、30天內死亡率、急診暫留過程中的輸液和輸血總量。

研究結果 總共有339位患者納入進行分析，其中在研究前期有241位患者而在研究後期有98位患者，這些患者年紀的中位數為52歲且以男性為主(66.1%)。在研究後期患者重大復甦事件比例為51%，前期為20.7%，差異具統計顯著性（adjusted Odds Ratio, aOR = 3.7, p < 0.01）。其中，重大復甦事件中的收縮壓< 90毫米汞柱(aOR = 2.56, p = 0.02) 與休克指數>1具統計顯著差異(aOR = 4.92, p < 0.001)。次要指標中，延長加護病房住院、30天內死亡率及輸液總量在前後期無顯著差異。而紅血球輸注量於後期顯著增加（調整後平均差異：0.88單位，p =0.02）

研究結論 在本前瞻性(prospective)的前後對照(before-after study) 研究中發現，在置入動脈導管的創傷患者，可以增加重大復甦事件(major resuscitative event) 的偵測率，其中又以收縮壓< 90毫米汞柱與休克指數>1為主要有差異的事件。

Introduction Trauma-related injuries rank among the top ten causes of death in Taiwan, with traffic accidents and falls accounting for 70% of cases. Hemorrhagic shock is a common and preventable cause of death in trauma patients. Accurate blood pressure monitoring and timely interventions during the “golden hour” are critical for improving survival rates. However, the current standard of non-invasive, intermittent blood pressure (NIBP) monitoring has limitations in both accuracy and timeliness, potentially delaying the recognition and treatment of hypotension. In contrast, arterial catheterization offers real-time, continuous blood pressure monitoring, yet its clinical utility in emergency trauma settings lacks sufficient evidence. This study aimed to evaluate the efficacy of arterial catheterization in detecting hypotension and major resuscitative events (MRE) in trauma patients using a prospective, before-after study design.

Methods This before-after study included two phases: the before phase (January 1, 2020, to December 31, 2020) involved retrospective data collection from trauma patients monitored with NIBP; the after phase (January 1, 2023, to December 31, 2024) prospectively enrolled trauma patients at Yunlin National Taiwan University Hospital Emergency Department who underwent arterial catheterization for continuous blood pressure monitoring. Inclusion criteria were patients aged 18 or older meeting institutional trauma activation criteria, jointly established by the emergency and trauma teams, which included indicators such as vital signs, mechanisms of injury, injury location, and special patient conditions. Exclusion criteria included age below 18, pregnancy, refusal or inability to provide informed consent, and pre-hospital traumatic cardiac arrest. The primary outcome of the study was the detection rate of MRE, defined as the occurrence of any of the following during the emergency department observation period: systolic blood pressure < 90 mmHg, use of inotropic agents, in-hospital cardiac arrest, or a shock index (heart rate/systolic blood pressure) > 1. The secondary outcomes of the study included prolonged intensive care unit (ICU) stay (defined as > 6 days), 30-day mortality, and the total volume of fluid and blood transfusions administered during the emergency department observation period.

Results A total of 339 patients were enrolled; 241 in the before period and 98 in the after period. The median patient age was 52 years, and most were male (66.1%). In the after phase, the detection rate of MREs was 51%, compared to 20.7% in the before phase, a statistically significant difference (adjusted odds ratio [aOR] = 3.7, p < 0.01). Among MREs, systolic blood pressure < 90 mmHg (aOR = 2.56, p = 0.02) and shock index > 1 (aOR = 4.92, p < 0.001) showed significant improvement in detection. Secondary outcomes, including extended ICU stays, 30-day mortality, and total fluid infusion volume, showed no significant differences between phases. However, red blood cell transfusion volume was significantly higher in the after phase (adjusted mean difference: 0.88 units, p = 0.02).

Conclusion This prospective before-after study demonstrated that arterial catheterization improved the detection rate of MREs in trauma patients, particularly in identifying systolic blood pressure < 90 mmHg and shock index > 1. These findings support the potential value of arterial catheterization in enhancing trauma care in emergency settings.