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研究生:林澂
研究生(外文):Chen Lin
論文名稱:外科重症病人的短期和長期存活之評估--心率變異度之線性與非線性分析
論文名稱(外文):Short-term and Long-term Outcome Assessment in Surgical Critically-Ill Patients -- Linear and Nonlinear analyses of Heart Rate Dynamics
指導教授:高毓儒
指導教授(外文):Yu-Ru Kou
學位類別:碩士
校院名稱:國立陽明大學
系所名稱:生理學研究所
學門:醫藥衛生學門
學類:醫學學類
論文種類:學術論文
論文出版年:2004
畢業學年度:92
語文別:中文
論文頁數:74
中文關鍵詞:外科重症病人加護病房心率變異度預後評估
外文關鍵詞:surgical critically-ill patientsintensive care unitheart rate variabilityoutcome assessment
相關次數:
  • 被引用被引用:6
  • 點閱點閱:271
  • 評分評分:
  • 下載下載:54
  • 收藏至我的研究室書目清單書目收藏:2
發展出可信度高並且可以準確地評估疾病嚴重程度的工具,對臨床上每日要作的治療決策有相當大的幫助,線性與非線性心率變異度的分析方法已經被應用在評估許多不同疾病的疾病嚴重程度和預後,但是在加護病房中相關此類分析應用的研究卻並不是很清楚,因此本研究的目的在探討:(1)線性(包含SDNN、pNN20、頻譜分析)和非線性(包含Poincaré plot圖、detrended fluctuation analysis)的分析方法是否能應用於評估外科加護病人的疾病嚴重程度變化。 (2)比較傳統最常被使用的Acute Physiology and Chronic Health Evaluation (APACHE) II評分系統和這些心率變異度的預測準確性是否有差別。(3)現有心率變異度參數和APACHE II評分系統,對外科重症病人,一年內長期預後是否有所相關。結果顯示存活組病人在SDNN、pNN20、極低頻區、低頻區的功率、低頻/高頻功率的比值,在最後一天都明顯的比死亡組高,而且低頻/高頻功率的比值在存活組的病人明顯的上升而死亡組的病人則相反,並且這些結果在死亡組的病人和APACHE II改變的趨勢相同,在量化Poincaré plot圖的分析上,SD2在最後一天,存活組的病人明顯的高於死亡組的病人,在死亡組病人的SD1/SD2的比值,在最後一天不但明顯的高於存活組,而且相較於第一天也明顯的上升,在detrended fluctuation analysis方面,測量短時間內長期相關性的參數DFAα1在轉入加護病房的第一天存活組的病人就明顯的高於死亡組的病人,而較長時間內長期相關性的參數DFAα2相較於第一天有顯著的下降,不論是DFAα1或DFAα2,死亡組的病人在最後一天都明顯的低於存活組的病人。更進一步,我們發現,DFAα1這偵測短時間內是否有長期相關性的參數,在轉入加護病房的24小時內,對預後評估的準確率比其餘現有心率變異參數和APACHE II高,並且對一年內外科病人的預後評估也有顯著的效果。由上述的結果,我們作以下的結論(1)不論是線性或非線性的分析方法都可以提供臨床一個替代的,可評估外科重症病人疾病嚴重程度的指標。(2) Poincaré plot可做為一個連續性、非侵入性,並且可將心跳變異圖像化的一個臨床監測工具。(3) 不管是評估短期或長期的預後,DFAα1都是所有參數中(APACHE II和心率變異分析),準確率最高的。
It is important to develop a reliable and accurate classification system to assess the severity of illness and to aid the clinical decision-making. Various linear and nonlinear analyses of heart rate variability (HRV) have been applied in the prediction of clinical outcomes of many diseases. However, relative few studies have focused on the comprehensive evaluation of these analyses in patients in intensive care unit (ICU). The purposes of this study were 1) to compare the applicability of linear (SDNN, pNN20, and power spectrum analysis) and nonlinear (Poincaré plot analysis, Detrended fluctuation analysis) indexes of HRV in the progression of severity and mortality prediction in sepsis, 2) to compare the prognostic power of HRV and the Acute Physiologic, Age and Chronic Health Evaluation II (APACHE II; a traditional assessment system), and 3) to find out the correlation of long-term survival time with these indexes in the surgical ICU patients. Our results showed that the SDNN (p<0.001), pNN20 (p=0.033), VLF (p<0.001), LF (p<0.001) power, and LH ratio (p<0.001) in the survival group patients were significantly higher than those in the expired group 24 hours before discharge from or dead in SICU. While the LH ratio was markedly increased (p=0.04) in the survival group, it markedly decreased (p<0.001) in the expired group; these results corresponded to those of APACHE II scores. In the Poincaré plot analysis, the SD2 of the survival group was significantly higher than that in the expired group. The SD1/SD2 ratio was greater in the expired group 24 hours before discharging from SICU. On the other hand, SD1/SD2 ratio increased significantly (p<0.001) in the expired group. In detrended fluctuation analysis, the short-term long-range correlation exponent, α1, was the only HRV index that was significantly higher (p=0.016) in the survival group compare with the expired group at the first 24 hours after admission to the SICU. The long-term correlation property, α2, reduced largely (p<0.001) in the expired group and both α1 and α2 were greater (p<0.001) in survival group than in expired group 24 hours before discharging from SICU. Furthermore, the short-term long-range correlation exponent, α1, had better sensitivity, specificity, positive predictive accuracy, and negative predictive accuracy than APACHE II scoring system as well as other HRV parameters in the first 24 hours after admission to surgical ICU. We concluded that 1) both the linear and nonlinear analyses of HRV can be used as a tool to measure the severity and outcome of surgical critically-ills, 2) the poincaré plot may provide a visualized, non-invasive, continuous and real-time HRV monitoring for ICU patients, and 3) the detrended fluctuation analysis predicts the short- and long-term outcome more informative and earlier than other indexes in the surgical critically-ills.
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