臺灣博碩士論文加值系統

背景：對於加護病房的重症病人，有一些計分系統已被用來預測治療結果或死亡率，如急性生理和長期健康評估表II計分 (APACHE II score)、敗血症相關的器官衰竭評估計分 (SOFA score)、多重器官失調系統計分 (MODS score)、邏輯的器官失調系統計分 (LODS score)等。其他用來評估急症嚴重度的方法亦可用來預測治療結果或疾病導致的死亡，如社區型肺炎的肺炎嚴重度指數 (PSI)、院內型肺炎/呼吸器相關性肺炎的臨床肺部感染計分(CPIS)、急性胰臟炎的Ranson criteria。然而，這些方法通常過於繁瑣並且須監測許多因子。現今，仍沒有研究評估當以單一因子作為預測加護病房病人治療結果或住院死亡的臨床實用價值。
研究目的：本研究希望檢驗當以血清乳酸去氫酶濃度作為單一因子來預測內科加護病房重症病人治療結果或住院死亡的實用價值。
研究設計：本研究回溯性評核在2007年共一整年間，於中山醫學大學附設醫院內科加護病房住院的273位病患的醫療記錄。血清乳酸去氫酶跟C反應蛋白濃度如同急性生理和長期健康評估表II計分也被評核來檢驗重症病人治療結果和住院死亡。
結果：依據病患來源分析，普通病房轉入者比急診轉入者有統計學上顯著較高的血清乳酸去氫酶和C反應蛋白濃度，p=0.006，p=0.03；而急性生理和長期健康評估表II計分則沒有統計學上的差異，p=0.057。依據住院死亡結果分析，在死亡組比存活組有統計學上顯著較高的血清乳酸去氫酶濃度跟急性生理和長期健康評估表II計分 (p<0.001, p<0.001)，但血清C反應蛋白濃度在兩組之間並無統計學上顯著的的差異 (p=0.499)。在存活組方面，只有急性生理和長期健康評估表II計分顯示轉到呼吸照護中心組較轉到普通病房組病情在統計學上較為嚴重(p=0.008)。血清乳酸去氫酶和C反應蛋白濃度則無統計學上的差異(p=0.737, p=0.815)。在Pearson相關性分析的住院死亡結果，急性生理和長期健康評估表II計分有最強的相關性 (r=0.359)，乳酸去氫酶次之(r=0.218)，C反應蛋白則無法顯示(r=0.026)。而在Logistic迴歸分析也呈現同樣的結果。
結論：血清乳酸去氫酶濃度跟急性生理和長期健康評估表II計分在加護病房住院死亡組比存活組在統計學上都顯著較高。雖然急性生理和長期健康評估表II計分比血清乳酸去氫酶濃度在住院死亡有較高的相關性，當以血清乳酸去氫酶濃度做為住院死亡的單一預測因子，其結果是可以接受的。這個發現建議我們可以經由規則追蹤血清乳酸去氫酶濃度作為監測內科加護病房病患治療結果之簡單而實用的方法。

Background: Some scoring system have been used to predict the treatment outcome or mortality rate for the critically ill patients in the intensive care unit (ICU), such as acute physiology and chronic health evaluation II (APACHE II) score；sepsis-related organ failure assessment (SOFA) score；multiple organ dysfunction system (MODS) score、logistic organ dysfunction system (LODS) score. Other methods which are used to evaluate the severity of acute illness are also useful to predict the treatment outcome or disease-associated mortality, such as pneumonia severity index (PSI) for the community-acquired pneumonia；clinical pulmonary infection score (CPIS) for the nosocomial pneumonia/ ventilator- associated pneumonia, Ranson criteria for the acute pancreatitis。 However, these methods are usually complicated and need to monitor many factors. Nowadays, there was no study to evaluate clinically practical value when use a single factor to predict the treatment outcome or mortality for ICU patients.
Study objectives: In this study we wish to examine the practical value when serum level of lactate dehydrogenase (LDH) was used as a single factor to predict the treatment outcome or mortality for critically ill patients who were admitted to medical ICU.
Design and setting: We retrospectively reviewed medical records of 273 patients who were admitted to medical ICU in Chung-Shan University Hospital from the beginning to the end of 2007. The serum levels of LDH and C-reacting protein (CRP) as well as APACHE II score were reviewed and were used to examine the treatment outcome and mortality for these critically ill patients.
Results: By the difference of patient source, those patients who were transferred from ordinary ward had significantly higher serum levels of LDH and CRP than those from emergency room, p=0.006, p=0.03 respectively, but there was no statistic difference in APACHE II score, p=0.057. By the results of mortality, serum LDH level and APACHE II score were significantly higher in the mortality group than in the survival group (p&lt;0.001, p&lt;0.001), but there was no difference between these two groups in CRP (p=0.499). To the survivals, only APACHE II score were significantly higher in patients who were transferred to respiratory care center (RCC) than in patients who were referred to ordinary ward (p=0.008). There was no statistic difference in serum level of LDH and CRP (p=0.737, p=0.815). By the results of the Pearson correlation analysis for mortality, APACHE II score has the most strong correlation (r=0.359), and followed by LDH (r=0.218), but no correlation with CRP (r=0.026). The same results were also acquired from the Logistic regression analysis.
Conclusion: Both serum levels of LDH and APACHE II score were significantly higher in patients of ICU mortality than in survivals. Although APACHE II score had higher correlation with mortality than LDH, when used LDH as a singer predictor for mortality, the results were acceptable. These findings suggest that it is a simple and useful way in monitoring the outcome of ICU patients by regular follow-up of serum level of LDH.

目 錄
中文摘要.......................................................................................................1
英文摘要.......................................................................................................3
目錄...........................................................................................................6
表目錄.........................................................................................................8
圖目錄.........................................................................................................9
第一章 緒論..................................................................................................10
第一節 前言..................................................................................................10
第二節 研究背景與動機........................................................................................12
第三節 研究目的..............................................................................................13
第四節 名詞解釋..............................................................................................14
第五節 研究特色..............................................................................................19
第六節 研究架構..............................................................................................20
第二章 材料與方法............................................................................................23
第一節 研究對象..............................................................................................23
第二節 內科加護病房住院病患背景資料與分組....................................................................24
第三節 統計分析..............................................................................................25
第三章 研究結果分析..........................................................................................26
第一節 病患分組及血清乳酸去氫酶最初值、急性生理和長期健康評估表II計分、血清C反應蛋白最初值之分析.............26
第二節 乳酸去氫酶最初值、急性生理和長期健康評估表II、C反應蛋白最初值和內科加護病房住院死亡之相關性分析.......29
第四章 討論..................................................................................................30
第一節 研究討論..............................................................................................30
第二節 研究範圍及研究限制....................................................................................34
第五章 結論與建議............................................................................................35
第六章 參考文獻..............................................................................................36

表 目 錄
表 一 收案條件(Selection Criteria)...........................................................................39
表 二 臨床評估表(Case Report Form)...........................................................................40
表 三 內科加護病房全部患者之分析.............................................................................41
表 四 內科加護病房患者之分析—住院來源之比較(急診轉入組和普通病房轉入組).....................................42
表 五 內科加護病房患者之分析—治療結果之比較(存活組和死亡組).................................................43
表 六 內科加護病房患者之分析—治療結果之比較(轉到普通病房組和轉到呼吸照護中心組).............................44

圖 目 錄
圖 一 內科加護病房患者收案流程...............................................................................45
圖 二 內科加護病房患者分組流程...............................................................................46
圖 三 血清乳酸去氫酶最初值和治療結果盒狀圖比較...............................................................47
圖 四 急性生理和長期健康評估表II計分和治療結果盒狀圖比較.....................................................48
圖 五 血清C反應蛋白最初值和治療結果盒狀圖比較................................................................49
圖 六 乳酸去氫酶最初值、急性生理和長期健康評估表II、C反應蛋白最初值和內科加護病房住院死亡之Pearson相關性分析.50
圖 七 血清乳酸去氫酶最初值和內科加護病房住院死亡之Logistic迴歸分析...........................................51
圖 八 急性生理和長期健康評估表II計分和內科加護病房住院死亡之Logistic迴歸分析.................................52
圖 九 血清C反應蛋白最初值和內科加護病房住院死亡之Logistic迴歸分析............................................53

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