臺灣博碩士論文加值系統

目的：
探討BZD類藥物過量病人（BZDs overdose）須入加護病房（ICU）的臨床預測因子及其在急診時的臨床特徵。

方法:
本研究是一個回顧性病例對照研究，納入了2012年7月1日至2015年6月30日到本院急診年紀大於18歲的急性BZDs過量患者。我們收集了人口統計資料、過往病史，入急診時的初始表現， BZDs過量使用的藥物分類與原因及其併發症，分析到急診之後的動向與結果，預估進入ICU的臨床預測因子。

結果：
本研究共納入140例，平均年齡為51.3±19.1歲（平均值加減標準差），BZDs過量使用的最常見原因是企圖自殺(Suicide attempt)。最常見的潛在疾病是嚴重抑鬱症或躁鬱症 (bipolar disorder)，佔所有研究患者的85.7％。企圖自殺佔所有研究患者的84.3％（118/140），其中41.4％（58/140）有既往企圖自殺病史。59.3％（83/120）需要住院，其中20例（14.3％）ICU入院，3例患者死亡（2.1％，3/140）。須入住ICU的臨床預測因子為肺炎以及在急診中有使用flumazenil.

結論：
BZDs過量患者的死亡率很低，但入住ICU的患者死亡率仍然很高（15％）。建議急診醫師更多關注在這些病人中有肺炎以及在急診中有使用flumazenil，並留意其過往病史是否有自殺未遂情況以及有嚴重抑鬱/雙相情感障礙。醫院醫療團隊的介入，具有強制力來預防這些病人再次發生BZDs過量使用的情況

Objective:
To investigate the clinical predictors for intensive care unit (ICU) admission for patients with benzodiazepine (BZD) overdose and their clinical characteristics in the emergency department (ED).

Methods:
A retrospective case-control study of acute BZD overdose patients aged ≥ 18 years presenting to the ED in our hospital from July 1st, 2012 through June 30th, 2015 were enrolled in this study. We collected demographic information on underlying diseases, initial presentations, causes and the classifications of BZD, complications, dispositions, and outcomes. Analyses were conducted among subgroups and were identified the possible predictive clinical factors determining ICU admission in these patients.

Results:
A total of 140 patients were enrolled in the study, with a mean age of 51.3±19.1 years (mean  SD) and female predominance with 2.59:1. The most common cause of BZD overdose was suicidal attempt. The most common underlying disease is major depression disease or bipolar disorder occupying 85.7% of all study patients. Suicide attempt accounted for 84.3% (118/140) of all study patients, among whom 41.4% (58/140) has previous history of suicide attempt. 59.3% (83/120) needed hospital admission, including 20 patients (14.3%) with ICU admission and a total three patients mortalities (2.1%, 3/140). Two clinical predictive factors of ICU admission were identified, including pneumonia and flumazenil use in ED

Conclusion:
The incidence of mortality in patients with BZD overdose is low, but all cause mortality remains high in those admitted to ICU (15%). Emergency physicians are suggested to pay more attentions on BZD overdose patients with suicidal attempt and major depression/bipolar disorder, who have pneumonia or flumazenil use in the ED. The incorporation of hospital healthcare team resource management in dealing with the recording, intervention, and prevention of these patients was mandatory to decrease repeat overdose, enhance care quality, and improve outcomes.

致謝 …………………………………………………………………….…. …..i
中文摘要………………………………………………………………...….ii- iii
英文摘要………………………………………………………………....…iv- v
目錄……………………………………………………………………..…...…vi
圖目錄…………………………………………………………………..…..…vii
表目錄 ………………………………………………………………..………viii
第一章 緒論………………………………………………………….….…1-3
第二章 方法………………………………………………………….………4
第一節研究設計………………………………………………….………5
第二節資料收集………………………………………………….….....5-6
第三節研究之擬訂 ………………………………………….….……..6-7
第四節統計分 …………………………………………………….….7-8
第三章 結果 ………………………………………………………….……...9
第一節 所有納入研究者之整體臨床表徵……………………...………10
第二節須入加護病房與普通病房及直接出院三組之比較…………10-12
第四章 討論……………………………………………………………….…13
第一節 研究主要發現及其他研究比較……………………………14-16
第二節 研究限制…………………………………………….…………17
第三節 結論……………………………………………….……………18
第五章 參考文獻………………………………………………..………..19-23
附錄……………………………………………………………….………...30-31
圖目錄
圖一 研究病患的流程圖………………………………………………24
表目錄
表一 病患特徵及分析……………………………………………….….…25

表二 加護病房與非加護病房病患比較分析……………………….….…26

表三 加護病房與一般病房及出院動向病患之比較分析………….….…27

表四 是否入住加護病房之邏輯式回歸分析預測因子………..……..…..28

表五 針對病房族群之邏輯式回歸分析是否入住加護病房預測因子..…29

1. Kyong YY, Park JT, Choi KH. Serial monitoring of sedation scores in benzodiazepine overdose. Am J Emerg Med 2014;32:1438.e5-6.
2. Sessler CN, Grap MJ, Ramsay MA. Evaluating and monitoring analgesia and sedation in the intensive care unit. Crit Care 2008;12 Suppl 3:S2.
3. Griffin CE 3rd, Kaye AM, Bueno FR, et al. Benzodiazepine pharmacology and central nervous system-mediated effects. Ochsner J 2013;13:214-223.
4. Prescott K, Stratton R, Freyer A, et al. Detailed analyses of self-poisoning episodes presenting to a large regional teaching hospital in the UK. Br J Clin Pharmacol 2009;68:260-268.
5. Longo LP, Johnson B. Addiction: Part I. Benzodiazepines--side effects, abuse risk and alternatives. Am Fam Physician 2000;61:2121-2128.
6. Berger A, Edelsberg J, Sanders KN, et al. Medication adherence and utilization in patients with schizophrenia or bipolar disorder receiving aripiprazole, quetiapine, or ziprasidone at hospital discharge: a retrospective cohort study. BMC Psychiatry 2012 Aug 2;12:99. doi: 10.1186/1471-244X-12-99.
7. Novack V, Jotkowitz A, Delgado J, et al. General characteristics of hospitalized patients after deliberate self-poisoning and risk factors for intensive care admission. Eur J Intern Med 2006;17:485-489.
8. Höjer J, Baehrendtz S, Gustafsson L. Benzodiazepine poisoning: experience of 702 admissions to an intensive care unit during a 14-year period. J Intern Med 1989;226:117-122.
9. Hu YH, Chou HL, Lu WH, et al. Features and prognostic factors for elderly with acute poisoning in the emergency department. J Chin Med Assoc 2010;73:78-87.
10. Vukcević NP, Ercegović GV, Segrt Z, et al. Benzodiazepine poisoning in elderly. Vojnosanit Pregl 2016;73:234-238.
11. Henderson A, Wright M, Pond SM. Experience with 732 acute overdose patients admitted to an intensive care unit over six years. Med J Aust 1993;158:28-30.
12. Vancayseele N, Portzky G, van Heeringen K. Increase in self-injury as a method of self-harm in Ghent, Belgium: 1987-2013. PLoS One 2016;11(6):e0156711.
13. Afshari R, Majdzadeh R, Balali-Mood M. Pattern of acute poisonings in Mashhad, Iran 1993-2000. J Toxicol Clin Toxicol 2004;42:965-975.
14. Karbakhsh M, Zandi NS. Pattern of poisoning in the elderly: an experience from Tehran. Clin Toxicol (Phila) 2008;46:211-217.
15. Jacobsen D, Frederichsen PS, Knutsen KM, et al. A prospective study of 1212 cases of acute poisoning: general epidemiology. Hum Toxicol 1984;3:93-106.
16. Rahman A, Martin C, Graudins A, et al. Deliberate self-poisoning presenting to an emergency medicine network in South-East melbourne: a descriptive study. Emerg Med Int 2014;2014:461841. doi: 10.1155/2014/461841. Epub 2014 Jun 12.
17. Hendrix L, Verelst S, Desruelles D, et al. Deliberate self-poisoning: characteristics of patients and impact on the emergency department of a large university hospital. Emerg Med J 2013;30(1):e9. doi: 10.1136/emermed-2011-201033. Epub 2012 Feb 10.
18. Aguilera P, Garrido M, Lessard E, et al. Medication overdoses at a public emergency department in Santiago, Chile. West J Emerg Med 2016;17:75-80.
19. Neale G, Smith AJ. Self-harm and suicide associated with benzodiazepine usage. Br J Gen Pract 2007;57:407-408.
20. Krisanda TJ. Flumazenil: an antidote for benzodiazepine toxicity. Am Fam Physician 1993;47:891-895.
21. Chern CH, Chern TL, Wang LM, et al. Continuous flumazenil infusion in preventing complications arising from severe benzodiazepine intoxication. Am J Emerg Med 1998;16:238-241.
22. Shih HI, Lin MC, Lin CC, et al. Benzodiazepine therapy in psychiatric outpatients is associated with deliberate self-poisoning events at emergency departments-a population-based nested case-control study. Psychopharmacology (Berl) 2013;229:665-671.
23. Sivilotti ML. Flumazenil, naloxone and the 'coma cocktail'. Br J Clin Pharmacol 2016;81:428-436.
24. Ngo AS, Anthony CR, Samuel M, et al. Should a benzodiazepine antagonist be used in unconscious patients presenting to the emergency department? Resuscitation 2007;74:27-37.
25. Thomson JS, Donald C, Lewin K. Use of flumazenil in benzodiazepine overdose. Emerg Med J 2006;23:162.
26. Seger DL. Flumazenil--treatment or toxin. J Toxicol Clin Toxicol 2004;42:209-216.
27. Huang HH, Fan JS, Chen YC, et al. Coordination between medical care providers and information technology resources in the management of patients with suicide attempts attending the emergency department. J Chin Med Assoc 2014;77:275-276.