探討加護病房非計畫性氣管內管移除之概況與預測因子

The exploration and the predictors of the patients with unplanned extubation in intensive care units

目的：結果：探討加護病房非計劃性氣管內管移除（unplanned extubation，UE）之概況、預測因子與造成個案之影響，期能做為醫護團隊照顧的指引。方法：以回溯性個案對照研究法（case-control study）搜集南部某醫院成人加護病房2008年～2010年UE事件，個案數共160人。預測因子探討係擷取資料較完整的2010年度個案，UE個案數為54人，對照組為「計劃性」氣管內管移除（planned extubation，PE）個案，研究組與對照組個案數比為1：4，以性別和年齡作配對，再以簡單隨機抽樣方式找出216個對照組個案。結果：我們發現160人UE中，以自拔（131人，81.9％）、臥床休息狀態（142人，88.8％）發生機率較高，且高齡（平均年齡65.46±17.45歲）、男性122人（76.3％）、具中樞神經系統共病症（44人，27.5％）、清醒佔多數（111人，69.4％）；主護以N_2（54人，33.8％）居多、角落床位達半數（93床，58.1％）；緞帶膠固定佔多數（64人，40％）。有身體約束佔89人（55.6％），一半的身體約束技術不適當（50／89，56.1％）。發生UE後98.8％造成中度傷害，而38.8％個案重插管。2010年度之54位UE與隨機抽樣216個PE病人比較，UE之預測因子為躁動、有中樞神經系統共病症、管路移除前昏迷指數較低、以五分帶管路固定方式共4個變項。結論：須密切監控UE高危險個案，如躁動、有中樞神經系統共病症、昏迷指數較低、以五分帶管路固定之病患，並及早給予介入性措施，避免增加護理照顧的人力與時間，及醫療資源的耗費。

Objective: The purpose of this study was to explore the current condition, predictor and the consequence of unplanned extubation (UE) after endotracheal intubation, which may be used as a guide for further medical team care. Material & method: This is a retrospective case control study. A survey of 160 patients with UE was conducted within adult ICUs from 2008 to 2010 in a medical center in southern Taiwan. In a ratio one to four, we compared 54 patients of UE group with randomized 216 patients of planned extubation (PE) group as matching by sex and age in 2010. We wanted to survey the predictive factors of patients with UE. Results: In 160 patients with UE, most were self-removal (131/160, 81.9%), in bed rest status (142/160, 88.8%), elderly (with an average age of 65.46±17.45 years), male (122/160, 76.3%), with the co-morbidity of cerebrovascular accidence (44/160, 27.5%), and awake (111/160, 69.4%). The majority of the clinical ladder of nursing associatedwith UE was N2 (54/160, 33.8%). More than half of UE patients were located on the corner of unit (93/160, 58.1%). The most common material used to fix endotracheal tube was the adhesive ribbon (64/160, 40%). The physical restrains used in UE patients was 55.6% (89/160), and half of them were inappropriately restrained (50/89, 56.1%). There were about 98.8% of UE patients with moderate injury, and 38.8% of them needed to be re-intubated. As compared with PE patients, the factors predicted UE included: agitation, cerebrovascular accidence, lower consciousness level, and the way to fix endotracheal tube. Conclusion: It is mandatory to closely monitor the high risk patients with UE. Agitation, cerebrovascular accidence, lower consciousness level, and the way to fix endotracheal tube were the predictors of UE. The staffs should perform the intervention as early as possible to prevent the occurrence of UE and the unnecessary expenditure of extra care.