脓毒症并发肝损伤患者临床特征及其危险因素分析
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摘要
目的分析脓毒症患者并发肝损伤的影响因素,为其早期防治提供科学依据。方法 2013年1月～2017年12月收治的117例脓毒症患者,并发肝损伤58例,未并发肝损伤59例。采用Logistic回归分析脓毒症并发肝损伤的影响因素。结果在117例脓毒症患者中,原发感染灶主要为腹腔(48.7%)、呼吸系统(32.5%)、皮肤软组织(7.7%)、泌尿系统(6.0%)、血液系统(1.7%)、心血管系统(0.9%)、消化系统(0.9%)、中枢系统(0.9%)和纵膈(0.9%);肝损伤患者年龄为(61.0±14.9)岁,显著大于未并发肝损伤患者的【(52.6±18.0)岁,P<0.01】,住ICU时间为【9(5,12)】d,显著长于未并发肝损伤患者的【4(4,10)d,P<0.01】,SOFA评分为(8.7±2.4),显著大于无肝损伤患者的【(7.1±2.2),P<0.01】,APACHE Ⅱ评分为(21.9±6.4),显著大于无肝损伤患者的【(18.4±6.0),P<0.01】;在58例肝损伤患者中,呈高胆红素型21例,高转氨酶型24例,混合型13例,不同型肝损伤患者血清C-反应蛋白水平差异具有统计学意义(P<0.05),混合型病死率为53.8%,显著高于高胆红素型(9.6%)或高转氨酶型【(33.3%),P<0.05】;多因素分析显示年龄和APACHE Ⅱ评分为脓毒症患者发生肝损伤的独立危险因素。结论脓毒症患者年龄越大,APACHEⅡ评分越高,发生肝损伤的可能性越大,而混合型肝损伤患者预后差,应加强防治。
Objective To investigate the clinical features and risk factors of liver injuries in patients with sepsis. Methods A retrospective analysis was performed in 117 patients with sepsis between 2013 and 2017. Out of them,58 were complicated by liver injury. The Logistic regression analysis was applied to explore the risk factors for sepsis-associated liver injury. Results In this series,the primary infection foci included abdomen(48.7%),respiratory system(32.5%),skin(7.7%),urinary system(6.0%),blood(1.7%),cardiovascular system(0.9%),gut(0.9%),central nervous system(0.9%) and mediastina(0.9%);the age of patients with liver injuries was(61.0±14.9) yr,significantly older than 【(52.6±18.0)yr,P<0.01】 in patients without,ICU stay was 【9(5,12)】 d,much longer than 【4(4,10)d,P<0.01】,SOFA score was(8.7±2.4),significantly higher than 【(7.1±2.2),P<0.01】,and APACHE Ⅱ score was(21.9±6.4),significantly higher than 【(18.4±6.0),P<0.01】 in patients without;out of 58 patients with liver injuries,it presented as hyperbilirubinemia in 21,elevated serum ALT levels in 24 and mixed in13,serum C-reaction protein levels in patients with different types of liver injuries were statistically different(P<0.05),and the mortality in patients with mixed liver injuries was 53.8%,much higher than 9.6% in with hyperbilirubinemia or 33.3% in with elevated serum ALT levels(P<0.05);multivariate analysis showed than the age and APACHE Ⅱ score were the independent risk factors for liver injuries in patients with sepsis. Conclusion The older the patient with sepsis and the higher the APACHEⅡ score are,the more chance the likelihood of liver damage occur in patients with sepsis,which might take into consideration in clinical practice and deal with properly in time.
Objective To investigate the clinical features and risk factors of liver injuries in patients with sepsis. Methods A retrospective analysis was performed in 117 patients with sepsis between 2013 and 2017. Out of them,58 were complicated by liver injury. The Logistic regression analysis was applied to explore the risk factors for sepsis-associated liver injury. Results In this series,the primary infection foci included abdomen(48.7%),respiratory system(32.5%),skin(7.7%),urinary system(6.0%),blood(1.7%),cardiovascular system(0.9%),gut(0.9%),central nervous system(0.9%) and mediastina(0.9%);the age of patients with liver injuries was(61.0±14.9) yr,significantly older than 【(52.6±18.0)yr,P<0.01】 in patients without,ICU stay was 【9(5,12)】 d,much longer than 【4(4,10)d,P<0.01】,SOFA score was(8.7±2.4),significantly higher than 【(7.1±2.2),P<0.01】,and APACHE Ⅱ score was(21.9±6.4),significantly higher than 【(18.4±6.0),P<0.01】 in patients without;out of 58 patients with liver injuries,it presented as hyperbilirubinemia in 21,elevated serum ALT levels in 24 and mixed in13,serum C-reaction protein levels in patients with different types of liver injuries were statistically different(P<0.05),and the mortality in patients with mixed liver injuries was 53.8%,much higher than 9.6% in with hyperbilirubinemia or 33.3% in with elevated serum ALT levels(P<0.05);multivariate analysis showed than the age and APACHE Ⅱ score were the independent risk factors for liver injuries in patients with sepsis. Conclusion The older the patient with sepsis and the higher the APACHEⅡ score are,the more chance the likelihood of liver damage occur in patients with sepsis,which might take into consideration in clinical practice and deal with properly in time.
引文
[1]张蓉,李灵丰,张兵,等.异甘草酸镁联合谷胱甘肽治疗脓毒血症并发肝功能损害45例临床观察.实用肝脏病杂志,2013,18(5):460-461.
[2]张丽娜,王秋阳,宋岩.多烯磷脂酰胆碱治疗脓毒血症患者对肝脏的保护作用.实用肝脏病杂志,2014,15(4):360-360.
[3]Marshall JC.The liver in sepsis:shedding light on the cellular basis of hepatocyte dysfunction.Crit Care,2013,17(3):153-154.[4]Yan J,Li S,Li S.The role of the liver in sepsis.Int Rev Immunol,2014,33(6):498-510.
[5]马晓春.应提高对脓毒症肝损伤的认识.中华危重病急救医学,2013,25(4):198-200.
[6]Singer M,Deutschman CS,Seymour CW,et al.The third international consensus definitions for sepsis and septic shock(sepsis-3).JAMA,2016,315(8):801-810
[7]Kobashi H,Toshimori J,Yamamoto K.Sepsis-associated liver injury:incidence,classification and the clinical significance.Hepatol Res,2013,43(3):255-266.
[8]Stearnskurosawa DJ,Osuchowski MF,Valentine C,et al.The pathogenesis of sepsis.Annu Rev Pathol,2013,6(6):19-48.
[9]Bernal W.The liver in systemic disease:sepsis and critical illness.Clin Liver Dis,2016,7(4):88-91.
[10]Lelubre C,Vincent JL.Mechanisms and treatment of organ failure in sepsis.Nat Rev Nephrol,2018,8(3):53-65.
[11]Andrade KQD,Moura FA,Santos JMD,et al.Oxidative stress and inflammation in hepatic diseases:therapeutic possibilities of N-acetylcysteine.Int J Mol Sci,2015,16(12):30269-30308.
[12]Cheung WK,Chau LS,Mak II,et al.Clinical management for patients admitted to a critical care unit with severe sepsis or septic shock.Intens Crit Care Nur,2015,31(6):359-365.
[13]Chaari A,Abdel HK,Bousselmi K,et al.Pancreatic injury inpatients with septic shock:a literature review.World J Gastrointest Oncol,2016,8(7):526-531.
[14]Sadaka F,Ethmaneabouelmaali C,Cytron MA,et al.Predicting mortality of patients with sepsis:a comparison of APACHE IIand APACHE III scor ing systems.J Clin Med Res,2017,9(11):907-910.
[15]Moseson EM,Zhuo H,Chu J,et al.Intensive care unit scoring systems outperform emergency department scoring systems for mortality prediction in critically ill patients:a prospective cohort study.J Intensive Care,2014,2(1):1-10.
[16]中国医师协会急诊医师分会.中国急诊感染性休克临床实践指南.中华急诊医学杂志,2016,25(3):193-206.
[17]张曦文,谢剑锋,蔡施霞,等.全身性感染相关肝功能衰竭研究进展.中华外科杂志,2014,52(6):455-457.
[18]刘军.全身性感染免疫功能监测研究进展.中华医学杂志,2017,97(21):1677-1860.
[19]师灵灵,韩艳秋,任慧娟,等.脓毒症的病理生理机制研究进展.中华医院感染学杂志,2016,26(8):1914-1916.
[20]Gaieski DF,Edwards JM,Kallan MJ,et al.Benchmarking the incidence and mortality of severe sepsis in the United States.Crit Care Med,2013,41(5):1167-1174.
[21]Seymour CW,Liu VX,Iwashyna TJ,et al.Assessment of clinical criteria for sepsis:for the third international consensus definitions for sepsis and septic shock(sepsis-3).JAMA,2016,315(8):762-774.
[22]Liu K,Ogura T,Nakamura M,et al.Early mobilization in the acute phase of sepsis and septic shock improves patient outcomes.Crit Care Med,2018,46(4):705-718.
[2]张丽娜,王秋阳,宋岩.多烯磷脂酰胆碱治疗脓毒血症患者对肝脏的保护作用.实用肝脏病杂志,2014,15(4):360-360.
[3]Marshall JC.The liver in sepsis:shedding light on the cellular basis of hepatocyte dysfunction.Crit Care,2013,17(3):153-154.[4]Yan J,Li S,Li S.The role of the liver in sepsis.Int Rev Immunol,2014,33(6):498-510.
[5]马晓春.应提高对脓毒症肝损伤的认识.中华危重病急救医学,2013,25(4):198-200.
[6]Singer M,Deutschman CS,Seymour CW,et al.The third international consensus definitions for sepsis and septic shock(sepsis-3).JAMA,2016,315(8):801-810
[7]Kobashi H,Toshimori J,Yamamoto K.Sepsis-associated liver injury:incidence,classification and the clinical significance.Hepatol Res,2013,43(3):255-266.
[8]Stearnskurosawa DJ,Osuchowski MF,Valentine C,et al.The pathogenesis of sepsis.Annu Rev Pathol,2013,6(6):19-48.
[9]Bernal W.The liver in systemic disease:sepsis and critical illness.Clin Liver Dis,2016,7(4):88-91.
[10]Lelubre C,Vincent JL.Mechanisms and treatment of organ failure in sepsis.Nat Rev Nephrol,2018,8(3):53-65.
[11]Andrade KQD,Moura FA,Santos JMD,et al.Oxidative stress and inflammation in hepatic diseases:therapeutic possibilities of N-acetylcysteine.Int J Mol Sci,2015,16(12):30269-30308.
[12]Cheung WK,Chau LS,Mak II,et al.Clinical management for patients admitted to a critical care unit with severe sepsis or septic shock.Intens Crit Care Nur,2015,31(6):359-365.
[13]Chaari A,Abdel HK,Bousselmi K,et al.Pancreatic injury inpatients with septic shock:a literature review.World J Gastrointest Oncol,2016,8(7):526-531.
[14]Sadaka F,Ethmaneabouelmaali C,Cytron MA,et al.Predicting mortality of patients with sepsis:a comparison of APACHE IIand APACHE III scor ing systems.J Clin Med Res,2017,9(11):907-910.
[15]Moseson EM,Zhuo H,Chu J,et al.Intensive care unit scoring systems outperform emergency department scoring systems for mortality prediction in critically ill patients:a prospective cohort study.J Intensive Care,2014,2(1):1-10.
[16]中国医师协会急诊医师分会.中国急诊感染性休克临床实践指南.中华急诊医学杂志,2016,25(3):193-206.
[17]张曦文,谢剑锋,蔡施霞,等.全身性感染相关肝功能衰竭研究进展.中华外科杂志,2014,52(6):455-457.
[18]刘军.全身性感染免疫功能监测研究进展.中华医学杂志,2017,97(21):1677-1860.
[19]师灵灵,韩艳秋,任慧娟,等.脓毒症的病理生理机制研究进展.中华医院感染学杂志,2016,26(8):1914-1916.
[20]Gaieski DF,Edwards JM,Kallan MJ,et al.Benchmarking the incidence and mortality of severe sepsis in the United States.Crit Care Med,2013,41(5):1167-1174.
[21]Seymour CW,Liu VX,Iwashyna TJ,et al.Assessment of clinical criteria for sepsis:for the third international consensus definitions for sepsis and septic shock(sepsis-3).JAMA,2016,315(8):762-774.
[22]Liu K,Ogura T,Nakamura M,et al.Early mobilization in the acute phase of sepsis and septic shock improves patient outcomes.Crit Care Med,2018,46(4):705-718.