关于重症感染和感染性休克病人ICU治疗时间的影响因素分析
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摘要
目的
我院ICU收治大量的重症感染患者,其ICU治疗时间长短不等,分析不同住院时间的重症感染病人的若干指标,如:氧合指数、APACHE-Ⅱ评分、乳酸水平、机械通气时间、DIC和MODS的发病率,找到一个或数个影响重症感染病人ICU治疗时间长短的危险因素,并应用于临床,判断重症感染病人的预后。
方法
收集2006.6—2007.9中国医科大学附属第一医院ICU收治的腹部术后重症感染患者共51人,以ICU住院时间(T)为标准,T≤48小时为短期组,T＞48小时为长期组。观察氧合指数、APACHE-Ⅱ评分、机械通气时间、住院时间、乳酸水平、DIC和MODS的发病率。建立SPSS数据库,并应用SPSS15.0统计软件进行数据检验与统计学分析。两组计量资料比较采用两独立样本的t检验,数据以两组均数±标准差(x±s)表示。计数资料的比较采用x~2检验,数据以各组相应的发病率表示。
结果
ICU治疗时间超过48小时的患者与小于48小时的患者的基础疾病,患者年龄分布差异没有统计学意义,氧合指数、APACHE-Ⅱ评分、乳酸水平、DIC的发生率、机械通气时间、住院时间及MODS的发生率差异有统计学意义。ICU治疗时间超过48小时的患者,机械通气时间明显延长(P＜0.01),发生MODS的发病率高,总的住院时间长。随着APACHE-Ⅱ评分增高,ICU治疗时间延长。
结论
1.本研究显示对于腹部感染术后患者转入ICU后,氧合指数、APACHE-Ⅱ评分、乳酸水平、机械通气时间影响ICU治疗时间。是影响患者ICU治疗时间的预示因素。
2.对于ICU治疗时间超过48小时的患者,应针对MODS病死危险因素进行积极处理和干扰,可能是降低MODS病死率的关键。
Objective
To determine the relationship between PaO_2/FiO_2.APACHE-Ⅱscore.Serum Lactate.duration of ventilatory support.incidence of DIC.incidence of MODS and the duration of ICU,to find the risk factor which can influence the duration of ICU,and apply it to the clinic medicine to shorten the duration of ICU.
Methods
We studied 51 septic patients after abdominal operation who were admitted to ICU between June 2006 and September 2007.Patients were divided into short and long group according to the duration of ICU.Datas were collected as following: PaO_2/FiO_2.APACHE-Ⅱscore.Serum Lactate.duration of ventilatory support.incidence of DIC.incidence of MODS and the duration of hospitalization.Values were presented as mean±standard deviation(x±s),statistical analysis of the data was accomplished by using student's t test and x~2 analysis.A statistically significant difference was indicated by a P value(P＜0.05).
Result
There was significant difference in PaO_2/FiO_2.APACHE-Ⅱscore.Serum Lactate. the incidence of DIC.the duration of ventilatory support.the,duration of hospitalization and the incidence of MODS between the two groups patients.Patients with over 48 hours duration of ICU had significant longer time than did those less than 48 hours(P＜0.01).And they had higher incidence of MODS.
Conclusion
1.This study supports the concept that PaO2/FiO2.APACHE-Ⅱscore.Serum Lactate. the duration of ventilatory support,can influence the duration of ICU when the patients with abdominal operation were adimitted to ICU.They are the reliable predictors of the duration of ICU.
2.We must provide aggressive therapy for the patients who will stay in ICU for more than 48 hours,maybe which is the key to reduce the mortality of MODS.
我院ICU收治大量的重症感染患者,其ICU治疗时间长短不等,分析不同住院时间的重症感染病人的若干指标,如:氧合指数、APACHE-Ⅱ评分、乳酸水平、机械通气时间、DIC和MODS的发病率,找到一个或数个影响重症感染病人ICU治疗时间长短的危险因素,并应用于临床,判断重症感染病人的预后。
方法
收集2006.6—2007.9中国医科大学附属第一医院ICU收治的腹部术后重症感染患者共51人,以ICU住院时间(T)为标准,T≤48小时为短期组,T＞48小时为长期组。观察氧合指数、APACHE-Ⅱ评分、机械通气时间、住院时间、乳酸水平、DIC和MODS的发病率。建立SPSS数据库,并应用SPSS15.0统计软件进行数据检验与统计学分析。两组计量资料比较采用两独立样本的t检验,数据以两组均数±标准差(x±s)表示。计数资料的比较采用x~2检验,数据以各组相应的发病率表示。
结果
ICU治疗时间超过48小时的患者与小于48小时的患者的基础疾病,患者年龄分布差异没有统计学意义,氧合指数、APACHE-Ⅱ评分、乳酸水平、DIC的发生率、机械通气时间、住院时间及MODS的发生率差异有统计学意义。ICU治疗时间超过48小时的患者,机械通气时间明显延长(P＜0.01),发生MODS的发病率高,总的住院时间长。随着APACHE-Ⅱ评分增高,ICU治疗时间延长。
结论
1.本研究显示对于腹部感染术后患者转入ICU后,氧合指数、APACHE-Ⅱ评分、乳酸水平、机械通气时间影响ICU治疗时间。是影响患者ICU治疗时间的预示因素。
2.对于ICU治疗时间超过48小时的患者,应针对MODS病死危险因素进行积极处理和干扰,可能是降低MODS病死率的关键。
Objective
To determine the relationship between PaO_2/FiO_2.APACHE-Ⅱscore.Serum Lactate.duration of ventilatory support.incidence of DIC.incidence of MODS and the duration of ICU,to find the risk factor which can influence the duration of ICU,and apply it to the clinic medicine to shorten the duration of ICU.
Methods
We studied 51 septic patients after abdominal operation who were admitted to ICU between June 2006 and September 2007.Patients were divided into short and long group according to the duration of ICU.Datas were collected as following: PaO_2/FiO_2.APACHE-Ⅱscore.Serum Lactate.duration of ventilatory support.incidence of DIC.incidence of MODS and the duration of hospitalization.Values were presented as mean±standard deviation(x±s),statistical analysis of the data was accomplished by using student's t test and x~2 analysis.A statistically significant difference was indicated by a P value(P＜0.05).
Result
There was significant difference in PaO_2/FiO_2.APACHE-Ⅱscore.Serum Lactate. the incidence of DIC.the duration of ventilatory support.the,duration of hospitalization and the incidence of MODS between the two groups patients.Patients with over 48 hours duration of ICU had significant longer time than did those less than 48 hours(P＜0.01).And they had higher incidence of MODS.
Conclusion
1.This study supports the concept that PaO2/FiO2.APACHE-Ⅱscore.Serum Lactate. the duration of ventilatory support,can influence the duration of ICU when the patients with abdominal operation were adimitted to ICU.They are the reliable predictors of the duration of ICU.
2.We must provide aggressive therapy for the patients who will stay in ICU for more than 48 hours,maybe which is the key to reduce the mortality of MODS.
引文
1 Philip s.Epidemidogy of multiple organ dysfunction syndrome in critical surgical illness[j].Surgical Injection.2000;(3):173-186
2 Bilevicius E,Dragasavac D.Multiple organ failure in septic patients[J].Braz J infect Dis.2001;5(3):103-110
3 凌平 孙大治,APACHEⅡ评分在外科重症监护病房中的应用价值 重庆医学 2006(07)
4 Derek C,David T,Walter T,et al,Short-time and long term outcome prediction with the acute physiology and chronic health evaluation Ⅱ system after orthotopic liver transplantation.Crit Care Me.2000;28(1):150-156
5 王勇强 孙丽莹等,APACHEⅡ评分等因素对肝移植后ICU停留时间影响 天津医药,2002;30(8):457-458
6 刘效辉 APACHEⅡ和APACHEⅢ在肝切除手术中的应用 重庆医科大学学报 2007
7 管向东,陈娟,欧阳彬等,失血性低血容量休克氧动力学和血乳酸的临床评估作用[J].中国实用外科杂志,2000;20(7):401-403
8 Gruttadauria S.Marino IR,et al Correlation between peri-operative serum lactate levels and outcome in pancreatic resection for pancreatic cancer preliminary report J Exp Clin Cancer Res.2002 Dec;21(4):539-45
9 Donnino MW.Miller T.Goyal N.et al Effective lactate clearance is associated with improved outcome in post-cardiac arrest patients.Resuscitation.2007 Nov;75(2):229-34
10 Abramson D,Scalea TM et al.Lactate clearance and survival following injury J Trauma.1993 Oct;35(4):584-8
11 徐向东 早期乳酸清除率评估外科严重脓毒症预后的临床价值研究 中国实用外科杂志,2007;27(12):969-970
12 Nguyen HB,Rivers EP,Knoblich BP,et al.Early lactate clearance is associated with improved outcome in severe sepeis and septic shock[J].Crit Care Med.2004;32(8):1637-1642
13 Sivula M,Tallgren M et al.Modified score for disseminated intravascular coagulation in the critically ill.Intensive Care Med.2005 Sep;31(9):1209-14
14 Sakr Y,Reinhart K,Hagel S,Antithrombin levels;morbidity;and mortality in a Surgical intensive care unit.Anesth Analg 2007 Sep;105(3):715-23
15 熊丽丽,魏文宁 抗凝血酶活性检测在诊断弥散性血管内凝血的意义 第四届全国临床检验学术会议 论文会编,2006.
16 Angstwurm MW,Dempfle CE,Spannagl M.New disseminated intravascular coagulation score:A useful tool to predict mortality in comparison with Acute physiology and Chronic Health Evaluation Ⅱ and logistic Organ Dysfunction scores.Crit Care Med.2006 Feb;34(2):314-20
17 彭炎强 重症监护室患者并发急性肾功能衰竭的临床特点及预后评估 中国实用内科杂志 2007;11(22)
18 Macintyre NR,Cook DJ,Ely EW,et al.Evidence-based guidelines for weaning and discontinuing ventilatory support.Chest.2001;120:375s-395s
19 Marshall JC.SIRSand MOPS:what is their relevance to the science and practice of intensive care? shock.2000;14:586-589
20 Deitch EA,Xu D,Kkaise VL.Role of the gut in the development of injury and shock induced SIRS and MODS:the gutlymph hypothesis,a review.Front Bisci.2006;11:520-528
21 Knotzer H,Pajk w,Dunser MW,et al.Regional microvascular function and vascular reactivity in patients with different degrees of multiple organ dysfunction syndrome.Analg.2006;102:1187-1193
1 Joseph D,et,al J Trauma.l992;32:714
2 Jornow MH,et al.New horizons. 1995;4(3):488
3 Nadia Smail,MD. Resuscitation after Uncontrolled Venous Hemorrhage:Does Increased Resuscitation Volume Improve Regional Perfusion? The Journal of Trauma. Vol 44.NO.4,1998
4 Peter Carrillo,MD.Prolonged Severe Hemorrhagic Shock and Resuscitation in Rats Does Not Cause Subtle Brain Damage.The Journal of Trauma: Injury, Infection ,and critical Care.l998;Vol.45.N0 2.
5 Capone AC.lmproved outcome with fluid restriction in treatment of uncontrolled hemorrhagic shock. J of Amerian college Of surgeon. (180).1995;49-56
6 Frank Smith, et al.Traumatic brain injury,hemorrhagic shock,and fluid resuscitation effect on intracranial pressure and brain compliance.J Neurosurg 79 421-427 1993.
7 Louis Riddez.MD.Central and Regional Hemodynamics during Crystalloid Fluid Therapy after Uncontrolled Intra-abdominal Bleeding.The Journal of Trauma:Injury,Infection,and critical care 1998 Vol 44 No.37
8 Aulel,KL,et al.Pediatr Neurel,1995;12:323
9 Kelly MD.Hyperemia following traumic brain injury:relationship to intracranial hypertensing and outcome.J Neurosurg. 1996 (85) :762-771
10 Bouma GJ,muizelaer Jp:Relationship between cardia output and cerebral blood flow in patients with and with impaired autoregulation. F Neurosurg. 1996 (73) :368-374
11 Muizeluar JRmarmawnA,edsalles AAF,et al.J Neurosurg 71:63-71 1989
12 Robcrtson CS,contant CF,Gokarlan zL,et al.J Neurol Neurosury Rsy chiatry 55.594-603 1992
13 牟朝晖等 重度颅脑损伤后液体疗法的探讨 浙江医学2001,(23)6。
14 Taylor G,et al.J Dediatric surgery,1996;31(1):65.
15 Peter.Hor, Hypertonic,Saline solution for control of elevated intracranial pressure in patients with elevated intracranial pressure in patients with exhausted response To mannitol and barbiturates .Neurological research,1999,Volume21,December 758-763
16 Finfers, Bellom OR, Boyce N, etal A comparison of calbum in and saline for fluid resuscitation in the intensive care unit N Eng I J Med,2004;7:2256
17 Singbartl k,Innerhofer P,Radvan T,et al.Hemostasis and hemodilution:a quantitative mathematical guide for clinical practice J Anesth Analg 2003;96(4):929-935
18 邓群等。颅脑损伤合并出血性休克的液体复苏探讨 中国急救医学 2002,11(22):657-658
19 徐军等。四种溶液对失血性休克犬血流动力学的影响 中华急诊医学 2007(01)
20 Christer Eker,MD.Improved outcome after severe head injury with a New therapy based on principles for brain volume regulation and Preserved microcirculation.Crit Care Med 1998Vol.26,No.11
21 失血性休克液体复苏的新认识 实用全科医学 2007(03)
2 Bilevicius E,Dragasavac D.Multiple organ failure in septic patients[J].Braz J infect Dis.2001;5(3):103-110
3 凌平 孙大治,APACHEⅡ评分在外科重症监护病房中的应用价值 重庆医学 2006(07)
4 Derek C,David T,Walter T,et al,Short-time and long term outcome prediction with the acute physiology and chronic health evaluation Ⅱ system after orthotopic liver transplantation.Crit Care Me.2000;28(1):150-156
5 王勇强 孙丽莹等,APACHEⅡ评分等因素对肝移植后ICU停留时间影响 天津医药,2002;30(8):457-458
6 刘效辉 APACHEⅡ和APACHEⅢ在肝切除手术中的应用 重庆医科大学学报 2007
7 管向东,陈娟,欧阳彬等,失血性低血容量休克氧动力学和血乳酸的临床评估作用[J].中国实用外科杂志,2000;20(7):401-403
8 Gruttadauria S.Marino IR,et al Correlation between peri-operative serum lactate levels and outcome in pancreatic resection for pancreatic cancer preliminary report J Exp Clin Cancer Res.2002 Dec;21(4):539-45
9 Donnino MW.Miller T.Goyal N.et al Effective lactate clearance is associated with improved outcome in post-cardiac arrest patients.Resuscitation.2007 Nov;75(2):229-34
10 Abramson D,Scalea TM et al.Lactate clearance and survival following injury J Trauma.1993 Oct;35(4):584-8
11 徐向东 早期乳酸清除率评估外科严重脓毒症预后的临床价值研究 中国实用外科杂志,2007;27(12):969-970
12 Nguyen HB,Rivers EP,Knoblich BP,et al.Early lactate clearance is associated with improved outcome in severe sepeis and septic shock[J].Crit Care Med.2004;32(8):1637-1642
13 Sivula M,Tallgren M et al.Modified score for disseminated intravascular coagulation in the critically ill.Intensive Care Med.2005 Sep;31(9):1209-14
14 Sakr Y,Reinhart K,Hagel S,Antithrombin levels;morbidity;and mortality in a Surgical intensive care unit.Anesth Analg 2007 Sep;105(3):715-23
15 熊丽丽,魏文宁 抗凝血酶活性检测在诊断弥散性血管内凝血的意义 第四届全国临床检验学术会议 论文会编,2006.
16 Angstwurm MW,Dempfle CE,Spannagl M.New disseminated intravascular coagulation score:A useful tool to predict mortality in comparison with Acute physiology and Chronic Health Evaluation Ⅱ and logistic Organ Dysfunction scores.Crit Care Med.2006 Feb;34(2):314-20
17 彭炎强 重症监护室患者并发急性肾功能衰竭的临床特点及预后评估 中国实用内科杂志 2007;11(22)
18 Macintyre NR,Cook DJ,Ely EW,et al.Evidence-based guidelines for weaning and discontinuing ventilatory support.Chest.2001;120:375s-395s
19 Marshall JC.SIRSand MOPS:what is their relevance to the science and practice of intensive care? shock.2000;14:586-589
20 Deitch EA,Xu D,Kkaise VL.Role of the gut in the development of injury and shock induced SIRS and MODS:the gutlymph hypothesis,a review.Front Bisci.2006;11:520-528
21 Knotzer H,Pajk w,Dunser MW,et al.Regional microvascular function and vascular reactivity in patients with different degrees of multiple organ dysfunction syndrome.Analg.2006;102:1187-1193
1 Joseph D,et,al J Trauma.l992;32:714
2 Jornow MH,et al.New horizons. 1995;4(3):488
3 Nadia Smail,MD. Resuscitation after Uncontrolled Venous Hemorrhage:Does Increased Resuscitation Volume Improve Regional Perfusion? The Journal of Trauma. Vol 44.NO.4,1998
4 Peter Carrillo,MD.Prolonged Severe Hemorrhagic Shock and Resuscitation in Rats Does Not Cause Subtle Brain Damage.The Journal of Trauma: Injury, Infection ,and critical Care.l998;Vol.45.N0 2.
5 Capone AC.lmproved outcome with fluid restriction in treatment of uncontrolled hemorrhagic shock. J of Amerian college Of surgeon. (180).1995;49-56
6 Frank Smith, et al.Traumatic brain injury,hemorrhagic shock,and fluid resuscitation effect on intracranial pressure and brain compliance.J Neurosurg 79 421-427 1993.
7 Louis Riddez.MD.Central and Regional Hemodynamics during Crystalloid Fluid Therapy after Uncontrolled Intra-abdominal Bleeding.The Journal of Trauma:Injury,Infection,and critical care 1998 Vol 44 No.37
8 Aulel,KL,et al.Pediatr Neurel,1995;12:323
9 Kelly MD.Hyperemia following traumic brain injury:relationship to intracranial hypertensing and outcome.J Neurosurg. 1996 (85) :762-771
10 Bouma GJ,muizelaer Jp:Relationship between cardia output and cerebral blood flow in patients with and with impaired autoregulation. F Neurosurg. 1996 (73) :368-374
11 Muizeluar JRmarmawnA,edsalles AAF,et al.J Neurosurg 71:63-71 1989
12 Robcrtson CS,contant CF,Gokarlan zL,et al.J Neurol Neurosury Rsy chiatry 55.594-603 1992
13 牟朝晖等 重度颅脑损伤后液体疗法的探讨 浙江医学2001,(23)6。
14 Taylor G,et al.J Dediatric surgery,1996;31(1):65.
15 Peter.Hor, Hypertonic,Saline solution for control of elevated intracranial pressure in patients with elevated intracranial pressure in patients with exhausted response To mannitol and barbiturates .Neurological research,1999,Volume21,December 758-763
16 Finfers, Bellom OR, Boyce N, etal A comparison of calbum in and saline for fluid resuscitation in the intensive care unit N Eng I J Med,2004;7:2256
17 Singbartl k,Innerhofer P,Radvan T,et al.Hemostasis and hemodilution:a quantitative mathematical guide for clinical practice J Anesth Analg 2003;96(4):929-935
18 邓群等。颅脑损伤合并出血性休克的液体复苏探讨 中国急救医学 2002,11(22):657-658
19 徐军等。四种溶液对失血性休克犬血流动力学的影响 中华急诊医学 2007(01)
20 Christer Eker,MD.Improved outcome after severe head injury with a New therapy based on principles for brain volume regulation and Preserved microcirculation.Crit Care Med 1998Vol.26,No.11
21 失血性休克液体复苏的新认识 实用全科医学 2007(03)