单中心危重患者菌血症临床分析重症甲型流感病毒性肺炎患者救治经验

发布时间：2018-01-31 23:53

本文关键词： 重症患者菌血症临床预后甲型流感病毒肺炎急性呼吸窘迫综合征机械通气　出处：《山东大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的:自2014年1月至2015年12月,对齐鲁医院重症医学科一病区和二病区血微生物阳性标本进行回顾分析。方法:观察并记录菌血症患者的年龄、性别、基础疾病、血病原微生物类型、血管内侵袭性操作、人工气道、机械通气、营养支持途径、ICU住院时间(ICULOS)、总住院时间及预后。结果:共计219例患者入选本研究。其中ICU一病区患者130例(59.4),ICU二病区89例(40.6%)。男性 160例(73.1%),女性59例(26.9),年龄59.1±18.6岁。脑部外科病变46例(21.0%),腹腔病变46例(21.0%),神经肌肉病变34例(15.6%),大面积烧伤和复杂皮肤软组织感染30例(13.79%),COPD与重症肺炎24例(10.9%),骨科手术13例(5.9%),慢性肾功能衰竭11例(5.0%),其他15例(6.9%)。121例(55.3%)患者血培养为革兰阳性球菌,80例患者血培养为革兰阴性杆菌(36.5%),18例患者(8.2%)为念珠菌。位居前五位细菌分别为表皮葡萄球菌31例(14.2%),鲍曼不动杆菌27例(12.3%,人型葡萄球菌亚种23例(10.5%),屎肠球菌20例(9.1%),肺炎克雷伯菌16例(7.3%)。219例重症患者血培养阳性,其中119例(54.3%)患者仅一次血培养阳性,57例(26.0%)两次血培养阳性,23例患者(10.5%)三次血培养阳性,15例患者(6.8%)四次血培养阳性,1例患者(0.5%)5次血培养阳性,4例患者(1.8%)6次血培养阳性。锁骨下静脉置管90例(41.1%),股静脉置管51例(23.3%),颈内静脉置管16例(7.3%),PICC 14例(6.4%)。其中,83例(37.9%)患者存在动脉穿刺置管,气管插管与气管切开197例(90.0%),机械通气178例(81.3)。禁饮食12例(5.5%),49例(22.4)实施全胃肠外营养(TPN),158例(72.1%)实施肠内营养为主的营养支持治疗。126例(57.5%)痊愈出院,67例(30.6%)死亡,自动出院26例(11.9%)。ICU LOS 26.5±23.3天,总住院时间36.1±31.2天。结论:血培养标本采集不规范是革兰阳性球菌阳性率高主要因素之一。年龄和总住院时间延长是菌血症患者预后不良危险因素。目的:探讨重症甲型流感病毒性肺炎救治经验。方法:分析6例重症甲型流感病毒核酸阳性肺炎患者临床资料和治疗经过。结果:3例为新型H1N1甲型流感,3例未做进一步核酸亚型鉴定,患者均接受奥司他韦治疗。3例合并侵袭性肺曲霉菌病,4例接受有创机械通气,2例发生气胸。3例因急性肾损伤接受持续性血液滤过治疗,4例机械通气患者继发呼吸相关性肺炎,5例死亡。结论:罹患严重基础疾病、使用糖皮质激素、深镇静、继发肺部感染导致重症甲型流感病毒性肺炎高死亡率。
[Abstract]:Objective: from January 2014 to December 2015, blood microorganism positive specimens in the first and second areas of intensive care department of Qilu Hospital were retrospectively analyzed. Methods: the age of patients with bacteremia was observed and recorded. Sex, basic diseases, microorganism type of blood pathogen, invasive intravascular operation, artificial airway, mechanical ventilation, nutritional support pathway, ICU hospitalization time. Total hospitalization time and prognosis. Results: a total of 219 patients were included in this study. There were 89 cases of ICU in the second ward of ICU. There were 160cases of male and 59 cases of female. The age was 59.1 卤18.6 years old. 46 cases of brain surgical lesions were involved in 21. 0%, 46 cases of abdominal lesions were 21. 0%, and 34 cases of neuromuscular lesions were 15. 6%. Large area burn and complicated skin and soft tissue infection in 30 cases were compared with COPD and severe pneumonia in 24 cases (10.9%) and orthopedic surgery in 13 cases (5.9%). Eleven patients with chronic renal failure were diagnosed as Gram-positive cocci. The other 15 patients were found to be Gram-positive cocci. The blood culture of 80 patients was Gram-negative bacilli and 18 patients were Candida. The top five bacteria were Staphylococcus epidermidis in 31 cases and Staphylococcus epidermidis in 14.2). 27 cases of Acinetobacter baumannii, 23 cases of human staphylococcus subspecies, and 20 cases of Enterococcus faecium were found. 16 cases of Klebsiella pneumoniae were positive in blood culture of 7.3% and 219 cases of severe cases, among which 119 cases were positive for blood culture only once. 57 cases (26.0) two times positive and 23 cases (10.5) three times were positive and 15 cases were positive (6.8)) four times of blood culture were positive. One case was positive for 5 times of blood culture, 4 cases were positive for 6 times of blood culture, 90 cases had subclavian vein catheterization (41.1%), 51 cases had femoral vein tube (23.3%). Internal jugular vein catheterization was performed in 16 patients with PICC (14 patients with PICC, including 83 patients with internal jugular vein catheterization). Tracheal intubation and tracheotomy were performed in 197 cases (90.0%), mechanical ventilation in 178 cases (81.3%), diet in 12 cases (5.55%). Total parenteral nutrition (TPN) was performed in 158 cases (72.1) and enteral nutrition was given as the main nutritional support therapy. 126 cases (57.5%) were discharged from hospital. 67 cases died and 26 cases were discharged from hospital automatically. The LOS in ICU was 26. 5 卤23. 3 days. Total hospitalization time was 36.1 卤31.2 days. Conclusion:. The nonstandard collection of blood culture specimens is one of the main factors of high positive rate of Gram-positive cocci. Age and length of total hospital stay are the risk factors for poor prognosis of patients with bacteremia. Methods: the clinical data and treatment of 6 patients with severe influenza A virus nucleic acid positive pneumonia were analyzed. No further identification of nucleic acid subtype was made in 3 cases. All the patients were treated with oseltamivir in 3 cases with invasive pulmonary aspergillosis and 4 cases received invasive mechanical ventilation. 2 cases suffered pneumothorax. 3 cases received continuous hemofiltration because of acute renal injury. 5 cases died of respiratory associated pneumonia secondary to mechanical ventilation. Conclusion: severe basic diseases, glucocorticoid is used. Deep sedation, secondary pulmonary infection leading to severe influenza A virus pneumonia high mortality.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R515.3;R563.1

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