老年多器官衰竭的临床研究

发布时间：2018-05-05 15:40

本文选题：老年多器官衰竭 + 临床特征　；参考：《苏州大学》2013年硕士论文

【摘要】：目的 1.本研究通过对老年多器官衰竭（Mutiple organ failure in the elderly，MOFE）病例及对照病例的临床特征、生存时间、危险因素的调查研究，，为临床早期诊断、治疗和有效的二级预防、三级预防提供科学依据。对象与方法 1.对象：从通辽老年病医院老干部病房1998年9月至2008年8月期间门诊就诊及住院治疗的病人中选取符合MOFE组和对照组入选标准的患者为研究对象。 2.方法：参照MOFE的诊断标准及病例-对照研究的设计要求，我们采用1:3配比病例对照研究和随访研究的方法，分别对研究对象进行一般情况（年龄、性别），基础疾病的情况（数量、病种、轻重程度），临床表现（症状、体征、实验室检查、辅助检查等）、序贯发生器官衰竭的时间、序贯发生器官衰竭的顺序、患者的生存时间、危险因素（诱因、疾病状态）等进行调查随访研究。 3.统计分析：全部数据用SAS9.13进行统计分析。定量资料用均数和标准差描述，定性资料用率及其95%可信区间描述；均衡性检验定量资料采用t检验，定性资料采用x2检验，当p值接近0.05时用Fisher确切概率法。衰竭器官分期资料的分析采用秩和检验。病例对照OR值及其95%可信区间的计算采用单因素和多因素条件Logistic回归分析。生存率的计算和生存曲线的制作采用乘积限法。生存时间用四分位法，老年多器官衰竭死亡与危险因素和慢性基础疾病的RR值及其95%可信区间计算均采用Cox回归分析。所有报告的P值均为双侧检验。结果本次研究我们共收集MOFE患者153人，调查随访后，发现死亡113人，存活40人。MOFE的生存率26.14%，病死率73.69%同时按照对照组的入选标准，随机选取459人做为对照组。研究发现，MOFE患者最少累及2个衰竭器官，最多累及8个衰竭器官，死亡病例平均累及4.25个衰竭器官，存活病例平均累及3个衰竭器官；存活病例衰竭器官的个数明显少于死亡病例衰竭器官的个数（P＜O.OOO)；所有MOFE患者不同衰竭器官临床分期之间构成比有明显差别（P＜O.OOO)。 MOFE序贯发生器官衰竭的时间间隔多在10天以内（66.01%）一般不超过1个月（19.61%）。MOFE首衰器官多见于肺脏（38.96%）、心脏（19.48%）、中枢神经系统（14.94%）、肾脏（10.39%）、胃肠道（8.44%）等，序贯顺序分布为：肺脏（42.9%）、心脏（40.9%）、肾脏（32.6%）、中枢神经系统（21.9%）、胃肠道（14.5%）等。 MOFE患者50%的生存时间为243天（69～601天）。不同首衰器官由短到长的生存时间分别为：肺脏26天、中枢神经系统42天、心脏623天、肾脏1106天。 MOFE发病前患者一般均存在2种或2种以上的慢性基础疾病，3～6种者约占76.47%；最多的患有11种基础疾病（0.65%）；易发疾病为：冠心病（69.93%）、高血压（55.56%）、多发性脑梗塞（49.02%）、慢性支气管（37.25%）、老年肺炎（33.99%）、糖尿病（1、2型）（24.84%）和动脉硬化性肾病（22.88%）。单因素分析结果显示：营养状态不良、免疫功能低下、精神障碍、肠道营养摄入障碍、环境气候的急剧变化、单一或多器官功能不全、感染、低T3综合症、电解质紊乱、酸碱失衡、低蛋白血症或低血糖、慢性贫血、心律失常、心肌缺血发作、出血性卒中、缺血性卒中手术或创伤、精神打击等18个危险因素的暴露率在MOFE组和对照组之间的差别有明显的统计学意义（P＜0.023～0.000），表明上述危险因素存在条件下，患者更易出现MOFE。而营养状态不良、免疫功能低下、肠道营养摄入障碍、环境气候的急剧变化、电解质紊乱、低蛋白血症或低血糖、慢性贫血、心肌缺血发作等8个危险因素的暴露率在MOFE患者死亡组和存活组之间的差别有明显的统计学意义（P＜0.04～0.000）。表明上述危险因素存在条件下，患者更易出现MOFE患者的死亡。为进一步探讨MOFE发生与危险因素（诱因）的关联程度，同时控制混杂因素，先进行单因素条件Logitic回归分析，对单因素有统计学意义因素，再进行多因素分析，结果最终进入多因素条件Logitic回归模型的变量为：免疫功能低下、肠道营养摄入障碍、感染、电解质紊乱。其OR及95%CI为：5.26（2.10～13.19）、8.09（2.73～23.96）、9.33（3.43～25.37）、28.75（5.58～148.11）。为探讨MOFE发生与危险因素（疾病状态）的关联程度，同时控制混杂因素，先进行单因素条件Logitic回归分析，对单因素有统计学意义因素，再进行多因素条件Logitic回归分析，结果最终进入模型的变量为：营养状态不良、精神障碍、慢性贫血、心律失常、心肌缺血发作、出血性脑卒中、手术或创伤、精神打击。其OR及95%C1为：3.48（1.73～6.97）、4.57（1.84～11.27）、12.16（4.70～31.48）、2.80（1.41～5.55）、2.45（1.29～4.74）、7.17（1.20～43.00）、3.75（1.37～10.26）、3.95（1.08～14.54）、7.84（1.71～36.00）。结论 MOFE发病前均患有2种以上基础疾病，最多患11种疾病，有某种诱因激发，以短时间序贯发生多个器官衰竭为特征，最多可累及8个衰竭器官，首衰器官分布以肺、心、中枢神经及肾占前四位。多发序贯顺序肺列第一位，心和肾脏列二、三位。有50%病人发病后平均生存243天。以肺和中枢为首衰器官生存时间最短。发现营养状态不良、免疫功能低下、精神障碍、肠道营养摄入障碍、感染、电解质紊乱、慢性贫血、心律失常、心肌缺血发作、出血性卒中、手术或创伤、精神打击等12个因素是MOFE发病的独立危险因素。
[Abstract]:objective
1. by investigating the clinical features, survival time and risk factors of Mutiple organ failure in the elderly (MOFE) cases and control cases, this study provides a scientific basis for early clinical diagnosis, treatment and effective two level prevention and three level prevention.
Object and method
1. subjects: selected patients from the MOFE and the control groups from September 1998 to August 2008 in the old cadre ward of the Tongliao geriatric hospital for the study and the control group.
The 2. method: referring to the diagnostic criteria of MOFE and the design requirements of case control study, we used a 1:3 matched case-control study and follow-up study to carry out the general situation (age, sex), the condition of the basic disease (quantity, disease, degree), clinical manifestation (symptoms, signs, laboratory examination, auxiliary examination). The time of sequential organ failure, the sequence of sequential organ failure, the patient's survival time, the risk factors (inducement, disease state), etc. were investigated and followed up.
3. statistical analysis: all data were analyzed by SAS9.13. Quantitative data were described with mean and standard deviation, qualitative data utilization and its 95% confidence interval; t test was used for quantitative data of equilibrium test. Qualitative data was tested by x2 test. The exact probability method of Fisher was used when the value of P was close to 0.05. The analysis of the staging data of the failure organs was adopted. The rank sum test. The case control OR value and the 95% confidence interval were calculated by single factor and multiple factor conditional Logistic regression analysis. The survival rate calculation and the survival curve were made by the product limit method. The survival time using the four subdivision method, the RR value of the death and risk factors and the slow basic diseases in the elderly and the 95% confidence interval meter. The Cox regression analysis was used. All the P values of the reports were bilateral tests.
Result
In this study, we collected 153 patients with MOFE. After the follow-up, we found that 113 people died, and the survival rate of 40 people was 26.14%. The fatality rate was 73.69% at the same time. At the same time, 459 people were randomly selected as the control group according to the standard of the control group. The study found that the patients with MOFE were least involved in 2 exhaustive organs, with the maximum of 8 exhaustion organs and the average death cases. 4.25 exhaustion organs were involved, and the survival cases involved an average of 3 exhaustion organs, and the number of failure organs in the survival cases was significantly less than that of the dead organ failure organs (P < O.OOO); the ratio of the clinical stages of all MOFE patients was significantly different (P < O.OOO).
The time interval between MOFE sequential organ failure is more than 10 days (66.01%) generally not more than 1 months (19.61%).MOFE first failure organs in the lung (38.96%), heart (19.48%), central nervous system (14.94%), kidney (10.39%), gastrointestinal (8.44%), and so on. The sequential distribution is lung (42.9%), heart (40.9%), kidney (32.6%), central nervous system System (21.9%), gastrointestinal tract (14.5%), etc.
The survival time of 50% of patients with MOFE was 243 days (69~601 days). The survival time of different first failure organs from short to long was 26 days in the lungs, 42 days in the central nervous system, 623 days in the heart, and 1106 days in the kidney.
Before MOFE, there were 2 or more than 2 chronic basic diseases, 3~6 of which accounted for 76.47%, and the most had 11 basic diseases (0.65%); the prone diseases were coronary heart disease (69.93%), hypertension (55.56%), multiple cerebral infarction (49.02%), chronic bronchitis (37.25%), senile pneumonia (33.99%), diabetes (24.84%) (24.84%) and movement. Arteriosclerotic nephropathy (22.88%).
The results of single factor analysis showed: poor nutritional status, low immune function, mental disorder, intestinal nutrition intake disorder, rapid changes in environmental climate, single or multiple organ dysfunction, infection, low T3 syndrome, electrolyte disorder, acid-base imbalance, hypoproteinemia or hypoglycemia, chronic anemia, arrhythmia, myocardial ischemia attack, bleeding The exposure rates of 18 risk factors, such as stroke, ischemic stroke surgery or trauma, and mental shock, were significant statistically significant between the MOFE group and the control group (P < 0.023 to 0), indicating that the patients were more susceptible to MOFE. and poor nutritional status, low immune function, intestinal nutrition intake disorder, and rings under the conditions of the above risk factors. The exposure rates of 8 risk factors, such as dramatic changes in climate, electrolyte disturbance, hypoproteinemia or hypoglycemia, chronic anemia, and myocardial ischemia, have significant statistical significance between the death and survival groups of MOFE patients (P < 0.04 to 0). Death.
In order to further explore the degree of association between MOFE and risk factors (inducement), and control confounding factors and advanced single factor conditional Logitic regression analysis, the single factor had statistical significance, and then multifactor analysis was carried out. The result of the final entry into multi factor conditional Logitic regression model was: low immune function and enteral nutrition intake. OR and 95%CI were 5.26 (2.10 to 13.19), 8.09 (2.73 to 23.96), 9.33 (3.43 to 25.37), 28.75 (5.58 to 5.58).
To investigate the degree of association between MOFE and risk factors (disease status), and control confounding factors and advanced single factor conditional Logitic regression analysis, the single factor had statistical significance, and then multiple factor conditional Logitic regression analysis was carried out. The results of the final entry into the model were: malnutrition, mental disorder, chronic anemia, Arrhythmia, ischemic attack of myocardium, hemorrhagic stroke, operation or trauma, and mental shock. Its OR and 95%C1 are 3.48 (1.73 to 6.97), 4.57 (1.84 to 11.27), 12.16 (4.70 to 31.48), 2.80 (1.41 to 5.55), 2.45 (2.80).
conclusion
Before the onset of MOFE, there were more than 2 kinds of basic diseases, with a maximum of 11 diseases, a certain inducement, multiple organ failure in a short time sequence, and a maximum of 8 exhaustion organs. The first organ of the first failure was the first four in the lungs, heart, central nerve and kidney. The first sequence of the lung, the two of the heart and the kidneys, three. 50% The average survival time of the patients was 243 days after the onset of the disease. The survival time was the shortest with the lung and the central nervous system. The 12 factors, such as poor nutritional status, low immune function, mental disorder, intestinal nutrition intake disorder, infection, electrolyte disorder, chronic anemia, arrhythmia, myocardial ischemia, hemorrhagic stroke, operation or trauma, mental shock, were MOFE An independent risk factor for the disease.

【学位授予单位】：苏州大学
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R592

【参考文献】