急诊成人多器官功能障碍综合征的流行病学研究

发布时间：2018-05-19 19:25

本文选题：多器官功能障碍综合征 + 急诊　；参考：《山西医科大学》2014年硕士论文

【摘要】：目的了解急诊成人MODS的发病率、人口学特征、治疗和转归，分析其影响因素，并发掘MODS相关的预警指标，预期填补国内急诊MODS的流行病学空白，为提高对急诊成人MODS诊疗水平，改善预后提供理论依据。方法本研究采用横断面整群抽样的方法，前瞻性、多中心临床研究。选取16家三级甲等医院的急诊科，随机选择2012年中的12个调查点，每个调查点为24小时，收集病例资料共67例，收集包括人口学资料、生命体征、实验室检查结果、危重病程度评分、治疗及转归。以患者发病后出现功能障碍的器官≥2个纳入。各个器官/系统具体标准为：呼吸以PaO2/FiO2＜300；循环以收缩压＜80mmHg；肾脏以血清肌酐＞100μmol/L；肝脏以血清总胆红素＞20μmol/L；凝血以血小板＜120×109/L；神经以格拉斯哥昏迷评分＜15；胃肠以肠鸣音减弱。以Marshall标准中每个单一器官得分大于或等于3作为该器官功能衰竭的标准，胃肠道以麻痹性肠梗阻或应激性溃疡出血为衰竭标准。临床资料以盲法收集，录入数据库。应用统计软件包SPSS19.0进行分析MODS的发病率、病死率、危重程度评分、治疗及危险因素。结果在16家三甲医院急诊科12个时间段内，共收集13901例患者，排除年龄＜18岁患者288例及数据记录不完整患者165例，共纳入13448例。其中诊断为MODS的患者共67例，男35例，，女32例，年龄范围20~93岁，平均年龄为57.13±16.8。本研究急诊成人MODS的发病率为5.0‰。总的住院病死率为62.7%，全部死亡患者中男性患者占54.8%，女性患者占45.2%，χ2=0.278，P＞0.05，两组之间差异无统计学意义。感染、休克、创伤、心肺复苏术后、重症胰腺炎是MODS的主要原发病因。原发病因感染中肺部感染的比例高达74.3%，感染导致MODS的病死率最高为71.4%。死亡患者平均年龄为61.21±16.12，存活患者平均年龄为50.28±15.84，t=2.696，P＜0.01，差异有统计学意义。年龄≥60岁患者病死率85.7%，年龄＜60岁患者病死率为14.3%，χ2=20.06，P＜0.01，差异有统计学意义。有既往慢性病史的病死率为76.2%，无既往病史的病死率为23.8%，两者差异有统计学意义（χ2=20.01，P＜0.01）。单个器官或系统功能障碍的发生率最高的为肺82.1%，其次为心脏61.2%。其中病死率最高的受累器官为肺58.2%。最先受损器官是肺的患者为52例，占77.6%。MODS患者受累器官数量2个的死亡率为34.8%，累及3个器官死亡率为62.5%，累及4个及以上器官的死亡率为85.7%，其占全部MODS患者受累器官的发生率的比例最高41.8%。随器官功能障碍数量的增加，病死率显著升高（P＜0.05）。随着APACHEⅡ、MODS评分增加，患者的死亡率显著增加（P＜0.01）。MODS患者在住院期间的均采用了抗感染及营养治疗。应用机械通气76.7%，连续性肾脏替代治疗23.9%，应用血管活性药物79.1%，应用糖皮质激素26.9%，均对病死率的影响无统计学差异（P＞0.05），但CRRT和糖皮质激素在一定程度上延长患者存活时间。结论我国成人急诊MODS的发病率为5‰，病死率为62.7%。MODS的主要致病因素是感染，以肺部感染为主。MODS的启动器官及最易受损器官是肺。连续性肾脏替代治疗、机械通气、血管活性药物及糖皮质激素未能降低MODS病死率。年龄（≥60岁）、既往慢性疾病、器官功能障碍数量、MODS评分和APACHEⅡ评分是MODS的死亡危险因素，年龄≥60岁、功能障碍器官的数量是影响MODS预后的独立危险因素。
[Abstract]:Objective to understand the incidence of MODS in emergency adults, demographic characteristics, treatment and prognosis, analyze the influencing factors and explore the early warning indicators related to MODS, and expect to fill the epidemiological gap of MODS in domestic emergency, so as to provide a theoretical basis for improving the level of diagnosis and treatment of MODS in emergency adults and improving the prognosis.
Methods a cross-sectional cluster sampling method was used, prospective, multicenter clinical study. The emergency department of 16 first class three grade hospitals was selected, and 12 survey sites in 2012 were selected randomly. Each survey was 24 hours, and 67 cases were collected, including demographic data, vital signs, laboratory examination results and critical illness degree. Score, treatment and outcome. The organs and organs, which had dysfunction after the onset of the disease, were more than 2. The specific standards of each organ / system were PaO2/FiO2 < 300, circulation with systolic pressure < 80mmHg; kidney with serum creatinine > 100 u mol/L; liver with serum total bilirubin > 20 mol/L; blood clotting with 120 x 109/L; nerves; The Glasgow coma score was less than 15; the gastrointestinal enteric sound was weakened. The standard of the organ failure was the score of each single organ in the Marshall standard or equal to 3 as a standard for the failure of the organ. The gastrointestinal tract was a standard of exhaustion with paralytic intestinal obstruction or stress ulcer bleeding. The clinical data were collected by blind method and entered into a database. The application of statistical software package SPSS19.0 The incidence, mortality, severity score, treatment and risk factors of MODS were analyzed.
Results in the 12 time period of emergency department of 16 third class hospital, 13901 patients were collected, 288 cases of age 18 year old patients and 165 cases of incomplete data records were excluded, and 13448 cases were included. Among them, 67 cases were diagnosed as MODS, male 35 cases, 32 women, age range 20~93 years, average age of 57.13 + 16.8. in the study of emergency adult MODS hair. The rate of disease was 5 per thousand. The total hospitalization mortality rate was 62.7%, the male patients accounted for 54.8% of all the deaths, 45.2% of the female patients, Chi 2=0.278 and P > 0.05. The difference between the two groups was not statistically significant. The severe pancreatitis was the main cause of MODS after the infection, shock, trauma, and cardiopulmonary resuscitation. The proportion of the primary causes of the infection of the lung was 74. .3%, the highest mortality rate of MODS was 61.21 + 16.12, the average age of the patients with 71.4%. was 50.28 + 15.84, t=2.696, P < 0.01, the difference was statistically significant. The mortality rate of patients aged 60 years old was 85.7%, the mortality rate of patients aged < 60 years old was 14.3%, 2=20.06, P < 0.01, the difference was statistically significant. The difference was statistically significant. The difference was statistically significant. The difference was statistically significant. There was a significant difference in the past. The fatality rate of sexual history was 76.2%, the mortality rate without previous medical history was 23.8%, the difference was statistically significant (x 2=20.01, P < 0.01). The highest incidence of single organ or system dysfunction was 82.1% of lung, followed by heart 61.2%. with the highest fatality rate, the first damaged organ of lung 58.2%. was 52 cases, accounting for 77. The death rate of 2 organs involved in.6%.MODS was 34.8%, the death rate of 3 organs was 62.5%, and the death rate of 4 or more organs was 85.7%. The highest rate of 41.8%. in all MODS patients was increased with the increase of organ dysfunction (P < 0.05). With APACHE II, MODS score The mortality of patients increased significantly (P < 0.01).MODS patients were treated with anti infection and nutritional therapy during hospitalization. Mechanical ventilation 76.7%, continuous renal replacement therapy 23.9%, vasoactive drugs 79.1%, and glucocorticoid 26.9% were applied to the mortality rate (P > 0.05), but CRRT and glucocorticoid Hormone prolongs the patient's survival to a certain extent.
Conclusion the incidence of MODS in adult emergency in China is 5 per thousand. The main pathogenic factor of 62.7%.MODS is infection. The starting organ of.MODS and the most vulnerable organ are lung. Continuous renal replacement therapy, mechanical ventilation, vasoactive drugs and glucocorticoid can not reduce the death rate of MODS. The number of organ dysfunction, the number of organ dysfunction, the MODS score and the APACHE II score are the risk factors for the death of MODS. The age is more than 60 years, and the number of functional organs is an independent risk factor for the prognosis of MODS.
【学位授予单位】：山西医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R459.7

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