河北省三级医院重症医学科脓毒症、脓毒症心肌抑制的流行病学调查

发布时间：2018-06-26 11:50

本文选题：重症医学科 + 脓毒症　；参考：《河北医科大学》2017年硕士论文

【摘要】：目的:脓毒症(Sepsis)在重症医学科(Intensive Care Unit,ICU)中非常常见,可导致严重脓毒症、脓毒症心肌抑制等严重并发症,是ICU病死率增加的主要原因,对人类健康产生巨大威胁,受到重症医学业内人士的广泛关注。本研究旨在观察河北省三级医院ICU脓毒症、脓毒症心肌抑制患者的患病率、病死率、人口学特点、感染特征,超声相关数据和预后情况等数据,分析探讨影响脓毒症及脓毒症心肌抑制的预后因素。为脓毒症、脓毒症心肌抑制的临床和基础研究提供重要的参考数据,提高相关医务工作者对脓毒症的认识、进一步了解其流行病学特征,填补脓毒症、脓毒症心肌抑制的流行病学空白,为提高脓毒症诊疗水平,改善预后提供理论依据。方法:本研究根据2012年SSC指南关于脓毒症的诊断标准,纳入了2016年5月至2016年9月河北省30家三级医院ICU的脓毒症患者,对其进行前瞻性、观察性研究。每家ICU均具备规范管理脓毒症及其并发症的能力。对入选的每位患者均进行超声心动图检查,应用Simpson’s法测出患者左室射血分数(LVEF),判断患者是否存在心肌抑制;录入患者的基本临床资料,包括姓名、性别、年龄、主要感染部位,机械通气时间,住ICU时间,28天预后情况;收集入科24小时内采集的血常规,电解质,肝肾功能,动脉血气分析,免疫功能检查等化验检查结果,包含了氧合指数(P/F)、血乳酸(Lac)、白细胞计数(WBC)、血清降钙素原(PCT)、C-反应蛋白(CRP)、血肌酐(Scr)以及肌钙蛋白I(Tn I)等多项指标;以入科24小时内指标最差值计算APACHE II、SOFA及MODS评分。所有数据根据28天预后情况分为脓毒症存活组和死亡组,心肌抑制存活组和死亡组。收集的数据由专人汇总后,统一录入电脑,采用SPSS22.0统计软件进行统计,分析其患病率、病死率、感染特点、预后及死亡危险因素等。结果:1本实验入选了5704名患者,排除拒绝参加本实验、超声显示不清者及中途退出者,最终共纳入4897例患者,根据2012年SSC指南中关于脓毒症的诊断标准,确诊为脓毒症患者1536例,患病率约为31.48%,28天病死率约为27.40%;其中严重脓毒症患者486例,患病率约为9.39%,28天病死率约为50.41%;脓毒症心肌抑制患者234例,患病率为4.79%,28天病死率为42.31%。2脓毒症患者平均年龄为69(60,79)岁。其中男性966人(63.6%),女性570人(36.4%),男性患者明显多于女性患者。APACHE II评分为19(14,25)、SOFA评分为8(6,12)、MODS评分为6(4,8)。脓毒症患者常见的前三位感染部位为肺部感染,腹腔感染,胸腔感染。其中肺部感染889人(57.8%),腹腔感染298人(19.4%),胸腔感染101人(6.6%),泌尿系感染98人(6.4%),胆系感染64人(4.2%),皮肤软组织感染43人(2.8%),盆腔感染16人(1.0%),中枢系统感染13人(0.8%),血行感染9人(0.6%),感染部位不确定者5人(0.3%)。脓毒症心肌抑制组患者平均年龄为70(63,80)岁,男性148人(63.25%),女性86人(36.75%),APACHE II评分为21(16,26)、SOFA评分为9(7,12)、MODS评分为6(4,9)。常见感染部位前三位为肺部感染、腹腔感染、泌尿系感染。其中肺部感染156人(66.7%)、腹腔感染35人(15.0%)、泌尿系感染14人(5.9%),胆系感染12人(5.1%),胸腔感染10人(4.3%),皮肤软组织感染6人(2.6%),中枢系统感染1人(0.4%)。3死亡组与存活组相比较脓毒症存活组与死亡组比较:死亡组患者的年龄、APACHE II评分、SOFA评分、MODS评分、Lac、Scr、WBC、PCT、CRP均高于存活组,差异具有统计学意义(P0.05);死亡组的氧合指数、LVEF、住ICU时间均少于存活组,差异具有统计学意义(P0.05);两组的Tn I与机械通气时间无统计学差异(P0.05)。脓毒症心肌抑制存活组与死亡组比较:死亡组患者年龄、APACHE II评分、SOFA评分、MODS评分、Lac、WBC、PCT、CRP均高于生存组,差异具有统计学意义(P0.05);存活组LVEF高于死亡组,差值具有统计学意义(P0.05);而Scr、氧合指数、住ICU时间、Tn I与机械通气时间两组并无统计学差异(P0.05)。4对脓毒症患者而言,单因素分析表明心肌抑制、年龄、APACHEⅡ评分、SOFA评分、MODS评分、LVEF、Lac、WBC、PCT、CRP、Scr、住ICU时间对其生存预后均有影响(P0.05)。多因素Logistic回归分析显示年龄、APACHE II评分、Lac、PCT是影响其预后的独立危险因素。脓毒症心肌抑制患者单因素分析显示年龄、APACHE II评分、SOFA评分、MODS评分、LVEF、Lac、WBC、PCT、CPR对生存预后产生影响,多因素分析影响预后的独立危险因素为APACHE II评分、PCT。结论:河北省脓毒症患者的发病较高,可达31.48%,是ICU病死率增加的主要原因,脓毒症心肌抑制患者死亡率高达近50%。脓毒症及脓毒症心肌抑制最常见的主要感染部位是肺部感染,腹腔感染。脓毒症心肌抑制不影响脓毒症患者的预后。年龄、APACHE II评分、Lac、PCT是影响脓毒症预后的独立危险因素。而APACHE II评分、PCT是影响脓毒症心肌抑制患者预后的独立危险因素。
[Abstract]:Objective: sepsis (Sepsis) is very common in the Intensive Care Unit (ICU), which can lead to severe sepsis, sepsis and myocardial inhibition. It is the main cause of the increase in the mortality of ICU and has a great threat to human health. It is widely concerned by the people in the intensive medicine industry. The aim of this study is to observe Hebei three The prevalence, mortality, demographic characteristics, infection characteristics, ultrasound related data and prognosis of patients with sepsis, sepsis, sepsis, sepsis, sepsis, sepsis, sepsis, sepsis and sepsis were analyzed to provide important reference data for the clinical and basic research of sepsis and sepsis cardiac arrest. To improve the awareness of sepsis by related medical workers, to further understand its epidemiological characteristics, to fill the epidemiological gap of sepsis and sepsis, and to provide a theoretical basis for improving the level of diagnosis and treatment of sepsis and improving the prognosis. Methods: according to the diagnostic criteria of sepsis in the south of SSC in 2012, this study was included in May 2016. A prospective, observational study of sepsis in ICU, a 30 grade three hospital in Hebei province in September 2016. Each ICU had the ability to regulate sepsis and its complications. Echocardiography was performed on each patient selected and the left ventricular ejection fraction (LVEF) was measured by Simpson 's method to determine whether the patient existed. Myocardial inhibition; the basic clinical data of the patients, including name, sex, age, main infection site, mechanical ventilation time, ICU time, 28 days' prognosis, blood routine, electrolyte, liver and kidney function, arterial blood gas analysis, immune function examination, including oxygen index (P/F), blood, were collected within 24 hours of admission to the Department. Lactic acid (Lac), leukocyte count (WBC), serum calcitonin (PCT), C- reactive protein (CRP), serum creatinine (Scr), and troponin I (Tn I) were used to calculate APACHE II, SOFA, and score. All data were divided into the survival group and the death group of the sepsis according to the 28 day prognosis. The data collected from the death group were collected by the special person, unified into the computer, and used the SPSS22.0 statistics software to analyze its prevalence, mortality, infection characteristics, prognosis and death risk factors. Results: 1 experiments were carried out in 5704 patients, excluding the refusal to participate in the actual test, the unclear ultrasound and the midway exit, and finally a total of 4 897 patients, according to the diagnostic criteria of sepsis in the 2012 SSC guide, confirmed 1536 cases of sepsis, the prevalence rate was about 31.48%, and the 28 day fatality rate was about 27.40%, of which 486 cases were severe sepsis, the prevalence rate was about 9.39%, the mortality rate was about 50.41% in 28 days, 234 cases of sepsis cardiac arrest patients, the prevalence rate 4.79%, 28 day fatality rate. The average age of 42.31%.2 sepsis was 69 (60,79) years. Among them, 966 (63.6%) and 570 women (36.4%) were male. The male patients were significantly more than the female patients with.APACHE II score 19 (14,25), SOFA score 8 (6,12) and MODS score 6 (4,8). The most common sites of sepsis were pulmonary infection, abdominal infection, and thoracic infection. Pulmonary infection was 889 (57.8%), abdominal infection was 298 (19.4%), thoracic infection was 101 (6.6%), urinary tract infection was 98 (6.4%), biliary infection 64 (4.2%), cutaneous soft tissue infection 43 (2.8%), pelvic infection 16 (1%), central infection, infection sites, and sepsis myocardial inhibition group. The average age was 70 (63,80), male 148 (63.25%), 86 (36.75%), APACHE II score 21 (16,26), SOFA score 9 (7,12), and MODS score 6 (4,9). The first three sites of common infection were pulmonary infection, abdominal infection, urinary tract infection, 156 (66.7%) lung infection, peritoneal infection 35 (15%), urinary infection 14 Bile system infection 12 (5.1%), thoracic infection 10 (4.3%), skin soft tissue infection 6 (2.6%), central system infection 1 (0.4%).3 death group compared with the survival group compared with the survival group and the survival group compared with the death group: the age of the death group, APACHE II score, SOFA score, MODS score, Lac, Scr, WBC, PCT, CRP are higher than the survival group, the difference is statistically higher than the survival group, the difference has statistics Study significance (P0.05); the oxygenation index of the death group, LVEF, and ICU time were less than the survival group, the difference was statistically significant (P0.05); there was no statistical difference between the two groups of Tn I and mechanical ventilation time (P0.05). The mortality group was compared with the death group: the mortality group was compared with the death group: the age of the death group, APACHE II score, SOFA score, MODS score, Lac The difference was statistically significant (P0.05), the survival group LVEF was higher than the death group, the difference was statistically significant (P0.05), while Scr, oxygen index, ICU time, Tn I and mechanical ventilation time were not statistically different between two groups (P0.05).4 for patients with sepsis, single factor analysis showed that myocardial inhibition, age, APACHE II score, SOFA. Scores, MODS scores, LVEF, Lac, WBC, PCT, CRP, Scr, and ICU time had an impact on their survival (P0.05). Multiple factor Logistic regression analysis showed age, APACHE II score, which was an independent risk factor for its prognosis. WBC, PCT and CPR have an impact on survival prognosis. The independent risk factor of multiple factors analysis affecting prognosis is APACHE II score. PCT. conclusion: the incidence of sepsis in Hebei is higher, up to 31.48%, and the main cause of the increase of ICU mortality. The mortality of sepsis patients with cardiac arrest is most common to 50%. sepsis and sepsis. The main infection site is pulmonary infection and abdominal infection. Sepsis myocardial inhibition does not affect the prognosis of patients with sepsis. Age, APACHE II score, Lac, PCT are independent risk factors affecting the prognosis of sepsis. While APACHE II score, PCT is an independent risk factor affecting the prognosis of sepsis patients with myocardial inhibition.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R459.7

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