中国十家大学附属医院重症监护病房重症脓毒血症流行病学研究

发布时间：2018-04-24 12:39

本文选题：中国 + 十家　；参考：《浙江大学》2007年硕士论文

【摘要】： 背景脓毒血症(sepsis)是由感染(infection)引起的炎症反应综合症(SIRS)，当感染后的炎症反应导致一个或一个以上器官功能不全时被定义为重症脓毒血症(severe sepsis)。脓毒症尤其是重症脓毒血症已经成为长期困扰重症医学的一种疾患，在美国，每年大约有750，000例重症脓毒血症患者，死亡率高达30％到50％，并且发病率在以每年1.5％的速度递增，其医疗费用也相当惊人，平均每例$22，100，另外，有研究报道，收住重症脓毒血症患者，极大的加重了ICU的医护工作负担。因此，引起了各国临床专家的广泛关注，进行了各方面的研究。但是在中国，由于医疗统计系统尚在发展中，重症脓毒血症流行病学的研究资料并不多，大多为单中心的资料统计，缺乏代表性。为了提供中国人群的重症脓毒血症的流行病学资料，从而反应我国重症监护病房对于重症脓毒血症的诊治水平，并为我国重症脓毒血症的临床治疗及研究提供重要的参考数据，课题组在全国范围内十家大学附属医院的重症监护病房对于2004—2005年重症脓毒血症患者的发病率、死亡率及死亡危险因子进行了资料采集和整体分析。方法本次研究是一项前瞻性的观察性研究，未对结果行任何人工干预。选择全国十家床位数大于800张的大学附属医院的成人重症监护病房(ICU)，调取2004年12月1日至2005年11月30日入住参加调查的ICU的病人病案资料，由课题组事先经过培训的4名调查员依据1992年和2002年美国胸科医师协会/美国危重病学会(ACCM/SCCM)联合会议通过的脓毒症相关定义及序贯器官功能不全评分系统(SOFA)，排除术后常规ICU过渡病人，，筛选出符合标准的重症脓毒血症患者，采集基本人口学资料、主要诊断、感染特点、预后及医护工作负担等数据，登记在预先设计的资料登记表中。十家医院的数据汇总后，统一登记入电脑Access系统，最后运用SPSS软件分析重症脓毒症的发病率、死亡率、感染特点、工作负担及死亡的危险因素。结果在2004年12月1日至2005年11月30日，共有6653人入住10家ICU，除去术后常规过渡病人，3665人进入研究。依据1992年ACCM/SCCM通过的脓毒症相关定义及序贯器官功能不全评分系统(SOFA)，共318人诊断为重症脓毒血症，发病率为8.68％，其中男性患者占64.8％，患者年龄中位数为64(47-74)岁。 228名患者有明确培养结果，171(53.8％)名患者为革兰氏阴性菌感染，146(45.9％)名患者为革兰氏阳性菌感染，还有90(22.0％)名患者证明有侵袭性真菌感染。腹腔(72.3％)和肺部(52.8％)是最容易发生感染的部位。本研究中，重症脓毒症患者的医院死亡率为48.7％。经过多变量双向Logistic回归分析，对于死亡的危险因子为：年龄、恶性肿瘤病史、革兰氏阳性菌感染、侵袭性真菌感染、APS评分及入院时呼吸及循环系统的SOFA评分。本研究采用TISS评分系统评价病人给予医护人员主要是护士带来的工作负担，对于重症脓毒血症，TISS中位值为43(38-49)，这表示每8小时护士要为一名照顾及护理重症脓毒血症患者花费7.58(6.71-8.48)小时时间。结论本研究显示，与国外类似调查结果一致，在中国危重症病房，重症脓毒血症是一项发生率、死亡率高及工作负担重的综合症，但是，在中国，重症脓毒血症也有其不同的特点，如革兰氏阴性菌感染为主、侵袭性真菌感染的比例较高等，需要更大规模更深入的调查来进一步明确与国外研究迥异的根本原因。
[Abstract]:Background

Septic sepsis ( sepsis ) is a syndrome of inflammation caused by infection , which is defined as severe sepsis when a post - infection inflammatory response leads to an incomplete function of one or more organs . Septic sepsis , especially severe sepsis , has become a disease of severe sepsis in the long term . In the United States , there are approximately 750 , 000 patients with severe sepsis each year , with a mortality rate of up to 30 % to 50 % , with an average annual rate of $ 22,100 .

In order to provide the epidemiological data of severe sepsis in Chinese population , the diagnosis and treatment of severe sepsis in intensive care unit in China were analyzed . The data were collected and analyzed for the incidence , mortality and death risk factors of severe sepsis in China .

method

This study was a prospective observational study and did not have any manual intervention on the results . Four investigators selected a total of ten beds in the country were more than 800 university affiliated hospitals in ICU . Four investigators who had previously trained in the study group received data on sepsis - related definitions and sequential organ dysfunction score systems ( SOFA ) , which met the criteria in 1992 and 2002 . Data collected from basic demographic data , major diagnosis , infection characteristics , prognosis and burden of medical care were collected and registered in the pre - designed data registration form .

Ten hospitals data were collected and recorded into the computer access system . Finally , the morbidity , mortality , infection characteristics , workload and risk factors of death were analyzed by SPSS software .

Results

From December 1 , 2004 to November 30 , 2005 , a total of 6,53 people were admitted to 10 ICU to remove postoperative conventional transition patients and 3665 people were enrolled in the study . According to the related definitions of sepsis and sequential organ dysfunction scoring system ( SOFA ) adopted in 1992 , 318 people were diagnosed with severe sepsis , with an incidence of 8.68 % , of which 64.8 % were male patients and 64 ( 47 - 74 ) years of age median age .

Of the 228 patients , 171 ( 53.8 % ) patients were Gram - negative bacteria , 146 ( 45.9 % ) were Gram - positive bacteria , and 90 ( 22 . 0 % ) patients demonstrated invasive fungal infections . The abdominal cavity ( 72.3 % ) and the lungs ( 52.8 % ) were the most susceptible sites .

In this study , the hospital mortality rate was 48.7 % in patients with severe sepsis . The risk factors for death were age , history of malignant tumor , Gram - positive bacteria infection , invasive fungal infection , APS score and SOFA score of circulatory system at admission .

The TISS scoring system was used to evaluate the work burden of nurses , especially for nurses , and for severe sepsis , the median value of TISS was 43 ( 38 - 49 ) , which means that the nurse would spend 7.58 ( 6.71 - 8.48 ) hours per 8 - hour nursing care and care for severe sepsis patients .

Conclusion

This study shows that in China , severe sepsis is a syndrome of high incidence , high mortality and heavy workload in critical wards in China . However , in China , severe sepsis also has its different characteristics , such as Gram - negative bacteria infection , invasive fungal infection , and higher proportion of invasive fungal infections .

【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2007
【分类号】：R459.7;R181.3

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