多中心严重烧伤住院患者流行病学调查分析

发布时间：2018-04-29 17:19

本文选题：严重烧伤 + 流行病学　；参考：《第三军医大学》2017年硕士论文

【摘要】：目的分析近年来我国严重烧伤住院患者的流行病学特征,为严重烧伤预防与救治提供科学依据。方法依托“临床多中心严重烧伤流行病学病例数据与生物样本录入系统”,收录我国8家烧伤中心在2012年1月至2015年12月收治的所有严重烧伤住院患者共1137例,其中儿童患者440例,占比38.7%,成年患者(18岁,≤65岁)共615例,占比54.1%,老年患者(65岁)共82例,占比7.2%。统计分析严重烧伤住院患者的人口统计学特征、烧伤原因及环境、烧伤病情、院前与院内救治情况、以及治疗结果等。其中儿童患者分为5个年龄段(≤1岁、1岁且≤3岁、3岁且≤6岁、6岁且≤12岁、12岁且≤18岁)进行分析;老年患者与成年患者进行对比分析。结果一、儿童严重烧伤住院患者流行病学调查分析1、儿童严重烧伤患者占全部严重烧伤患者的38.7%,以≤6岁、男性和农村患儿居多,比例分别为86.6%、61.4%和74.5%;不同年龄段的严重烧伤患儿性别和居住地分布无统计学差异;63.8%的患儿住院费用无医保覆盖,且年龄越小、医保覆盖的比例越低。2、儿童严重烧伤的主要原因为烫伤,占80.9%,主要烧伤场所为私人住宅,占90.9%,高发季节为夏季,占29.5%。6岁以后,随年龄增长,烫伤所占比例逐步降低,火焰和电烧伤所占比例显著增加;同时,私人住宅作为烧伤场所的比例逐渐降低,而公共场所的比例逐渐升高。在私人住宅发生的儿童严重烧伤以烫伤为主,占86.0%,而在公共场所则以火焰烧伤为主,占40.0%。3、儿童严重烧伤的总面积以11%~40%TBSA居多,占80.9%。患儿年龄段与烧伤总面积、三度烧伤发生率和三度烧伤面积之间具有显著正相关(r值依次为0.177、0.129和0.316)。儿童严重烧伤最常见的部位为躯干、下肢和上肢,发生率分别为81.1%、78.6%和67.8%。6岁以后,随着患儿年龄增加,头面颈、手、足部位的烧伤发生率呈增长趋势。27例合并吸入性损伤,占比6.1%,以中度最常见。患儿年龄与吸入性损伤发生率呈正相关(r值为0.220)。4、儿童严重烧伤延迟复苏的比例为11.4%。延迟复苏与患儿烧伤总面积及三度烧伤显著相关。住院期间前三位的并发症为低蛋白血症、创面感染和休克,发生率为60.5%、21.1%和10.5%,烧伤面积、三度烧伤和是否手术为其独立危险因素。发生率居前三位的脏器并发症为肝功不全、肺部感染和心功能不全,发生率依次为2.7%、2.3%和1.6%。5、本组严重烧伤儿童平均住院天数为28.6±35.1天;最终治愈347例,治愈率为79.4%;出院时病情恶化和死亡的患儿共12例,不良结局率为2.7%;前3位死亡原因为感染性休克、脓毒症和MODS。吸入性损伤、休克、脓毒症及ARDS为严重烧伤患儿不良结局的独立危险因素。二、成年和老年严重烧伤的流行病学调查的对比分析1、成年和老年严重烧伤均以男性、农村患者为主(男性:79.8%VS.58.5%;农村:58.0%VS.75.6%)。成年患者以受中等教育程度为主,占61.6%;老年患者以受初等教育程度为主,占43.9%。2、成年和老年严重烧伤的主要原因均为火焰烧伤,但老年患者火焰烧伤的比例显著高于成年患者(85.4%VS.57.2%)。成年严重烧伤最常见的烧伤场所为工作场所,占47.8%;最常发生于夏季,占35.9%。老年严重烧伤绝大多数发生于私人住宅,占72.0%;最常发生于冬季,占36.6%。3、老年严重烧伤患者伤前存在重要脏器疾病的发生率显著高于成年患者(61.0%VS.13.2%),其中,28.0%存在中枢神经系统疾病,40.2%存在心血管系统疾病,12.2%存在呼吸系统疾病,OR值分别是成年患者的12.9倍、11.2倍和9.4倍。4、老年严重烧伤患者烧伤总面积中位数略低于成年患者(40.0%VS.48.9%),但三度烧伤发生率和三度烧伤面积中位数均高于成年患者(三度烧伤发生率:90.2%VS.82.0%;三度烧伤面积中位数:23.4%VS.19.8%)。两组患者最常见的烧伤部位均为躯干、上肢和下肢,吸入性损伤发生率无显著差别。5、老年严重烧伤延迟复苏的比例高于成年患者(8.7%VS.4.7%),其住院期间切/削痂植皮手术率低于成年患者(35.4%VS.72.0%),其发生ARDS、肝功能不全、急性肾功能不全和心功能不全的危险度分别为成年患者的3.4倍、3.3倍、5.7倍和10.8倍,脓毒症、休克为其独立危险因素。6、本研究中成年和老年严重烧伤患者的平均住院天数分别为63.0±76.7天和22.8±29.8天。老年严重烧伤患者最终治愈20例,治愈率为24.4%,显著低于成年患者(治愈475例,治愈率77.2%),其不良结局发生率(恶化和死亡)约为成年患者的5倍(37.8%VS.7.5%),其放弃治疗率高达57.3%(成年严重烧伤患者仅为7.8%)。成年及患者前三位死亡原因均为多器官功能衰竭、感染相关疾病和心跳呼吸骤停。分析显示,休克为老年患者不良结局的独立危险因素。结论一、儿童严重烧伤流行病学调查分析1、儿童患者占全部严重烧伤患者的38.7%,是我国目前严重烧伤的重要群体。≤6岁、男性、农村患儿是儿童严重烧伤的高危人群,夏季、烫伤、私人住宅是导致儿童严重烧伤的高危因素,因而加强6岁以下儿童家庭生活烫伤的预防(尤其农村家庭)是减少儿童严重烧伤发生的关键。2、6岁以后,随着儿童年龄增长,火焰烧伤和电击伤增多,公共场所致伤比例增高,伤情加重,手足、头面颈等功能容貌部位烧伤大幅上升,提示加强6岁以上儿童户外烧伤的预防是减轻儿童严重烧伤程度的关键。3、儿童严重烧伤住院期间的主要并发症为低蛋白血症、创面感染和休克,三度烧伤、烧伤总面积为其独立危险因素,同时脓毒症、ARDS、休克、吸入伤是儿童严重烧伤不良结局的独立危险因素。提示加强感染控制、肺部并发症及吸入伤的防治和呼吸道管理、液体复苏及防治休克等,将有助于进一步提高儿童严重烧伤救治成功率。二、老年和成年严重烧伤流行病学调查的对比分析1、男性和农村人口既是成年严重烧伤也是老年严重烧伤的高危人群;与成年患者不同,低教育程度、冬季、私人住宅、火焰烧伤和伴有伤前中枢神经系统疾病(如脑梗塞等)是老年严重烧伤的高危因素。因此,加强针对家庭(尤其农村家庭)冬季防火的预防宣教和伴有中枢神经系统疾病老年人的生活照护,将有助于降低老年严重烧伤发生。2、老年严重烧伤患者伤前重要脏器疾病的发生率约为成年患者的4倍,且三度烧伤发生率和三度烧伤面积中位数均高于成年患者,提示:较之成年严重烧伤患者,老年患者不仅基础疾病多,而且伤情也更重。3、老年严重烧伤患者出现ARDS、肝功能不全、急性肾功能不全和心功能不全的危险度为成年患者的2.9-10.8倍;最终治愈率不足成年患者的1/3,不良结局发生率(恶化和死亡)为成年患者的5.0倍,出现不良结局的危险度为成年患者的7.5倍,休克和脓毒症是上述并发症和不良结局的独立危险因素。提示,加强早期液体复苏、休克与感染的的防治及加强重要脏器的保护与支持,可能是改善当前老年严重烧伤救治水平的有效措施。4、老年严重烧伤患者放弃治疗率为成年患者的7.3倍,危险度为成年患者的15.9倍,提示老年严重烧伤的救治不仅面临医学挑战,还可能涉及社会学、经济学等诸多层面的问题。
[Abstract]:Objective to analyze the epidemiological characteristics of hospitalized patients with severe burns in recent years, and to provide a scientific basis for the prevention and treatment of severe burns. Methods relying on the "clinical data of epidemiological cases of clinical multi center severe burns and the entry system of biological samples", all of the 8 burn centers in China were admitted from January 2012 to December 2015. There were 1137 cases of hospitalized burn patients, including 440 children, 38.7%, 615 adult patients (18 years old, less than 65 years), 54.1% and 82 aged patients (65 years old), accounting for statistical analysis of the demographic characteristics of hospitalized patients with severe burns, burn causes and conditions, pre hospital and hospital treatment, and treatment results. Among them, children were divided into 5 age groups (less than 1 years old, 1 and less than 3 years old, 3 and less than 6 years old, 6 and less than 12 years old, 12 and less than 18 years of age) analysis. The elderly patients and adult patients were compared and analyzed. Results 1. Epidemiological investigation and analysis of hospitalized patients with severe burns in children 1, children severely burned patients accounted for 38.7% of all severely burned patients. At the age of 6, the majority of children and rural children were 86.6%, 61.4% and 74.5%, and there was no statistical difference in the sex and residence of children with severe burns in different age groups. 63.8% of the children were hospitalized without medical coverage, and the younger the age, the lower the proportion of medical insurance coverage was.2, and the main cause of severe burns for children was 80.9%, accounting for the main cause. The place of burn is private residence, accounting for 90.9%. The high incidence season is summer. After 29.5%.6 years of age, the proportion of burn is gradually reduced with age, and the proportion of flame and electric burn increases significantly. At the same time, the proportion of private residence as a burn place gradually decreases, and the proportion of public places is increasing gradually. The children in private residence are strict. The main burn was burn, accounting for 86%, while in public places, 40.0%.3 was mainly burned with flame burns. The total area of severe burns in children was 11%~40%TBSA, which accounted for the age of 80.9%. and total area of burn. The incidence of three degree burns and three degree burn area had significant positive correlation (R value was 0.177,0.129 and 0.316). The most common parts of the burn were trunk, lower limbs and upper limbs. The incidence of burn was 81.1%, 78.6%, and 67.8%.6 years old. With the age of children, the incidence of burns in the head, neck, hand and foot was increased in.27 cases combined with inhalation injury, which was 6.1% and the most common. The age of children was positively correlated with the incidence of inhalation injury (r value was 0.). 220).4, the proportion of delayed resuscitation in severe burns for children was a significant correlation between 11.4%. delayed resuscitation and total burn area and three degree burns in children. The first three complications were hypoproteinemia, wound infection and shock, incidence of 60.5%, 21.1% and 10.5%, burn area, three degree burns and operation as independent risk factors. The first three visceral complications were liver dysfunction, pulmonary infection and cardiac insufficiency, the incidence rate was 2.7%, 2.3% and 1.6%.5, the average hospitalization day was 28.6 + 35.1 days in this group of severely burned children, 347 cases were cured, the cure rate was 79.4%, 12 cases with deteriorated and dead children at discharge, the bad outcome rate was 2.7%; the former 3 died. Because of septic shock, sepsis and MODS. inhalation injury, shock, sepsis and ARDS as an independent risk factor for bad outcomes in children with severe burns. Two, comparative analysis of epidemiological investigations of severe burns in adults and old age 1, both adult and elderly severe burns were male and rural patients (male: 79.8%VS.58.5%; rural: 58.0%VS.75) .6%). The majority of adult patients are subject to secondary education, accounting for 61.6%; elderly patients are mainly subject to primary education, accounting for 43.9%.2. The main causes of severe burns in adult and old age are flame burns, but the proportion of flame burns in elderly patients is significantly higher than that of adult patients (85.4% VS.57.2%). The most common burn place for adult severe burns is work. Places, accounting for 47.8%, most often occur in the summer, most of the severe burns in 35.9%. are in private residence, accounting for 72%. Most often occur in winter, accounting for 36.6%.3. The incidence of important organ diseases in the elderly patients with severe burn is significantly higher than that of adult patients (61% VS.13.2%), of which 28% have central nervous system disease and 40.2% exist. In cardiovascular disease, 12.2% had respiratory disease. The OR value was 12.9 times, 11.2 times and 9.4 times.4 in adult patients. The median of burn total area in elderly patients with severe burn was slightly lower than that of adult patients (40.0%VS.48.9%), but the incidence of three degree burns and the median of three degree burn area were higher than those of adult patients (three degree burn rate: 90.2% VS.82.0%; the median of three degree burn area: 23.4%VS.19.8%). The most common burn sites in the two groups were trunk, upper limb and lower extremity, the incidence of inhalation injury was not significantly different from that of adult patients (8.7%VS.4.7%), and the rate of cut / eschar skin grafting during the period of hospitalization was lower than that of adult patients (35.4%VS.72 .0%), the risk of ARDS, liver dysfunction, acute renal insufficiency and cardiac insufficiency were 3.4 times, 3.3 times, 5.7 times and 10.8 times, respectively, and sepsis, and shock was the independent risk factor.6. The average hospitalization days of patients with severe burn in this study were 63 + 76.7 days and 22.8 + 29.8 days respectively. 20 cases of severe burn were cured, the cure rate was 24.4%, which was significantly lower than that of adult patients (475 cases were cured, the cure rate was 77.2%), the incidence of bad outcome (worsening and death) was about 5 times (37.8%VS.7.5%) of adult patients (37.8%VS.7.5%), and the rate of abandonment treatment was 57.3% (only 7.8% in adult severely burned patients). The three deaths of adult and patients were all more than those of adults and patients. Organ failure, infection related diseases and heartbeat respiratory arrest. Analysis shows that shock is an independent risk factor for bad outcome of elderly patients. Conclusion 1. Epidemiological investigation and analysis of severe burns in children 1, children accounted for 38.7% of all severely burned patients. It is an important group of severe burns in China. Less than 6 years old, male, rural children It is a high-risk group of severe burns in children. Summer, scald and private housing are the high risk factors for serious burns in children. Therefore, the prevention of family life burns for children under 6 years of age (especially in rural families) is the key to reduce the incidence of severe burns in children, with the increase of children's age, flame burns and electrical injuries, and the increase in public health. The proportion of injuries in the places increased, the injuries were aggravated, the parts of the parts of the hand, foot and head and neck were greatly increased. It was suggested that the prevention of outdoor burn in children over 6 years old was the key to reduce the degree of severe burn in children. The main complications of severe burns in children were low egg leukaemia, wound infection and shock, three degree burns, and burns. The area is an independent risk factor, and sepsis, ARDS, shock, and inhaled injury are independent risk factors for the bad outcome of severe burn in children. It is suggested that the control of infection, the prevention and control of pulmonary complications and inhalation injury and respiratory management, fluid resuscitation and shock treatment will help to further improve the success rate of the treatment of severe burns in children. Two, A comparative analysis of the epidemiological investigation of severe burns between the elderly and adults (1), both male and rural population are both adult and severe burns at high risk of severe burns; low education, winter, private housing, flame burns, and central nervous system diseases such as cerebral infarction, such as cerebral infarction, are severe burns in the elderly. Therefore, strengthening the prevention propaganda for the winter fire prevention in the family (especially the rural family) and the living care of the elderly with the central nervous system disease will help to reduce the incidence of severe burn in the elderly with.2. The incidence of important organ diseases in the elderly severely burned patients is about 4 times that of the adult patients and the incidence of three degree burns. The median of three degree burns was higher than that of adult patients. It was suggested that the elderly patients with severe burn were not only with more basic diseases, but also more.3, ARDS, liver dysfunction, acute renal insufficiency and heart dysfunction were 2.9-10.8 times of adult patients, and the final cure rate was not. The incidence of adverse outcomes (worsening and death) of adult patients was 5 times as high as that of adult patients. The risk of adverse outcomes was 7.5 times as high as that of adult patients. Shock and sepsis were independent risk factors for these complications and adverse outcomes. It was suggested to strengthen early fluid resuscitation, shock and infection and to strengthen the protection of important organs. Protection and support may be an effective measure to improve the current level of treatment for serious burns in the elderly.4. The rate of abandonment of treatment for elderly patients with severe burns is 7.3 times as high as that of adult patients, and the risk is 15.9 times as high as that of adult patients. It is suggested that the treatment of severe burn in the elderly not only face medical challenges but also social and economic problems.

【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R644

【参考文献】