本文選題：重癥醫(yī)學科 + 膿毒癥��； 參考：《河北醫(yī)科大學》2017年碩士論文

【摘要】：目的:膿毒癥(Sepsis)在重癥醫(yī)學科(Intensive Care Unit,ICU)中非常常見,可導致嚴重膿毒癥、膿毒癥心肌抑制等嚴重并發(fā)癥,是ICU病死率增加的主要原因,對人類健康產生巨大威脅,受到重癥醫(yī)學業(yè)內人士的廣泛關注。本研究旨在觀察河北省三級醫(yī)院ICU膿毒癥、膿毒癥心肌抑制患者的患病率、病死率、人口學特點、感染特征,超聲相關數據和預后情況等數據,分析探討影響膿毒癥及膿毒癥心肌抑制的預后因素。為膿毒癥、膿毒癥心肌抑制的臨床和基礎研究提供重要的參考數據,提高相關醫(yī)務工作者對膿毒癥的認識、進一步了解其流行病學特征,填補膿毒癥、膿毒癥心肌抑制的流行病學空白,為提高膿毒癥診療水平,改善預后提供理論依據。方法:本研究根據2012年SSC指南關于膿毒癥的診斷標準,納入了2016年5月至2016年9月河北省30家三級醫(yī)院ICU的膿毒癥患者,對其進行前瞻性、觀察性研究。每家ICU均具備規(guī)范管理膿毒癥及其并發(fā)癥的能力。對入選的每位患者均進行超聲心動圖檢查,應用Simpson’s法測出患者左室射血分數(LVEF),判斷患者是否存在心肌抑制;錄入患者的基本臨床資料,包括姓名、性別、年齡、主要感染部位,機械通氣時間,住ICU時間,28天預后情況;收集入科24小時內采集的血常規(guī),電解質,肝腎功能,動脈血氣分析,免疫功能檢查等化驗檢查結果,包含了氧合指數(P/F)、血乳酸(Lac)、白細胞計數(WBC)、血清降鈣素原(PCT)、C-反應蛋白(CRP)、血肌酐(Scr)以及肌鈣蛋白I(Tn I)等多項指標;以入科24小時內指標最差值計算APACHE II、SOFA及MODS評分。所有數據根據28天預后情況分為膿毒癥存活組和死亡組,心肌抑制存活組和死亡組。收集的數據由專人匯總后,統(tǒng)一錄入電腦,采用SPSS22.0統(tǒng)計軟件進行統(tǒng)計,分析其患病率、病死率、感染特點、預后及死亡危險因素等。結果:1本實驗入選了5704名患者,排除拒絕參加本實驗、超聲顯示不清者及中途退出者,最終共納入4897例患者,根據2012年SSC指南中關于膿毒癥的診斷標準,確診為膿毒癥患者1536例,患病率約為31.48%,28天病死率約為27.40%;其中嚴重膿毒癥患者486例,患病率約為9.39%,28天病死率約為50.41%;膿毒癥心肌抑制患者234例,患病率為4.79%,28天病死率為42.31%。2膿毒癥患者平均年齡為69(60,79)歲。其中男性966人(63.6%),女性570人(36.4%),男性患者明顯多于女性患者。APACHE II評分為19(14,25)、SOFA評分為8(6,12)、MODS評分為6(4,8)。膿毒癥患者常見的前三位感染部位為肺部感染,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%),膽系感染64人(4.2%),皮膚軟組織感染43人(2.8%),盆腔感染16人(1.0%),中樞系統(tǒng)感染13人(0.8%),血行感染9人(0.6%),感染部位不確定者5人(0.3%)。膿毒癥心肌抑制組患者平均年齡為70(63,80)歲,男性148人(63.25%),女性86人(36.75%),APACHE II評分為21(16,26)、SOFA評分為9(7,12)、MODS評分為6(4,9)。常見感染部位前三位為肺部感染、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%),膽系感染12人(5.1%),胸腔感染10人(4.3%),皮膚軟組織感染6人(2.6%),中樞系統(tǒng)感染1人(0.4%)。3死亡組與存活組相比較膿毒癥存活組與死亡組比較:死亡組患者的年齡、APACHE II評分、SOFA評分、MODS評分、Lac、Scr、WBC、PCT、CRP均高于存活組,差異具有統(tǒng)計學意義(P0.05);死亡組的氧合指數、LVEF、住ICU時間均少于存活組,差異具有統(tǒng)計學意義(P0.05);兩組的Tn I與機械通氣時間無統(tǒng)計學差異(P0.05)。膿毒癥心肌抑制存活組與死亡組比較:死亡組患者年齡、APACHE II評分、SOFA評分、MODS評分、Lac、WBC、PCT、CRP均高于生存組,差異具有統(tǒng)計學意義(P0.05);存活組LVEF高于死亡組,差值具有統(tǒng)計學意義(P0.05);而Scr、氧合指數、住ICU時間、Tn I與機械通氣時間兩組并無統(tǒng)計學差異(P0.05)。4對膿毒癥患者而言,單因素分析表明心肌抑制、年齡、APACHEⅡ評分、SOFA評分、MODS評分、LVEF、Lac、WBC、PCT、CRP、Scr、住ICU時間對其生存預后均有影響(P0.05)。多因素Logistic回歸分析顯示年齡、APACHE II評分、Lac、PCT是影響其預后的獨立危險因素。膿毒癥心肌抑制患者單因素分析顯示年齡、APACHE II評分、SOFA評分、MODS評分、LVEF、Lac、WBC、PCT、CPR對生存預后產生影響,多因素分析影響預后的獨立危險因素為APACHE II評分、PCT。結論:河北省膿毒癥患者的發(fā)病較高,可達31.48%,是ICU病死率增加的主要原因,膿毒癥心肌抑制患者死亡率高達近50%。膿毒癥及膿毒癥心肌抑制最常見的主要感染部位是肺部感染,腹腔感染。膿毒癥心肌抑制不影響膿毒癥患者的預后。年齡、APACHE II評分、Lac、PCT是影響膿毒癥預后的獨立危險因素。而APACHE II評分、PCT是影響膿毒癥心肌抑制患者預后的獨立危險因素。
[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.
【學位授予單位】：河北醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R459.7

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本文編號：2070300