多中心嚴(yán)重?zé)齻≡夯颊吡餍胁W(xué)調(diào)查分析
發(fā)布時(shí)間：2018-04-29 17:19
本文選題：嚴(yán)重?zé)齻?/strong> + 流行病學(xué)�。� 參考：《第三軍醫(yī)大學(xué)》2017年碩士論文
【摘要】：目的分析近年來我國嚴(yán)重?zé)齻≡夯颊叩牧餍胁W(xué)特征,為嚴(yán)重?zé)齻A(yù)防與救治提供科學(xué)依據(jù)。方法依托“臨床多中心嚴(yán)重?zé)齻餍胁W(xué)病例數(shù)據(jù)與生物樣本錄入系統(tǒng)”,收錄我國8家燒傷中心在2012年1月至2015年12月收治的所有嚴(yán)重?zé)齻≡夯颊吖?137例,其中兒童患者440例,占比38.7%,成年患者(18歲,≤65歲)共615例,占比54.1%,老年患者(65歲)共82例,占比7.2%。統(tǒng)計(jì)分析嚴(yán)重?zé)齻≡夯颊叩娜丝诮y(tǒng)計(jì)學(xué)特征、燒傷原因及環(huán)境、燒傷病情、院前與院內(nèi)救治情況、以及治療結(jié)果等。其中兒童患者分為5個年齡段(≤1歲、1歲且≤3歲、3歲且≤6歲、6歲且≤12歲、12歲且≤18歲)進(jìn)行分析;老年患者與成年患者進(jìn)行對比分析。結(jié)果一、兒童嚴(yán)重?zé)齻≡夯颊吡餍胁W(xué)調(diào)查分析1、兒童嚴(yán)重?zé)齻颊哒既繃?yán)重?zé)齻颊叩?8.7%,以≤6歲、男性和農(nóng)村患兒居多,比例分別為86.6%、61.4%和74.5%;不同年齡段的嚴(yán)重?zé)齻純盒詣e和居住地分布無統(tǒng)計(jì)學(xué)差異;63.8%的患兒住院費(fèi)用無醫(yī)保覆蓋,且年齡越小、醫(yī)保覆蓋的比例越低。2、兒童嚴(yán)重?zé)齻闹饕驗(yàn)闋C傷,占80.9%,主要燒傷場所為私人住宅,占90.9%,高發(fā)季節(jié)為夏季,占29.5%。6歲以后,隨年齡增長,燙傷所占比例逐步降低,火焰和電燒傷所占比例顯著增加;同時(shí),私人住宅作為燒傷場所的比例逐漸降低,而公共場所的比例逐漸升高。在私人住宅發(fā)生的兒童嚴(yán)重?zé)齻誀C傷為主,占86.0%,而在公共場所則以火焰燒傷為主,占40.0%。3、兒童嚴(yán)重?zé)齻目偯娣e以11%~40%TBSA居多,占80.9%。患兒年齡段與燒傷總面積、三度燒傷發(fā)生率和三度燒傷面積之間具有顯著正相關(guān)(r值依次為0.177、0.129和0.316)。兒童嚴(yán)重?zé)齻畛Ｒ姷牟课粸檐|干、下肢和上肢,發(fā)生率分別為81.1%、78.6%和67.8%。6歲以后,隨著患兒年齡增加,頭面頸、手、足部位的燒傷發(fā)生率呈增長趨勢。27例合并吸入性損傷,占比6.1%,以中度最常見�；純耗挲g與吸入性損傷發(fā)生率呈正相關(guān)(r值為0.220)。4、兒童嚴(yán)重?zé)齻舆t復(fù)蘇的比例為11.4%。延遲復(fù)蘇與患兒燒傷總面積及三度燒傷顯著相關(guān)。住院期間前三位的并發(fā)癥為低蛋白血癥、創(chuàng)面感染和休克,發(fā)生率為60.5%、21.1%和10.5%,燒傷面積、三度燒傷和是否手術(shù)為其獨(dú)立危險(xiǎn)因素。發(fā)生率居前三位的臟器并發(fā)癥為肝功不全、肺部感染和心功能不全,發(fā)生率依次為2.7%、2.3%和1.6%。5、本組嚴(yán)重?zé)齻麅和骄≡禾鞌?shù)為28.6±35.1天;最終治愈347例,治愈率為79.4%;出院時(shí)病情惡化和死亡的患兒共12例,不良結(jié)局率為2.7%;前3位死亡原因?yàn)楦腥拘孕菘�、膿毒癥和MODS。吸入性損傷、休克、膿毒癥及ARDS為嚴(yán)重?zé)齻純翰涣冀Y(jié)局的獨(dú)立危險(xiǎn)因素。二、成年和老年嚴(yán)重?zé)齻牧餍胁W(xué)調(diào)查的對比分析1、成年和老年嚴(yán)重?zé)齻阅行�、農(nóng)村患者為主(男性:79.8%VS.58.5%;農(nóng)村:58.0%VS.75.6%)。成年患者以受中等教育程度為主,占61.6%;老年患者以受初等教育程度為主,占43.9%。2、成年和老年嚴(yán)重?zé)齻闹饕蚓鶠榛鹧鏌齻?但老年患者火焰燒傷的比例顯著高于成年患者(85.4%VS.57.2%)。成年嚴(yán)重?zé)齻畛Ｒ姷臒齻麍鏊鶠楣ぷ鲌鏊?占47.8%;最常發(fā)生于夏季,占35.9%。老年嚴(yán)重?zé)齻^大多數(shù)發(fā)生于私人住宅,占72.0%;最常發(fā)生于冬季,占36.6%。3、老年嚴(yán)重?zé)齻颊邆按嬖谥匾K器疾病的發(fā)生率顯著高于成年患者(61.0%VS.13.2%),其中,28.0%存在中樞神經(jīng)系統(tǒng)疾病,40.2%存在心血管系統(tǒng)疾病,12.2%存在呼吸系統(tǒng)疾病,OR值分別是成年患者的12.9倍、11.2倍和9.4倍。4、老年嚴(yán)重?zé)齻颊邿齻偯娣e中位數(shù)略低于成年患者(40.0%VS.48.9%),但三度燒傷發(fā)生率和三度燒傷面積中位數(shù)均高于成年患者(三度燒傷發(fā)生率:90.2%VS.82.0%;三度燒傷面積中位數(shù):23.4%VS.19.8%)。兩組患者最常見的燒傷部位均為軀干、上肢和下肢,吸入性損傷發(fā)生率無顯著差別。5、老年嚴(yán)重?zé)齻舆t復(fù)蘇的比例高于成年患者(8.7%VS.4.7%),其住院期間切/削痂植皮手術(shù)率低于成年患者(35.4%VS.72.0%),其發(fā)生ARDS、肝功能不全、急性腎功能不全和心功能不全的危險(xiǎn)度分別為成年患者的3.4倍、3.3倍、5.7倍和10.8倍,膿毒癥、休克為其獨(dú)立危險(xiǎn)因素。6、本研究中成年和老年嚴(yán)重?zé)齻颊叩钠骄≡禾鞌?shù)分別為63.0±76.7天和22.8±29.8天。老年嚴(yán)重?zé)齻颊咦罱K治愈20例,治愈率為24.4%,顯著低于成年患者(治愈475例,治愈率77.2%),其不良結(jié)局發(fā)生率(惡化和死亡)約為成年患者的5倍(37.8%VS.7.5%),其放棄治療率高達(dá)57.3%(成年嚴(yán)重?zé)齻颊邇H為7.8%)。成年及患者前三位死亡原因均為多器官功能衰竭、感染相關(guān)疾病和心跳呼吸驟停。分析顯示,休克為老年患者不良結(jié)局的獨(dú)立危險(xiǎn)因素。結(jié)論一、兒童嚴(yán)重?zé)齻餍胁W(xué)調(diào)查分析1、兒童患者占全部嚴(yán)重?zé)齻颊叩?8.7%,是我國目前嚴(yán)重?zé)齻闹匾后w�！�6歲、男性、農(nóng)村患兒是兒童嚴(yán)重?zé)齻母呶Ｈ巳?夏季、燙傷、私人住宅是導(dǎo)致兒童嚴(yán)重?zé)齻母呶Ｒ蛩?因而加強(qiáng)6歲以下兒童家庭生活燙傷的預(yù)防(尤其農(nóng)村家庭)是減少兒童嚴(yán)重?zé)齻l(fā)生的關(guān)鍵。2、6歲以后,隨著兒童年齡增長,火焰燒傷和電擊傷增多,公共場所致傷比例增高,傷情加重,手足、頭面頸等功能容貌部位燒傷大幅上升,提示加強(qiáng)6歲以上兒童戶外燒傷的預(yù)防是減輕兒童嚴(yán)重?zé)齻潭鹊年P(guān)鍵。3、兒童嚴(yán)重?zé)齻≡浩陂g的主要并發(fā)癥為低蛋白血癥、創(chuàng)面感染和休克,三度燒傷、燒傷總面積為其獨(dú)立危險(xiǎn)因素,同時(shí)膿毒癥、ARDS、休克、吸入傷是兒童嚴(yán)重?zé)齻涣冀Y(jié)局的獨(dú)立危險(xiǎn)因素。提示加強(qiáng)感染控制、肺部并發(fā)癥及吸入傷的防治和呼吸道管理、液體復(fù)蘇及防治休克等,將有助于進(jìn)一步提高兒童嚴(yán)重?zé)齻戎纬晒β�。二、老年和成年�?yán)重?zé)齻餍胁W(xué)調(diào)查的對比分析1、男性和農(nóng)村人口既是成年嚴(yán)重?zé)齻彩抢夏陣?yán)重?zé)齻母呶Ｈ巳?與成年患者不同,低教育程度、冬季、私人住宅、火焰燒傷和伴有傷前中樞神經(jīng)系統(tǒng)疾病(如腦梗塞等)是老年嚴(yán)重?zé)齻母呶Ｒ蛩亍Ｒ虼?加強(qiáng)針對家庭(尤其農(nóng)村家庭)冬季防火的預(yù)防宣教和伴有中樞神經(jīng)系統(tǒng)疾病老年人的生活照護(hù),將有助于降低老年嚴(yán)重?zé)齻l(fā)生。2、老年嚴(yán)重?zé)齻颊邆爸匾K器疾病的發(fā)生率約為成年患者的4倍,且三度燒傷發(fā)生率和三度燒傷面積中位數(shù)均高于成年患者,提示:較之成年嚴(yán)重?zé)齻颊?老年患者不僅基礎(chǔ)疾病多,而且傷情也更重。3、老年嚴(yán)重?zé)齻颊叱霈F(xiàn)ARDS、肝功能不全、急性腎功能不全和心功能不全的危險(xiǎn)度為成年患者的2.9-10.8倍;最終治愈率不足成年患者的1/3,不良結(jié)局發(fā)生率(惡化和死亡)為成年患者的5.0倍,出現(xiàn)不良結(jié)局的危險(xiǎn)度為成年患者的7.5倍,休克和膿毒癥是上述并發(fā)癥和不良結(jié)局的獨(dú)立危險(xiǎn)因素。提示,加強(qiáng)早期液體復(fù)蘇、休克與感染的的防治及加強(qiáng)重要臟器的保護(hù)與支持,可能是改善當(dāng)前老年嚴(yán)重?zé)齻戎嗡降挠行Т胧?、老年嚴(yán)重?zé)齻颊叻艞壷委熉蕿槌赡昊颊叩?.3倍,危險(xiǎn)度為成年患者的15.9倍,提示老年嚴(yán)重?zé)齻木戎尾粌H面臨醫(yī)學(xué)挑戰(zhàn),還可能涉及社會學(xué)、經(jīng)濟(jì)學(xué)等諸多層面的問題。
[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.
【學(xué)位授予單位】：第三軍醫(yī)大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R644
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