严重多发伤患者机械通气的危险因素分析

doi:10.19723/j.issn.1671-167X.2020.04.027

摘要/Abstract

摘要：

目的: 探讨严重多发伤患者机械通气和机械通气时间延长的危险因素。方法: 选取2016年12月至2019年12月北京大学人民医院创伤救治中心所收治的严重多发伤患者作为研究对象进行回顾性研究,按照住院期间有无机械通气对患者进行分组,进一步将机械通气患者按照通气时间是否≥7 d分成机械通气时间延长组和非延长组。对收集的临床资料进行单因素和多因素分析,明确机械通气和机械通气时间延长的危险因素。结果: 共纳入患者112例,其中男性82例、女性30例,中位年龄52岁(16~89岁),中位创伤严重程度评分(injury severe score,ISS)34分(16~66分)。车祸伤和坠落伤是最常见的受伤类型。使用机械通气患者62例,未使用机械通气患者50例,多因素分析表明,格拉斯哥昏迷评分(Glasgow coma scale,GCS)(OR=0.72,95%CI:0.53~0.92,P=0.03)、血液碱剩余(OR=0.56,95%CI:0.37~0.88,P=0.002)、肋骨骨折(OR=1.72,95%CI:1.60~2.80,P=0.012)是启动机械通气的独立危险因素。本组机械通气时间≥7 d者38例,<7 d者24例,结果显示ISS评分越高,GCS评分越低,患者机械通气时间越长。结论: GCS评分、血液碱剩余和肋骨骨折是机械通气的独立危险因素,同时,ISS评分高和颅脑损伤重可能会延长机械通气时间,患者气管切开的发生率高。

关键词: 多发伤, 机械通气, 肺挫伤, 肋骨骨折

Abstract:

Objective: To eludicate the risk factors of mechanical ventilation and prolonged mechanical ventilation in patients with severe multiple injuries. Methods: Consecutive patients with severe multiple injures who were treated in Peking University People’s Hospital Trauma Medical Center between December 2016 and December 2019 were enrolled in this restropective chart-review study. According to mechanical ventilation and ventilatory time, the patients were divided into mechanical ventilation (MV) group and non-mechanical ventilation (NMV) groups, prolonged mechanical ventilation (PMV) group and shortened mechanical ventilation (SMV) groups. Clinical data such as gender, age, base excess, mechanism of injury, Glasgow Coma Scale (GCS), abbreviated injury scale (AIS) and injury severity score (ISS) were collected. To indentify the risk factors of mechanical ventilation and prolonged mecha-nical ventilation, univariate and multivariate Logistic analyses were carried out. Results: In the present study, 112 patients (82 male, 30 female) with severe multiple injuries having a median age of 52 (range: 16-89 years) and a median ISS of 34 (range: 16-66) were enrolled. The primary mechanism of injury was traffic accident injury and falling injury. In the study, 62 and 50 patients were assigned to MV and NMV groups, respectively. Logistic analysis showed that GCS (OR=0.72, 95%CI: 0.53-0.92, P=0.03), base excess (OR=0.56, 95%CI: 0.37-0.88, P=0.002) and multiple rib fracture (OR=1.72, 95%CI: 1.60-2.80, P=0.012) were independent significant risk factors for mechanical ventilation after severe multiple injuries. Within the mechanical ventilation group, 38 and 24 patients were assigned to PMV and SMVgroups, respectively. Compared with the SMV group, the PMV group had a higher ISS and higher rate of severe head trauma. The length of hospital stay of PMV group was longer than that of SMV groups. Meanwhile, the incidence of tracheotomy in PMV group was high. Conclusion: GCS, base excess and rib fracture might be independent risk factors for mechanical ventilation. Higher ISS and lower GCS might prolong the ventilatory time and the length of hospital stay. Meanwhile, the incidence of tracheotomy was high in PMV group because of the longer ventilatory time and poor consciousness.

Key words: Multiple trauma, Mechanical ventilation, Pulmonary contusion, Rib fractures

中图分类号:

R641

郭辅政,朱凤雪,邓玖旭,杜哲,赵秀娟. 严重多发伤患者机械通气的危险因素分析[J]. 北京大学学报（医学版）, 2020, 52(4): 738-742.

Fu-zheng GUO,Feng-xue ZHU,Jiu-xu DENG,Zhe DU,Xiu-juan ZHAO. Risk factors for mechanical ventilation in patients with severe multiple trauma[J]. Journal of Peking University (Health Sciences), 2020, 52(4): 738-742.

图/表 4

表1

表2

使用机械通气与未使用机械通气患者单因素分析结果"

Variable	Mechanical ventilation (n=62)	Non-mechanical ventilation (n=50)	P
Age/years, $x ?$ ±s	50±16	49±12	0.716
Gender, n			0.578
Male	44	38
Female	18	12
ISS, median (P₂₅, P₇₅)	34 (26, 41)	22 (18, 29)	<0.001
GCS, median (P₂₅, P₇₅)	11 (3, 15)	15 (13, 15)	<0.001
AIS, median (P₂₅, P₇₅)
Head and neck	4 (2, 6)	3 (1, 4)	0.083
Thorax	6 (3, 8)	4 (1, 5)	0.010
Abdomen	2 (0, 4)	0 (0, 2)	0.001
Extremities and pelvis	2 (0, 4)	1 (0, 2)	0.087
Rib fracture, n (%)	5 (1, 8)	0 (0, 5)	0.009
Volume of pulmonary contusion≥20%, n (%)	28 (45.2)	8 (16.0)	0.040
Hydrothorax, n (%)	46 (74.2)	22 (44.0)	0.008
Pneumothorax, n (%)	22 (35.4)	12 (24.0)	0.558
Lactic acid/(mmol/L), median (P₂₅, P₇₅)	3.5 (1.5, 5.2)	0.9 (1.2, 2.1)	0.001
Base excess/(mmol/L), median (P₂₅, P₇₅)	-5.2 (-3.75, -7.55)	-1.28 (-3.57, 0.87)	<0.001
Length of hospital stay/d, median (P₂₅, P₇₅)	20 (15, 31)	15 (9, 22)	<0.001

表2

表3

表4

机械通气时间延长组和非延长组相关指标的比较"

Variable	SMV group (n=24)	PMV group (n=38)	P
Age/years, $x ?$ ±s	47±16	50±18	0.517
ISS, median (P₂₅, P₇₅)	29 (21, 37)	36 (29, 50)	0.022
GCS, median (P₂₅, P₇₅)	14 (12, 15)	8 (3, 12)	0.029
Ventilatory time/d, median (P₂₅, P₇₅)	5 (2, 6)	16 (9, 20)	<0.001
Length of hospital stay/d, median (P₂₅, P₇₅)	14 (8, 16)	24 (18, 42)	<0.001

表4

参考文献 26

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Variables	Data
Age/years, median (range)	52 (16-89)
Gender, n (%)
Male	82 (73.2)
Female	30 (26.8)
Mechanism of injury, n (%)
Traffic injury	48 (42.9)
High falling injury	30 (26.9)
Tumbles injury	16 (14.3)
Blast injury	8 (7.1)
Heavy pound injury	6 (5.4)
Stab injury	4 (3.6)
ISS, median (range)	34 (16-66)
GCS, median (range)	10 (3-15)
AIS, median (range)
Head an neck	4 (0-12)
Thorax	5 (0-13)
Abdomen	2 (0-6)
Extremities and pelvis	2 (0-7)
Pulmonary contusion, n (%)
Volume<20%	76 (67.9)
Volume≥20%	36 (32.1)
Lactic acid/(mmol/L), median (range)	2.4 (0.5-15.0)
Length of hospital stay/d, median (range)	18 (1-123)