急性胃肠损伤分级系统对重症患者适应性及临床预后的评估  

Clinical application of Acutegastrointestinal injury grading system assocaited with clinical severity outcome in critically ill patients： a multi-center prospective, observational study

作　　者：呼邦传[1] 孙仁华[1] 吴爱萍[1] 倪银[1] 刘景全[1] 应利君[2] 徐秋萍[3] 葛国平[4] 施云超 刘长文[6] 许磊 林荣海[8] 江荣林 陆军 朱寅南 吴伟东[12] 丁学军 谢波[14] Hu Bangchuan Sun Renhua Wu Aiping Ni Yin Hu Jingquan Ying Lijun Xu Qiuping Ge Guoping Shi Yunchao Liu Changwen Xu Lei Lin Ronghai Jiang Ronglin Lu Jun Zhu Yinnan Wu Weidong Ding Xnejun Xie Bo(Department of Intensive Care Medicine, Zhejiang Provincial People＇s Hospital, Huzhou 310014, China)

机构地区：[1]浙江省人民医院重症医学科,杭州310014 [2]绍兴市人民医院重症医学科 [3]浙江大学附属邵逸夫医院重症医学科 [4]金华市人民医院重症医学科 [5]嘉兴市人民医院重症医学科 [6]杭州市第一人民医院重症医学科 [7]宁波市李惠利医院重症医学科 [8]浙江省台州医院重症医学科 [9]浙江省中医药大学附属第一医院重症医学科 [10]浙江省中医药大学附属第二医院重症医学科 [11]诸暨市人民医院重症医学科 [12]丽水市中心医院重症医学科 [13]浙江省中医药大学附属第三医院重症医学科 [14]湖州市中心医院重症医学科

出　　处：《中华医学杂志》2017年第5期325-331,共7页National Medical Journal of China

摘　　要：目的观察急性胃肠损伤（AGI）分级系统在重症医学科（ICU）患者中临床应用可行性和AGI严重程度对临床预后的评估意义。方法2014年3至8月在浙江省14个综合医院ICU内连续招募550例预期入住ICU〉24h的患者，前瞻性采集患者临床、实验室和生存数据，患者入ICU后第1周每日进行胃肠道症状、肠内喂养状况以及合并器官功能障碍评估，采用AbViser系统测定腹腔内压（IAP），综合评估患者AGl分级。结果入选患者平均年龄为（64．9±17．2）岁；APACHEⅡ评分为（19．5±7．4）分，456例（82．9％）患者接受机械通气治疗；470例患者发生AGI，其中，人ICU第1天AGI分级分别为50。6％（I级，n=238），34．2％（Ⅱ级，n=161），12．4％（Ⅲ级，n=58）和2．8％（Ⅳ级，n=13），而综合患者ICU7d内最高AGI分级分别为24．5％（I级，n=115），49．4％（Ⅱ级，n=232），20．6％（Ⅲ级，n=97）和5．5％（Ⅳ级，n=26）；28d和60d病死率分别为29．3％和32．5％。与非AGI患者相比，AGI患者28d（31．1％比18．8％，P=0．025）和60d病死率（34．7％比20．0％，P=0．01）显著增加，AGl分级严重程度与患者28d和60d病死风险增加呈显著正相关。单因素Cox回归分析示：年龄、入ICU内科来源、脓毒症、2型糖尿病、冠心病，缩血管药物使用、血乳酸和肌酐、接受机械通气、入ICU综合AGI分级和APACHEⅡ评分与60d病死预后显著相关（P≤0．02）；多因素Cox回归分析示：ICU内科来源（x2=4．34，P=0．04）、2型糖尿病（x2=3．96，P=0．015）、血管活性药物使用（x2=6．55，P=0．01）、血乳酸（x2=4．73，P=0．03）、入ICU综合AGI分级（x2=7．10，P=0．008）和APACHEII评分（x2=12．1，P〈0．001）是预测重症患者60d病死独立危险因素。此外，402例7d存活患者亚组分析显示：在入ICU第1天AGI分级和临床因素预测死亡的基础上，7d喂养不耐受能提供�Objective To investigate the feasibility of utilizing the current acute gastrointestinal injury（AGI） grading system, and explore the association of severity of AGI grade with clinical outcome in critically ill patients. Methods The adult patients from 14 general ICUs in Zhejiang Province with an expected admission to ICU for at least 24 h were recruited, and all clinical, laboratory, and survival data were prospectively collected. The AGI grade was daily assessed based on GIsymptoms, feeding details and organ dysfunctionon the first week of admission to ICU. The intra-abdominal pressures （IAP） was measured using AbViser device. Results Of 550 patients enrolled, mean values for age and APACHE II score were （64. 9 ± 17.2 ） years and （ 19. 5 ±7. 4）, respectively. 456 patients （82. 9% ） took mechanical ventilation, and 470 patients were identified for AGI. The distribution of AGI grade on the frist day of ICU admission were 50. 6%（ I grade, n=238）, 34. 2%（ II grade, n=161）, 12.4%（ III grade, n=58） and 2. 8% （IV, n = 13 ）, respectively, while the distribution of the global AGI grade based on the 7-day AGI assessment of ICU admission were 24. 5% （ I grade, n = 115）, 49.4% （ II grade, n = 232）, 20. 6% （ Ill grade, n =97） and 5.5% （ IV, n =26）, respectively. 28- and 60-day mortality rate was 29. 3% （n = 161） and 32. 5% （n = 179）, respectively. The patients with AGI had a higher 28-（31.1% vs 18.8%, P= 0. 025） and 60-day survival rate（34. 7% vs 20. 0% ,P = 0, 01 ） than those with non-AGI, and also there were positive correlations between AGI grade and 28- and 60-day mortality （ P 〈 0. 001 ）. Univariate Cox regression analysis showed that age, the source of medicial admission, diabetes mellitus, coronary heart disease, the use of vasoactive drugs, serum creatinine and lactate, mechanical ventilation, APACHE II score, the AGI grade in the first day of ICU admission and feeding intolerance within the first week of ICU stay were significantly （P ≤

关 键 词：危重病 胃肠疾病 肠营养 耐受 

分 类 号：R57[医药卫生—消化系统]