缺血性脑卒中并机械通气患者发生呼吸机相关性肺炎危险因素及预后分析  

Risk factors of ventilator associated pneumonia and prognosis analysis of cerebral stroke patients with mechanical ventilation

作　　者：安媛[1] 周大伟[2] 石广志[2] An Yuan;Zhou Dawei;Shi Guangzhi(Department of Neurology,Beijing Tiantan Hospital,Capital Medical University,Beijing 100070,China;Department of Critical Care Medicine,Beijing Tiantan Hospital,Capital Medical University,Beijing 100070,China)

机构地区：[1]首都医科大学附属北京天坛医院神经内科,北京100070 [2]首都医科大学附属北京天坛医院重症医学科,北京100070

出　　处：《中华实验和临床感染病杂志（电子版）》2021年第3期164-170,共7页Chinese Journal of Experimental and Clinical Infectious Diseases(Electronic Edition)

基　　金：北京市科技计划课题(No.Z201100005520039)。

摘　　要：目的探讨影响入住重症监护室(ICU)的缺血性脑卒中并机械通气患者预后的相关因素及发生呼吸机相关性肺炎(VAP)的危险因素。方法采用回顾性队列研究方法,收集重症监护数据库(MIMIC-Ⅳ)中入住美国波士顿贝斯以色列女执事医疗中心ICU的2013年1月至2018年12月使用有创机械通气且出院第一诊断为缺血性脑卒中的患者。暴露因素为VAP发生与否,根据入组患者出院诊断记录中是否诊断为VAP分为VAP组(31例)和非VAP组(238例)。收集患者年龄、性别、体重指数、缺血性脑卒中分型、临床并发症(高血压病、糖尿病、慢性心力衰竭、慢性阻塞性肺疾病、慢性肾功能不全、恶性肿瘤病史及心房颤动)、格拉斯哥昏迷评分(GCS)、序贯器官衰竭评分(SOFA)、咽反射及咳嗽反射、机械通气当日血常规等。结局指标为机械通气时间、ICU入住及住院时间、ICU及院内病死率等。采用多因素Logistic回归分析探讨影响缺血性脑卒中并机械通气患者预后的相关因素及发生VAP的危险因素。结果共纳入269例入住ICU并使用机械通气的缺血性脑卒中患者,其中31例(11.5%)患者发生VAP。VAP组患者机械通气时间[234(178,327)h vs.82(59,149)h,Z=6.519、P<0.001]、ICU入住时间[13.0(10.0,17.5)d vs.5.0(3.0,9.0)d,Z=5.988、P<0.001]和住院时间[18.0(11.5,25.0)d vs.10.0(5.0,17.0)d,Z=3.936、P<0.001]均显著高于非VAP组患者,差异均有统计学意义。多因素回归分析显示:机械通气时间[优势比(OR)=1.13、95%可信区间(CI):1.06~1.24、P=0.005)]、体重指数(OR=1.14、95%CI:1.05~1.26、P=0.004)和淋巴细胞计数(OR=0.27、95%CI:0.11~0.61、P=0.002)均为发生VAP的危险因素;年龄(OR=1.04、95%CI:1.01~1.08、P=0.009)、GCS评分(OR=0.88、95%CI:0.78~0.97、P=0.017)和机械通气时间(OR=1.08、95%CI:1.01~1.17、P=0.048)均为影响缺血性脑卒中并机械通气患者预后的因素。VAP的发生(OR=1.01、95%CI:0.31~3.09、P=0.967)并非影响患者Objective To investigate the prognosis of ischemic stroke patients with mechanical ventilation who were admitted to intensive care unit(ICU)and the risk factors of ventilator-associated pneumonia(VAP).Methods This retrospective cohort study included adult ischemic stroke patients with mechanical ventilation who were admitted to ICU from January 2013 to December 2018 in MIMIC-Ⅳdatabase of Beth Israel Deaconess Medical Center in America.The exposure was VAP.Age,gender,body mass index,ischemic stroke classification,disease history(hypertension,diabetes mellitus,chronic heart failure,chronic obstructive pulmonary disease,chronic renal insufficiency,history of malignancy and atrial fibrillation),Glasgow coma score(GCS),sequential organ failure score(SOFA),gag reflex and cough reflex,blood routine on the day of mechanical ventilation were collected.The outcome indexes were duration of mechanical ventilation,ICU and hospital duration,ICU and hospital mortality.Risk factors of VAP and the prognosis of ischemic stroke patients with mechanical ventilation were analyzed by multivariate Logistic regression.Results Total of 269 patients with ischemic stroke and mechanical ventilation were enrolled,among whom,31(11.5%)had VAP.Compared with non-VAP patients,the duration of mechanical ventilation[234(178,327)hours vs.82(59,149)hours;Z=6.519,P<0.001],ICU duration(13.0(10.0,17.5)days vs.5.0(3.0,9.0)days,Z=5.988,P<0.001)and hospital duration[18.0(11.5,25.0)days vs.10.0(5.0,17.0)days,Z=3.936,P<0.001]were all significantly longer than those of VAP patients,with significant differences.Multivariate regression analysis showed that duration of mechanical ventilation[odds ratio(OR)=1.13,95%confidence interval(CI):1.06-1.24,P=0.005],body mass index(OR=1.14,95%CI:1.05-1.26,P=0.004)and lymphocyte count(OR=0.27,95%CI:0.11-0.61,P=0.002)were all risk factors for VAP;age(OR=1.04,95%CI:1.01-1.08,P=0.009),GCS score(OR=0.88,95%CI:0.78-0.97,P=0.017)and duration of mechanical ventilation(OR=1.08,95%CI:1.01-1.17,P=0.048)were risk factors for the pr

关 键 词：缺血性脑卒中 呼吸机相关性肺炎 危险因素 病死率 

分 类 号：R743.3[医药卫生—神经病学与精神病学] R563.1[医药卫生—临床医学]