中华危重病急救医学
中華危重病急救醫學
중화위중병급구의학
Chinese Critical Care Medicine
2015年
4期
263-269
,共7页
金魁%郭琳红%邵敏%周树生%刘宝
金魁%郭琳紅%邵敏%週樹生%劉寶
금괴%곽림홍%소민%주수생%류보
百草枯%中毒%血液灌流%灌流强度%救治%预后
百草枯%中毒%血液灌流%灌流彊度%救治%預後
백초고%중독%혈액관류%관류강도%구치%예후
Paraquat%Poisoning%Hemoperfusion%Intensity of hemoperfusion%Treatment%Prognosis
目的：探讨不同血液灌流（HP）强度对急性百草枯中毒患者7 d和28 d预后的影响，并分析影响医师临床开具不同强度HP处方的相关因素。方法采用回顾性队列研究方法，选择2012年8月至2014年8月安徽医科大学附属省立医院危重症医学科收治的急性百草枯中毒患者，纳入年龄＞18岁、口服百草枯至入院时间＜12 h、24 h内接受HP治疗、入院后存活时间＞24 h且资料完整的患者，根据HP强度分为低强度组（LHP组，单次HP 4 h，2个灌流器）和高强度组（HHP组，单次HP 6 h、3个灌流器）。记录患者入院时相关资料及7 d、28 d预后情况，采用多元logistic回归模型评估入院时导致急性百草枯中毒患者接受HHP治疗的相关因素。建立Cox比例风险回归模型进行多因素分析，评价HHP是否可降低7 d、28 d全因病死率。结果最终入选60例百草枯中毒患者，其中LHP组28例，7 d全因病死率53.6%（15例），28 d全因病死率64.3%（18例）；HHP组32例，7 d全因病死率43.8%（14例），28 d全因病死率62.5%（20例）。与LHP组比较，HHP组患者入院时血药浓度较高，合并呼吸性碱中毒（呼碱）、急性肾损伤（AKI）者较多，乳酸（Lac）较高，但7 d全因病死率较低。多变量logistic回归模型显示，对于服毒至入院时间＞4 h〔优势比（OR）＝1.461，95%可信区间（95%CI）＝1.132～1.435，P＜0.001〕、年龄＜50岁（40～49岁的OR＝1.397，95%CI＝1.251～1.703，P＝0.002；＜40岁的OR＝1.701，95%CI＝1.253～1.836，P＜0.001），及入院时血药浓度≥2 mg/L（OR＝3.140，95%CI＝1.511～3.091，P＜0.001）、白细胞计数（WBC）＞10×109/L（OR＝1.222，95%CI＝1.032～1.275，P＝0.018）、Lac＞2.0 mmol/L（OR＝2.392，95%CI＝2.090～2.734，P＜0.001）、合并AKI（AKI 2期OR＝2.350，95%CI＝2.160～3.910，P＜0.001；AKI 3期OR＝2.821，95%CI＝1.932～3.651，P＜0.001）、合并低氧血症（OR＝2.420，95%CI＝2.131～2.662，P＝0.003）的患者，医师更倾向于采用HHP治疗。与存活组比较，死亡组患者年龄较大，入院时和HP 4 h血药浓度较高，合并AKI者较多，入院时血肌酐（SCr）、 WBC、 Lac、急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分较高，动脉血二氧化碳分压（PaCO2）、pH值较低。Cox回归模型计算风险比（HR）并校正混杂因素后显示，HHP为患者7 d生存的保护因素（HR＝0.843，95%CI＝0.732～0.971，P＝0.032），但不是28 d生存的保护因素（HR＝0.930，95%CI＝0.632～1.411，P＝0.423）；而年龄＞50岁（HR＝1.282，95%CI＝1.050～1.530，P＝0.043）、入院时血药浓度每增加1 mg/L（HR＝2.521，95%CI＝2.371～3.825，P＝0.012）及入院时合并AKI（HR＝3.850，95%CI＝2.071～5.391，P＜0.001）、WBC＞10×109/L（HR＝1.932，95%CI＝1.782～2.171， P＝0.006）、Lac＞2.0 mmol/L（HR＝2.981，95%CI＝2.210～3.792，P＝0.002）、PaCO2＜35 mmHg（HR＝1.772，95%CI＝1.483～2.516，P＝0.008；1 mmHg＝0.133 kPa）是患者28 d死亡的独立危险因素。结论 HHP虽可降低急性百草枯中毒患者7 d全因病死率，但并不能改善患者28 d全因病死率。医师在临床决策患者HP强度时仍存在可改进之处，未来或需要建立更加完善的评估体系，合理使用诸如此类较为昂贵的医疗资源。
目的：探討不同血液灌流（HP）彊度對急性百草枯中毒患者7 d和28 d預後的影響，併分析影響醫師臨床開具不同彊度HP處方的相關因素。方法採用迴顧性隊列研究方法，選擇2012年8月至2014年8月安徽醫科大學附屬省立醫院危重癥醫學科收治的急性百草枯中毒患者，納入年齡＞18歲、口服百草枯至入院時間＜12 h、24 h內接受HP治療、入院後存活時間＞24 h且資料完整的患者，根據HP彊度分為低彊度組（LHP組，單次HP 4 h，2箇灌流器）和高彊度組（HHP組，單次HP 6 h、3箇灌流器）。記錄患者入院時相關資料及7 d、28 d預後情況，採用多元logistic迴歸模型評估入院時導緻急性百草枯中毒患者接受HHP治療的相關因素。建立Cox比例風險迴歸模型進行多因素分析，評價HHP是否可降低7 d、28 d全因病死率。結果最終入選60例百草枯中毒患者，其中LHP組28例，7 d全因病死率53.6%（15例），28 d全因病死率64.3%（18例）；HHP組32例，7 d全因病死率43.8%（14例），28 d全因病死率62.5%（20例）。與LHP組比較，HHP組患者入院時血藥濃度較高，閤併呼吸性堿中毒（呼堿）、急性腎損傷（AKI）者較多，乳痠（Lac）較高，但7 d全因病死率較低。多變量logistic迴歸模型顯示，對于服毒至入院時間＞4 h〔優勢比（OR）＝1.461，95%可信區間（95%CI）＝1.132～1.435，P＜0.001〕、年齡＜50歲（40～49歲的OR＝1.397，95%CI＝1.251～1.703，P＝0.002；＜40歲的OR＝1.701，95%CI＝1.253～1.836，P＜0.001），及入院時血藥濃度≥2 mg/L（OR＝3.140，95%CI＝1.511～3.091，P＜0.001）、白細胞計數（WBC）＞10×109/L（OR＝1.222，95%CI＝1.032～1.275，P＝0.018）、Lac＞2.0 mmol/L（OR＝2.392，95%CI＝2.090～2.734，P＜0.001）、閤併AKI（AKI 2期OR＝2.350，95%CI＝2.160～3.910，P＜0.001；AKI 3期OR＝2.821，95%CI＝1.932～3.651，P＜0.001）、閤併低氧血癥（OR＝2.420，95%CI＝2.131～2.662，P＝0.003）的患者，醫師更傾嚮于採用HHP治療。與存活組比較，死亡組患者年齡較大，入院時和HP 4 h血藥濃度較高，閤併AKI者較多，入院時血肌酐（SCr）、 WBC、 Lac、急性生理學與慢性健康狀況評分繫統Ⅱ（APACHEⅡ）評分較高，動脈血二氧化碳分壓（PaCO2）、pH值較低。Cox迴歸模型計算風險比（HR）併校正混雜因素後顯示，HHP為患者7 d生存的保護因素（HR＝0.843，95%CI＝0.732～0.971，P＝0.032），但不是28 d生存的保護因素（HR＝0.930，95%CI＝0.632～1.411，P＝0.423）；而年齡＞50歲（HR＝1.282，95%CI＝1.050～1.530，P＝0.043）、入院時血藥濃度每增加1 mg/L（HR＝2.521，95%CI＝2.371～3.825，P＝0.012）及入院時閤併AKI（HR＝3.850，95%CI＝2.071～5.391，P＜0.001）、WBC＞10×109/L（HR＝1.932，95%CI＝1.782～2.171， P＝0.006）、Lac＞2.0 mmol/L（HR＝2.981，95%CI＝2.210～3.792，P＝0.002）、PaCO2＜35 mmHg（HR＝1.772，95%CI＝1.483～2.516，P＝0.008；1 mmHg＝0.133 kPa）是患者28 d死亡的獨立危險因素。結論 HHP雖可降低急性百草枯中毒患者7 d全因病死率，但併不能改善患者28 d全因病死率。醫師在臨床決策患者HP彊度時仍存在可改進之處，未來或需要建立更加完善的評估體繫，閤理使用諸如此類較為昂貴的醫療資源。
목적：탐토불동혈액관류（HP）강도대급성백초고중독환자7 d화28 d예후적영향，병분석영향의사림상개구불동강도HP처방적상관인소。방법채용회고성대렬연구방법，선택2012년8월지2014년8월안휘의과대학부속성립의원위중증의학과수치적급성백초고중독환자，납입년령＞18세、구복백초고지입원시간＜12 h、24 h내접수HP치료、입원후존활시간＞24 h차자료완정적환자，근거HP강도분위저강도조（LHP조，단차HP 4 h，2개관류기）화고강도조（HHP조，단차HP 6 h、3개관류기）。기록환자입원시상관자료급7 d、28 d예후정황，채용다원logistic회귀모형평고입원시도치급성백초고중독환자접수HHP치료적상관인소。건립Cox비례풍험회귀모형진행다인소분석，평개HHP시부가강저7 d、28 d전인병사솔。결과최종입선60례백초고중독환자，기중LHP조28례，7 d전인병사솔53.6%（15례），28 d전인병사솔64.3%（18례）；HHP조32례，7 d전인병사솔43.8%（14례），28 d전인병사솔62.5%（20례）。여LHP조비교，HHP조환자입원시혈약농도교고，합병호흡성감중독（호감）、급성신손상（AKI）자교다，유산（Lac）교고，단7 d전인병사솔교저。다변량logistic회귀모형현시，대우복독지입원시간＞4 h〔우세비（OR）＝1.461，95%가신구간（95%CI）＝1.132～1.435，P＜0.001〕、년령＜50세（40～49세적OR＝1.397，95%CI＝1.251～1.703，P＝0.002；＜40세적OR＝1.701，95%CI＝1.253～1.836，P＜0.001），급입원시혈약농도≥2 mg/L（OR＝3.140，95%CI＝1.511～3.091，P＜0.001）、백세포계수（WBC）＞10×109/L（OR＝1.222，95%CI＝1.032～1.275，P＝0.018）、Lac＞2.0 mmol/L（OR＝2.392，95%CI＝2.090～2.734，P＜0.001）、합병AKI（AKI 2기OR＝2.350，95%CI＝2.160～3.910，P＜0.001；AKI 3기OR＝2.821，95%CI＝1.932～3.651，P＜0.001）、합병저양혈증（OR＝2.420，95%CI＝2.131～2.662，P＝0.003）적환자，의사경경향우채용HHP치료。여존활조비교，사망조환자년령교대，입원시화HP 4 h혈약농도교고，합병AKI자교다，입원시혈기항（SCr）、 WBC、 Lac、급성생이학여만성건강상황평분계통Ⅱ（APACHEⅡ）평분교고，동맥혈이양화탄분압（PaCO2）、pH치교저。Cox회귀모형계산풍험비（HR）병교정혼잡인소후현시，HHP위환자7 d생존적보호인소（HR＝0.843，95%CI＝0.732～0.971，P＝0.032），단불시28 d생존적보호인소（HR＝0.930，95%CI＝0.632～1.411，P＝0.423）；이년령＞50세（HR＝1.282，95%CI＝1.050～1.530，P＝0.043）、입원시혈약농도매증가1 mg/L（HR＝2.521，95%CI＝2.371～3.825，P＝0.012）급입원시합병AKI（HR＝3.850，95%CI＝2.071～5.391，P＜0.001）、WBC＞10×109/L（HR＝1.932，95%CI＝1.782～2.171， P＝0.006）、Lac＞2.0 mmol/L（HR＝2.981，95%CI＝2.210～3.792，P＝0.002）、PaCO2＜35 mmHg（HR＝1.772，95%CI＝1.483～2.516，P＝0.008；1 mmHg＝0.133 kPa）시환자28 d사망적독립위험인소。결론 HHP수가강저급성백초고중독환자7 d전인병사솔，단병불능개선환자28 d전인병사솔。의사재림상결책환자HP강도시잉존재가개진지처，미래혹수요건립경가완선적평고체계，합리사용제여차류교위앙귀적의료자원。
ObjectiveTo evaluate the influence of different hemoperfusion (HP) intensity on 7-day and 28-day mortality for patients with paraquat (PQ) poisoning, and examine the factors that may affect the decision of the clinicians to prescribe a high intensity HP.Methods A retrospective cohort study was conducted. The patients admitted to the department of critical care medicine of Anhui Provincial Hospital Affiliated to Anhui Medical University with the diagnosis of PQ poisoning from August 2012 to August 2014, fulfilling the following criteria were enrolled in the study: older than 18 years, interval from ingestion PQ to hospital admission shorter than 12 hours, and receiving HP treatment within 24 hours, and expecting surviving time exceeding 24 hours after admission, and data of the patients available for at least 28 days after admission. Depending on the intensity of HP, patients were assigned to either lower intensity HP group (LHP, defined as receiving HP for less than 4 hours, 2 columns) or higher intensity HP group (HHP, defined as receiving HP longer than 6 hours, 3 columns). Patients' data were retrieved from hospital's electronic database after hospital admission, and the results at 7th day and 28th day were recorded. Multiple logistic regression model was used to determine factors with which the clinician decided to choose the intensity of HP for the patients, and Cox regression model was used to evaluate 7-day and 28-day mortality.Results Data of 60 patients was finally available for this study. LHP group consisted of 28 patients, with a 7-day mortality of 53.6%(15 patients) and 28-day mortality of 64.3% (28 patients); 32 patients were assigned to HHP group with 7-day mortality of 43.8% (14 patients) and 28-day mortality of 62.5% (20 patients). Twenty-eight patients constituted as the HHP group, with higher PQ concentration in plasma, higher incidence of respiratory alkalosis and acute kidney injury (AKI), and higher level of lactate (Lac) compared with LHP group. However, a lower 7-day mortality was observed in the HHP group. Multiple logistic regression model indicated that at admission, interval from ingestion PQ to hospital admission longer than 4 hours [odds ratio (OR) = 1.461, 95% confidence interval (95%CI) = 1.132-1.435,P< 0.001], younger than 50 years old (40-49 years old:OR = 1.397, 95%CI = 1.251-1.703,P = 0.002;< 40 years old:OR = 1.701, 95%CI = 1.253-1.836,P< 0.001), PQ plasma concentration≥ 2 mg/L (OR = 3.140, 95%CI = 1.511-3.091,P< 0.001), white blood cell (WBC)> 10×109/L (OR = 1.222, 95%CI = 1.032-1.275, P = 0.018), Lac> 2.0 mmol/L (OR = 2.392, 95%CI = 2.090-2.734,P< 0.001), AKI on admission (stage 2:OR = 2.350, 95%CI = 2.160-3.910,P< 0.001; stage 3:OR = 2.821, 95%CI = 1.932-3.651,P< 0.001), accompanying hypoxia (OR = 2.420, 95%CI = 2.131-2.662,P = 0.003) were more likely to receive higher intensity of HP. Furthermore when compared with patients survived for 28 days, patients who were older, with higher levels of PQ concentration at admission or after 4 hours of HP, accompanied by AKI, increased serum creatinine (SCr), WBC, Lac, and acute physiology and chronic health evaluationⅡ (APACHEⅡ) score, lower arterial partial pressure of carbon dioxide (PaCO2) and lower pH value were more likely to die. After adjusted for con-variables in COX regression model, HHP was associated with lower 7-day mortality after admission [hazard ratio (HR) = 0.843, 95%CI = 0.732-0.971, P = 0.032], but devoid of lowering effect on 28-day mortality rate (HR = 0.930, 95%CI = 0.632-1.411,P = 0.423). In addition, age> 50 years old (HR = 1.282, 95%CI = 1.050-1.530,P = 0.043), PQ concentration increased by 1 mg/L (HR = 2.521, 95%CI = 2.371-3.825,P = 0.012), AKI on admission (HR = 3.850, 95%CI = 2.071-5.391,P< 0.001), WBC>10×109/L (HR = 1.932, 95%CI = 1.782-2.171,P = 0.006), Lac> 2.0 mmol/L (HR = 2.981, 95%CI =2.210-3.792,P = 0.002), and PaCO2< 35 mmHg (HR = 1.772, 95%CI = 1.483-2.516,P = 0.008; 1 mmHg =0.133 kPa) were independent risk factors for 28-day mortality.Conclusions Though HHP was helpful in lowering mortality rate in patients with PQ poisoning within 7 days, it did not influence on 28-day mortality. Clinicians' decisions on HP intensity need further investigation, and more perfect clinical evaluation system is required for reasonable use of expensive medical resources such as HP.
