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
7期
601-605
,共5页
岳茂奎%刘芙蓉%赵蕾%张福森%王春亭
嶽茂奎%劉芙蓉%趙蕾%張福森%王春亭
악무규%류부용%조뢰%장복삼%왕춘정
急性呼吸窘迫综合征%集束化治疗%血液滤过%病死率
急性呼吸窘迫綜閤徵%集束化治療%血液濾過%病死率
급성호흡군박종합정%집속화치료%혈액려과%병사솔
Acute respiratory distress syndrome%Bundles%Hemofiltration%Mortality
目的：探讨中/重度急性呼吸窘迫综合征（ARDS）患者集束化治疗的疗效。方法采用与历史对照的前瞻性观察研究方法，纳入山东省泰安市中心医院重症医学科及河北省邯郸市中心医院重症医学科18～65岁、符合2011年ARDS柏林标准的肺内源性因素所致的中/重度ARDS患者共73例。以2012年9月至2014年5月为前瞻性观察期（集束化治疗组，33例）；以2010年1月至2012年8月为历史对照期（对照组，40例）。集束化治疗组在积极治疗原发病的基础上采用集束化治疗，包括：限制性液体管理、呼吸支持治疗、大剂量沐舒坦联合血必净注射液、呼吸机相关性肺炎（VAP）的预防、制定个体化镇静方案、重症患者应用连续性血液净化治疗；成立ARDS集束化治疗小组以保证各项措施顺利执行。比较两组患者治疗后5 d急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分和氧合指数，以及患者机械通气时间、重症加强治疗病房（ICU）住院时间、VAP发生率及28 d病死率。结果两组患者性别、年龄、病因构成、病情严重程度等基础特征比较差异均无统计学意义（均P＞0.05），有可比性。与对照组比较，集束化治疗组治疗后APACHEⅡ评分无明显变化（分：15.1±2.8比16.2±3.0，t＝1.618，P＝0.110），氧合指数明显增加〔mmHg（1 mmHg＝0.133 kPa）：135.4±34.5比117.1±34.2，t＝-2.273，P＝0.026〕，机械通气时间明显缩短（d：8.70±2.50比10.10±2.67，t＝2.308，P＝0.024），VAP发生率明显下降〔18.2%（6/33）比32.5%（13/40），χ2＝5.027，P＝0.025〕，28 d病死率明显降低〔24.2%（8/33）比37.5%（15/40），χ2＝4.372，P＝0.037〕，但在两组间ICU住院时间差异无统计学意义（d：10.40±1.94比11.30±2.34，t＝1.620，P＝0.110）。结论集束化治疗干预能缩短中/重度ARDS患者的机械通气时间，减少VAP发生率，改善患者预后。
目的：探討中/重度急性呼吸窘迫綜閤徵（ARDS）患者集束化治療的療效。方法採用與歷史對照的前瞻性觀察研究方法，納入山東省泰安市中心醫院重癥醫學科及河北省邯鄲市中心醫院重癥醫學科18～65歲、符閤2011年ARDS柏林標準的肺內源性因素所緻的中/重度ARDS患者共73例。以2012年9月至2014年5月為前瞻性觀察期（集束化治療組，33例）；以2010年1月至2012年8月為歷史對照期（對照組，40例）。集束化治療組在積極治療原髮病的基礎上採用集束化治療，包括：限製性液體管理、呼吸支持治療、大劑量沐舒坦聯閤血必淨註射液、呼吸機相關性肺炎（VAP）的預防、製定箇體化鎮靜方案、重癥患者應用連續性血液淨化治療；成立ARDS集束化治療小組以保證各項措施順利執行。比較兩組患者治療後5 d急性生理學與慢性健康狀況評分繫統Ⅱ（APACHEⅡ）評分和氧閤指數，以及患者機械通氣時間、重癥加彊治療病房（ICU）住院時間、VAP髮生率及28 d病死率。結果兩組患者性彆、年齡、病因構成、病情嚴重程度等基礎特徵比較差異均無統計學意義（均P＞0.05），有可比性。與對照組比較，集束化治療組治療後APACHEⅡ評分無明顯變化（分：15.1±2.8比16.2±3.0，t＝1.618，P＝0.110），氧閤指數明顯增加〔mmHg（1 mmHg＝0.133 kPa）：135.4±34.5比117.1±34.2，t＝-2.273，P＝0.026〕，機械通氣時間明顯縮短（d：8.70±2.50比10.10±2.67，t＝2.308，P＝0.024），VAP髮生率明顯下降〔18.2%（6/33）比32.5%（13/40），χ2＝5.027，P＝0.025〕，28 d病死率明顯降低〔24.2%（8/33）比37.5%（15/40），χ2＝4.372，P＝0.037〕，但在兩組間ICU住院時間差異無統計學意義（d：10.40±1.94比11.30±2.34，t＝1.620，P＝0.110）。結論集束化治療榦預能縮短中/重度ARDS患者的機械通氣時間，減少VAP髮生率，改善患者預後。
목적：탐토중/중도급성호흡군박종합정（ARDS）환자집속화치료적료효。방법채용여역사대조적전첨성관찰연구방법，납입산동성태안시중심의원중증의학과급하북성함단시중심의원중증의학과18～65세、부합2011년ARDS백림표준적폐내원성인소소치적중/중도ARDS환자공73례。이2012년9월지2014년5월위전첨성관찰기（집속화치료조，33례）；이2010년1월지2012년8월위역사대조기（대조조，40례）。집속화치료조재적겁치료원발병적기출상채용집속화치료，포괄：한제성액체관리、호흡지지치료、대제량목서탄연합혈필정주사액、호흡궤상관성폐염（VAP）적예방、제정개체화진정방안、중증환자응용련속성혈액정화치료；성립ARDS집속화치료소조이보증각항조시순리집행。비교량조환자치료후5 d급성생이학여만성건강상황평분계통Ⅱ（APACHEⅡ）평분화양합지수，이급환자궤계통기시간、중증가강치료병방（ICU）주원시간、VAP발생솔급28 d병사솔。결과량조환자성별、년령、병인구성、병정엄중정도등기출특정비교차이균무통계학의의（균P＞0.05），유가비성。여대조조비교，집속화치료조치료후APACHEⅡ평분무명현변화（분：15.1±2.8비16.2±3.0，t＝1.618，P＝0.110），양합지수명현증가〔mmHg（1 mmHg＝0.133 kPa）：135.4±34.5비117.1±34.2，t＝-2.273，P＝0.026〕，궤계통기시간명현축단（d：8.70±2.50비10.10±2.67，t＝2.308，P＝0.024），VAP발생솔명현하강〔18.2%（6/33）비32.5%（13/40），χ2＝5.027，P＝0.025〕，28 d병사솔명현강저〔24.2%（8/33）비37.5%（15/40），χ2＝4.372，P＝0.037〕，단재량조간ICU주원시간차이무통계학의의（d：10.40±1.94비11.30±2.34，t＝1.620，P＝0.110）。결론집속화치료간예능축단중/중도ARDS환자적궤계통기시간，감소VAP발생솔，개선환자예후。
ObjectiveTo investigate the efficacy of bundle treatment on patients with moderate or severe acute respiratory distress syndrome (ARDS).Methods A multicenter prospective observational study comparing the result of historical treatment strategy and bundle treatment was conducted. According to the new Berlin standard of definition, 73 patients with moderate or severe ARDS due to pulmonary factors, age from 18 to 65 years, admitted to Department of Critical Care Medicine of Taian Central Hospital and Handan Central Hospital were enrolled. Thirty-three patients admitted during September 2012 to May 2014 (prospective observation period) were enrolled as the bundle treatment group. Forty patients with matched disease history admitted from January 2010 to August 2012 were enrolled as the control group. The patients in bundle treatment group received bundle treatment based on the treatment strategy of primary diseases. Bundle treatment included restrictive fluid management, respiratory support, high-dose ambroxol combined with Xuebijing injection, prevention of ventilation associated pneumonia (VAP), individualized sedation plan, installation of continuous blood purification treatment for critical patients. A special team was organized to ensure the successful implementation of all bundle measures. The acute physiology and chronic health evaluationⅡ (APACHEⅡ) score, oxygenation index, duration of mechanical ventilation, the length of intensive care unit (ICU) stay, incidence of VAP, and 28-day mortality 5 days after treatment were compared between two groups.Results There were no significant differences in basic characteristics of patients between the two groups, including gender, age, etiology, severity, etc. (allP> 0.05) with comparability. Compared with the control group, there was no significant difference in APACHEⅡ score 5 days after treatment in bundle treatment group (15.1±2.8 vs. 16.2±3.0,t = 1.618,P = 0.110). Compared with control group, oxygenation index in bundle treatment group was significantly improved [mmHg (1 mmHg = 0.133 kPa): 135.4±34.5 vs. 117.1±34.2,t = -2.273,P = 0.026), the duration of mechanical ventilation was obviously reduced (days: 8.70±2.50 vs. 10.10±2.67,t = 2.308,P = 0.024), incidence of VAP was significantly lower [18.2% (6/33) vs. 32.5% (13/40),χ2 = 5.027,P = 0.025], and 28-day mortality rate was obviously lowered [24.2% (8/33) vs. 37.5% (15/40),χ2 = 4.372,P = 0.037], the length of ICU stay shown no statistical difference (days:10.40±1.94 vs. 11.30±2.34,t = 1.620,P = 0.110).Conclusion Implementation of bundle treatment can significantly shorten the duration of mechanical ventilation, reduce the incidence of VAP, and improve the prognosis of patients.
