协和医学杂志

2016, v.7(05) 371-378

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重症医学科严重大出血患者预后危险因素
Risk Factors Related to Outcome of Patients with Severe Massive Hemorrhage in Intensive Care Unit

周翔;刘大为;隆云;姚波;苏龙翔;
ZHOU Xiang;LIU Da-wei;LONG Yun;YAO Bo;SU Long-xiang;Intensive Care Unit,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences &Peking Union Medical College;

摘要(Abstract):

目的探讨影响重症医学科病房(Intensive Care Unit,ICU)严重大出血患者预后的危险因素。方法回顾性分析北京协和医院2013年1月至2015年12月全部收住ICU 24 h内输注红细胞(red blood cell,RBC)超过20 U的大出血患者的临床资料,比较生存组与死亡组的差异,并采用Logistic回归分析影响这些患者预后的危险因素。结果研究共纳入严重大出血患者141例,生存组和死亡组患者分别为78例和63例,住院死亡率44.7%。其中非手术相关大出血78例,手术相关大出血63例。全部严重大出血患者死亡组ICU输RBC量(P=0.002)、非手术相关大出血患者的比例(P=0.002)以及来自急诊的大出血患者的比例(P=0.010)均显著高于生存组,而来自手术科室患者的比例低于生存组(P=0.001),输RBC前凝血功能,肝、肾功能明显较生存组差(P均<0.05)。在非手术相关大出血患者中,死亡组感染造成大出血患者的比例显著高于生存组(P=0.009),而应激性溃疡导致大出血患者的比例(P=0.048)、输RBC前血小板水平(P=0.003)和采用手术止血措施的患者比例(P=0.039)均显著低于生存组。在手术相关大出血患者中,死亡组ICU输RBC量显著多于生存组(P=0.019),输RBC前基线肝、肾功能受损的比例显著高于生存组(P均<0.05)。Logistic回归分析显示患者凝血功能紊乱(P=0.014,OR=3.594)及入ICU后仍存在活动性大出血(P=0.025,OR=2.680)为全部严重大出血患者死亡危险因素。结论患者凝血功能紊乱及入ICU后仍存在活动性大出血是严重大出血患者的死亡危险因素。
Objective To investigate the risk factors related to outcome of patients with severe massive hemorrhage in Intensive Care Unit( ICU). Methods Clinical data of all patients receiving transfusion of red blood cell( RBC) of > 20 U for severe massive hemorrhage,who were hospitalized between January 2013 and December 2015 in ICU of Peking Union Medical College Hospital,were analyzed retrospectively. Comparisons were conducted between patients who died( death group) and those survived( survival group). Risk factors related to outcome were analyzed with Logistic regression. Results A total of 141 patients were identified,of whom78 survived. In-hospital mortality was 44. 7%( 63 /141). Among these patients with severe massive hemorrhage,there were 78 non-operation-related cases and 63 operation-related cases. The amount of RBC transfused in ICU( P = 0. 002),the proportion of non-operation-related cases( P = 0. 002),and the proportion of patients fromemergency department( P = 0. 010) were all significantly higher in the death group than in the survival group,while the proportion of patients from surgical departments was lower in the death group than in the survival group( P = 0. 001). The baseline coagulation,renal,and liver function before RBC transfusion were significantly worse in the death group than in the survival group( all P < 0. 05). Among the patients with non-operation-related severe massive hemorrhage,the death group had significantly higher proportion of severe massive hemorrhage due to infections( P = 0. 009),but significantly lower proportion of severe massive hemorrhage due to stress ulcer( P =0. 048),baseline platelet level( P = 0. 003),and proportion of patients receiving surgical hemostasis( P =0. 039). Among the patients with operation-related severe massive hemorrhage,the death group had higher volume of RBC transfusion in ICU( P = 0. 019),but higher proportions of patients with liver or renal function impairment before RBC transfusion( both P < 0. 05). Logistic regression analysis showed that coagulation disorders( P = 0. 014,OR = 3. 594) and the presence of active massive hemorrhage after admission into ICU( P = 0. 025,OR = 2. 680) were risk factors for death in the patients with severe massive hemorrhage. Conclusion For all the patients with severe massive hemorrhage,coagulation disorders and the presence of active massive hemorrhage in ICU may be risk factors for death.

关键词(KeyWords): 严重大出血;预后;危险因素;手术止血;重症医学科病房
severe massive hemorrhage;outcome;risk factor;surgical hemostasis;intensive care unit

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作者(Author): 周翔;刘大为;隆云;姚波;苏龙翔;
ZHOU Xiang;LIU Da-wei;LONG Yun;YAO Bo;SU Long-xiang;Intensive Care Unit,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences &Peking Union Medical College;

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