危重患者全身皮下水肿分布特征的临床研究

目的探讨重症患者全身皮下水肿的分布特征和相关危险因素及皮下水肿的严重程度对预后的影响。 方法采用简单随机抽样法对入住上海交通大学医学院附属瑞金医院重症医学科24 h内重症患者的7个区域36个位点进行皮下水肿半定量评估，采用按压凹陷试验并根据皮肤恢复时间将水肿分为4级。同时收集诊断、APACHE Ⅱ评分、器官功能等相关临床和实验室资料。采用二元logistic回归筛选全身及易发部位皮下发生水肿的影响因素及皮下水肿严重程度对预后的作用，采用受试者工作特征曲线来检验预后模型的预测效能。 结果研究共纳入135例重症患者，其中37例（27.4%）出现皮下水肿。36个测量位点皮下水肿得分中位数为0.61（0.31，0.78），其中腹壁皮下水肿的发生率最高（86.5%），水肿程度为0.75（0.5，1.25）。在上肢越接近远心端，皮下水肿的发生率和程度越高，对于胸壁、腹壁、大腿和小腿，越接近重力依赖区，皮下水肿的发生率和程度越高。Logistic回归结果显示APACHE Ⅱ评分（＞15分）和入科诊断（脓毒症）是全身及易发部分皮下水肿发生的危险因素。此外，全身皮下水肿总分为危重患者ICU住院内死亡的危险因素（OR=1.03，95% CI：1.00~1.06，P=0.038）。 结论重症患者存在不同部位、不同程度的皮下水肿，其在全身分布具有不均质性，更易发生于腹壁并呈现重力依赖性分布。重症患者具有皮下水肿发生的多个独立危险因素，且皮下水肿严重程度与不良预后密切相关，应得到足够的重视。

Distribution characteristics of generalized subcutaneous edema in critically ill patients

ObjectiveTo investigate the distribution characteristics and risk factors associated with generalized subcutaneous edema in critically ill patients and the impact of the severity of subcutaneous edema on prognosis. MethodsSemi-quantitative assessment of subcutaneous edema was performed at 36 sites in seven body parts of critically ill patients within 24 hours of admission to the Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine using convenience sampling, and the edema was classified into seven grades using the pressure depression test and according to the skin recovery time. Relevant clinical and laboratory data such as diagnosis, APACHE Ⅱ score, and organ function were also collected. ResultsBinary logistic regression was used to screen for factors influencing the occurrence of subcutaneous edema in the whole body and susceptible parts, and the role of the severity of subcutaneous edema on prognosis. The median subcutaneous edema score at the 36 measurement sites was 0.61 (0.31, 0.78), with the highest incidence of subcutaneous edema in the abdominal wall (86.5%), with a degree of edema of 0.75 (0.5, 1.25). Logistic regression showed that APACHE Ⅱ score (＞15) and admission diagnosis (sepsis) were risk factors for the development of subcutaneous edema in the general and vulnerable parts of the body. In addition, total systemic subcutaneous edema score was a risk factor for death within the ICU stay of critically ill patients (odds ratio=1.03, 95% confidence interval: 1.00~1.06, P=0.038). ConclusionCritically ill patients have subcutaneous edema at different sites and to different degrees, which is characterized by a heterogeneous distribution throughout the body, is more likely to occur in the abdominal wall, and shows a gravity-dependent distribution. The severity of subcutaneous edema is associated with a poor prognosis in critically ill patients.