机械通气并发应激性溃疡危险因素的Logistic回归分析

目的:探讨机械通气患者并发应激性溃疡的相关危险因素。方法:回顾我科急诊重症监护病房收治250例机械通气患者,对机械通气患者并发应激性溃疡相关危险因素进行单因素及多因素Logistic回归分析。结果:单因素分析显示机械通气患者并发应激性溃疡的危险因素包括年龄、意识障碍、APACHEⅡ评分、机械通气时间、白蛋白含量、呼吸机相关性肺炎(P0.05)。多因素Logistic回归分析显示意识障碍、APACHEⅡ评分、机械通气时间是机械通气患者并发应激性溃疡的独立危险因素(P0.05)。结论:对于有意识障碍、高APACHEⅡ评分以及可能需要长时间机械通气的患者要引起重视,及早地进行应激性溃疡的预防性治疗以及尽量缩短机械通气时间。     

重度颅脑损伤继发脑梗死危险因素分析

目的探讨重度颅脑损伤继发外伤性脑梗死（traumatic cerebral infarction,TCI）的危险因素。方法对126例重度颅脑损伤及合并伤患者就发生TCI进行单因素和多因素Logistic回归分析。结果继发TCI47例,脑梗死组与非梗死组在低血压、脑挫裂伤、蛛网膜下腔出血、脑疝、低血压时间、脑疝时间、糖尿病（或血糖≥11．1mol／L持续24h以上）、伤后或术后机械通气〈48h比较差异均有显著性（P〈0．05）,以上8因素均是发生TCI的重要危险因素;Logistic回归分析显示脑挫裂伤、伤后或术后机械通气〈48h、低血压时间、脑疝时间是发生TCI的独立危险因素。结论脑挫裂伤、伤后或术后机械通气〈48h、低血压时间、脑疝时间、低血压、蛛网膜下腔出血、脑疝、糖尿病（或血糖≥11．1mol／L持续24h）是重度颅脑损伤继发TCI的危险因素,其中脑挫裂伤、伤后或术后机械通气〈48h、低血压时间、脑疝时间是独立危险因素。     

颅脑损伤患者应激障碍与认知功能的关系

目的：探讨颅脑损伤患者创伤后应激障碍和认知功能的关系。方法：选择2003-01／2004—12在鹤壁矿务局总医院脑外科门诊及住院的76例颅脑损伤患者（符合颅脑损伤诊断标准，年龄≥18岁）为观察对象。排除严重并发症及其他严重躯体疾病。患者在发病后3个月采用创伤后应激障碍诊断标准进行是否合并创伤后应激障碍的确诊。创伤后应激障碍诊断标准包括4个方面的内容：①遭受异乎寻常的创伤性事件或处境。②参反复重现创伤性体验。③持续的警觉性增高。④对与刺激相似或有关的情境的回避。根据检测结果分出应激障碍组和无应激障碍组。选用湖南医科大学龚耀先修订的中国书氏成人智力测验量表对两组患者进行认知功能进行评估和调查，韦氏成人智力测验量表分语言（知识、领悟、算术、相似性和数字广度）和操作（词汇、数字符号、填图、木快、图形排列、图形拼凑）两部分11项分测验。评分越低，说明认知功能损害越严重。并与正常人常模比较。结果：参加测试的76例颅脑损伤患者，均进人结果分析。①76例颅脑损伤患者遭遇车祸事件后3个月时创伤后确诊成激障碍患者17例（应激障碍组），无应激障碍患者59例（无应激障碍组），患病率为22％。②应激障碍组患者与正常人常模韦氏成人智力测验量表智测成绩中，应激障碍患者的知识、领悟、算术、相似性、数字广度、词汇、数字符号、填图、木块图、图形排列、图形拼凑评分均明显低于正常人常模（t=2．65-8．25，P〈0.05）。（彭在韦氏成人智力测验培表智测成绩中应激障碍组患者的知识、算术、数字广度、数字符号、填图、木块图、图形排列、图形拼凑评分明显低于无应激障碍组（t=2.24-3．84，P〈0．05）。结论：颅脑损伤患者常伴有很高的应激障碍发病半及认知功能损害，颅脑损伤患者的应激障碍与认知功能密切相关.     

多发伤合并中重型颅脑损伤凝血功能障碍的相关因素分析

目的探讨多发伤合并中重型颅脑损伤凝血功能障碍的相关因素分析。方法回顾性分析2017年1月-2019年1月在我院神经外科收治的78例多发伤合并中重型颅脑损伤患者,入院后48 h检测凝血功能,按是否有凝血功能障碍分为两组,对照组30例为非凝血功能障碍,观察组48例为凝血功能障碍,比较两组患者的一般资料,并进行多因素Logistic回归分析。结果观察组在合并休克、限制性液体复苏、GCS评分、合并胸腹部损伤、多发脑挫裂伤、重型颅脑损伤均明显高于对照组(P<0.05);多因素Logistic回归分析显示,合并休克、限制性液体复苏、多发脑挫裂伤、合并胸腹部损伤、酗酒史是独立危险因素。结论多发伤合并中重型颅脑损伤凝血功能障碍是影响预后的重要因素,而凝血功能障碍与合并休克、限制性液体复苏、多发脑挫裂伤、合并胸腹部损伤、酗酒史有密切关联,临床应尽早实施限制性液体复苏,防止凝血障碍的高危因素,力争改善预后。     

影响颅脑损伤预后相关因素病例对照研究

目的探讨影响颅脑损伤预后的相关因素及预防对策。方法回顾性分析220例颅脑损伤患者的临床资料,将重残或病死患者作为观察组,按照1∶1比例选择痊愈或轻度功能障碍患者作为对照组,比较两组可能影响预后相关因素上的差异。结果 220例患者中重残或病死患者60例,占27.27%。单因素检验结果显示12个变量是影响预后的相关因素(P<0.05);Logistic回归分析影响预后的危险因素为:平均动脉压低、血糖水平高、发热、年龄大,危险因素暴露比值(OR)分别为3.56、3.15、2.78、2.43。结论影响颅脑损伤预后相关因素复杂,应尽可能减少低血压的发生和持续时间,控制高血糖,积极处理发热,加强老年疾病的处理。     

应激性溃疡早期预警因素临床分析研究

目的:探讨应激性溃疡早期预警因素。方法:93例急性应激性溃疡患者按照发病时主要诊断分为颅脑疾病组和非颅脑疾病组,对比分析两组患者出血方式及应激性溃疡相关病死率;93例急性应激性溃疡患者按照是否治愈分为治愈组和应激性溃疡相关死亡组,对比两组出血发生早期(24h内)血红蛋白水平、红细胞压积、心率、平均动脉压、血清胆碱酯酶、动脉血pH值、动脉血碱剩余、D-二聚体等指标的差异。结果:①颅脑疾病组和非颅脑疾病组在年龄、性别构成、出血方式及应激性溃疡治愈率方面差异无统计学意义(P>0.05)。②应激性溃疡治愈组与应激性溃疡相关死亡组间心率、碱剩余(BE)、D二聚体水平两组比较差异有统计学意义(P<0.05)。结论:应激性溃疡并发出血是危重症患者死亡的危险因素之一,发病24h内心率增快、D二聚体增高、碱剩余增加是提示应激性溃疡严重性的早期预警因素。     

氧化应激在MODS患者应激性溃疡形成中的作用

<正>1971年Lucas等〔1〕首次报道了应激性溃疡,危重症患者存在多种发生应激性溃疡的危险因素。据报道,多器官功能障碍综合征(multiple organ dysfunction syndrome,MODS)等危重症患者的应激性胃黏膜损伤的发生率为75%~100%。应激性溃疡将增加MODS患者的病死率和ICU住院时间,因此MODS患者应激性溃疡的预防和治疗显得尤为重要。     

重型颅损伤160例颅外并发症分析

目的：探讨重型颅脑损伤病人颅外并发症对预后的影响。方法：分析160例重型颅脑损伤病人颅外各种并发症以及预后的关系。结果：电解质紊乱发生率近2／3，但对预后影响不大，肺部感染、低血压、应激性溃疡、肾功能不全对预后有明显影响，凝血功能障碍为自限性疾病。结论；重型颅脑损伤病人的预后不仅取决于颅内因素，颅外并发症对其预后也有非常重要的作用。积极防治颅外并发症可降低死亡率，提高疗效。     

重型颅脑损伤并发应激性溃疡237例原因分析及护理对策

目的：探讨重型颅脑损伤并发应激性溃疡的原因及护理。方法：回顾分析2006-01/2008-06我科收治的237例重型颅脑损伤患者,密切观察病情,监测生化指标,合理的饮食及发生应激性溃疡后的积极护理。结果：237例患者,并发应激性溃疡72例,占30.3%,经保守治疗消化道出血症状完全消失。结论：积极预防和良好的护理降低了颅脑损伤并发应激性溃疡的发生率。     

重度颅脑损伤行机械通气患者肠内营养中误吸的相关因素分析与护理

机械通气是抢救重度颅脑损伤患者常用的治疗方法,重型颅脑损伤患者由于创伤或应激等因素,组织细胞代谢旺盛,能量消耗过度,机体多处于负氮平衡状态,易出现营养不良、免疫功能低下等并发症.     

Risk factors for clinically important upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group

OBJECTIVE: To evaluate the incidence and risk factors for clinically important upper gastrointestinal bleeding in critically ill patients requiring mechanical ventilation. DESIGN: In duplicate, blinded adjudicators determined the presence of clinically important gastrointestinal bleeding using a priori criteria, evaluating relevant clinical, laboratory, and diagnostic data. Cox proportional hazards regression analyses were used to examine baseline and time-dependent risk factors for bleeding. SETTING: Sixteen university-affiliated intensive care units (ICUs) in Canada. PATIENTS: A total of 1,077 critically ill ICU patients ventilated for at least 48 hrs. INTERVENTIONS: Patients were randomized to stress ulcer prophylaxis with intravenous ranitidine or nasogastric sucralfate; otherwise, management was at the discretion of the ICU team. MEASUREMENTS AND MAIN RESULTS: Demographic data included patient characteristics, Acute Physiology and Chronic Health Evaluation II score, and multiple organ dysfunction (MOD) score. Each day in the ICU, physiologic measurements including MOD score, feeding, and other treatment variables were recorded. The significant risk factors for upper gastrointestinal bleeding in the univariable analyses were low platelet count, maximum serum creatinine, maximum MOD score, maximum pulmonary component of the MOD score, maximum hepatic component of the MOD score, maximum renal component of the MOD score, enteral nutrition, and stress ulcer prophylaxis with ranitidine. The only independent predictors of bleeding in the multivariable analysis were maximum serum creatinine (relative risk = 1.16 [95% confidence interval = 1.02-1.32]), enteral nutrition (relative risk = 0.30 [95% confidence interval = 0.13-0.67]), and ranitidine administration (relative risk = 0.39 [95% confidence interval = 0.17-0.83]). CONCLUSIONS: In critically ill ventilated patients, renal failure was independently associated with an increased risk of clinically important gastrointestinal bleeding, whereas enteral nutrition and stress ulcer prophylaxis with ranitidine conferred significantly lower bleeding rates.     

外科重症患者压疮发生高危因素分析

目的：探讨外科重症患者压疮发生相关危险因素,为制定预防压疮的有效措施提供依据。方法：采用自设外科重症患者压疮危险因素调查表收集某三级甲等医院47例外科重症患者资料,将其中发生院内压疮的14例患者设为压疮组,未发生压疮的33例患者设为对照组,两组间对20项指标进行单因素分析及多因素Logistic回归分析,找出压疮发生的危险因素。结果：单因素分析显示,压疮组在ICU住院期间去甲肾上腺素使用总计小时数、动脉血乳酸最高值、机械通气总天数、血液净化治疗天数、排便失禁天数5项指标值高于对照组,差异有统计学意义（P〈0.05）;多因素Logistic回归分析显示,去甲肾上腺素使用总计小时数、动脉血乳酸最高值是压疮发生的高危因素（P〈0.05）。结论：应针对压疮高危人群和危险因素采取有针对性的措施,积极控制原发病,在抢救的同时采取积极的减压措施,以提高危重患者压疮防控的护理质量。     

Prospective endoscopic study of stress erosions and ulcers in critically ill neurosurgical patients: current incidence and effect of acid-reducing prophylaxis

We studied prospectively 40 critically ill neurosurgical patients who required prolonged mechanical ventilation to determine the current incidence of stress-related gastroduodenal erosions and ulcers, and to assess endoscopically the efficacy of acid-reducing prophylactic treatment. Nineteen patients were randomized to receive ranitidine plus antacids if necessary to maintain gastric pH at greater than or equal to 4. The remaining 21 patients were given no drug prophylaxis. Gastric pH was significantly (p less than .001) higher in the treated group: 78% of pH readings were at greater than or equal to 4 as compared to 32% in the control group. However, after five study days, incidence and severity of stress lesions were similar in the two groups: nine patients in each group had more than five erosions, one treated patient had a gastric ulcer, and one control patient had duodenal ulcerations. No patient experienced clinically relevant upper GI bleeding. The lack of severe stress bleeding and the low ulcer rate contrast with results from earlier reports on similar patient populations. Furthermore, drug prophylaxis had no detectable benefit, as assessed endoscopically. These findings suggest that routine stress lesion prophylaxis may not be necessary in critically ill patients with comparable risk factors.     

医院获得性急性肾功能衰竭的病死危险因素分析调查及临床对策

目的调查医院获得性急性肾功能衰竭(肾衰)的病死率及死亡危险因素。方法回顾性调查1991～1996年的1056例危重病患者,利用队列研究方法对医院获得性急性肾衰患者死亡危险因素进行分析。结果1　056例危重病患者中,143例发生急性肾衰,病死率64.34%。患者平均APACHEⅡ评分(24.20±8.53)分,而Liano急性肾衰预后评分(ATNISS)为(72.46±25.58)%。单纯急性肾衰的住院病死率为0,而急性肾衰合并肾外器官衰竭数目越多,患者的病死率越高。合并1个肾外器官衰竭者病死率25.00%,2个肾外器官衰竭者为47.62%,3个肾外器官衰竭者为81.58%,而发生4个肾外器官功能衰竭者病死率达90.20%。22个因素参与急性肾衰死亡危险因素的单因素分析,结果显示年龄(>60岁)、免疫功能低下、APACHEⅡ评分(>20分)、非手术、全身性炎症反应的程度、严重全身性感染、感染性休克、器官衰竭数目、机械通气、昏迷、低血压、黄疸及少尿等因素均与急性肾衰死亡关系显著(P均<0.05)。急性肾衰患者的最常见的直接病死原因是顽固性感染性休克(46.74%)。结论充分认识急性肾衰死亡的危险因素,并积极控制机体炎症反应,防治多器官功能衰竭,可能是降低急性肾衰病死率的关键。     

Helicobacter pylori infection: a risk factor for upper gastrointestinal bleeding after cardiac surgery?

OBJECTIVE: To determine the prevalence of Helicobacter pylori (H. pylori) in critically ill patients who develop upper gastrointestinal bleeding after cardiac surgery in relation to other risk factors. DESIGN: Prospective, single center, cohort study. SETTING: Surgical intensive care unit in a university hospital. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Over a 1-yr period, all consecutive patients with upper gastrointestinal hemorrhage from the stomach or duodenum were studied for H. pylori infection by serology. Additionally, the need for mechanical ventilation over 48 hrs, the duration cardiopulmonary bypass, and the aortic cross-clamp time were analyzed. For control, 229 patients with no evidence of gastrointestinal hemorrhage after cardiac surgery were studied. All patients received stress ulcer prophylaxis with ranitidine. Operations were performed on 2,956 patients during the study period. The incidence of upper gastrointestinal bleeding was 0.9%. Twenty (77%) of the 26 patients with upper gastrointestinal bleeding and 145 (63%) patients of the control group had serologic evidence for H. pylori infection (odds ratio, 1.9; 95% confidence interval 0.7-5.0; p = .2). Patients who required prolonged mechanical ventilation had a significantly greater risk for upper gastrointestinal bleeding (odds ratio, 22.1; 95% confidence interval 8.6-56.7; p<.001). Patients with upper gastrointestinal bleeding also had a significantly longer duration of cardiopulmonary bypass and aortic cross-clamp time (p<.001) CONCLUSIONS: H. pylori is not associated with upper gastrointestinal bleeding in critically ill patients who receive stress ulcer prophylaxis, whereas patients who require prolonged mechanical ventilation are at high risk. A prophylactic eradication of H. pylori is not justified.     

颅脑外伤患者呼吸机相关肺炎的危险因素及非药物性护理

目的探讨颅脑外伤患者呼吸机相关肺炎发生的相关因素,为临床危重患者的非药物性预防护理提供依据。方法回顾性调查重症监护病房颅脑外伤行机械通气患者的相关临床资料,采用χ^2检验,分析呼吸机相关肺炎的相关因素。结果机械通气患者300例,发生呼吸性相关肺炎患者164例,发生率为54．66％;不同年龄、原发肺部疾病、机械通气时间、胃内容物吸入等呼吸性肺炎的发生率不同（P〈0．01）。结论颅脑外伤行机械性通气患者易发生呼吸性相关肺炎,且直接影响预后,经过采取非药物性预防护理措施,控制易患因素,有效降低呼吸性相关肺炎的发生。     

Effect of critical illness polyneuropathy on the withdrawal from mechanical ventilation and the length of stay in septic patients

OBJECTIVES: No previous study has demonstrated whether critical illness polyneuropathy itself lengthens mechanical ventilation or whether this prolonged duration of ventilatory support is explained by concomitant risk factors for weaning failure. Our objectives were to evaluate the impact of critical illness polyneuropathy on the length of mechanical ventilation after controlling for coexisting risk factors for weaning failure and to assess the impact of critical illness polyneuropathy on the length of the stay in a cohort of septic patients. DESIGN: Prospective cohort study. SETTING: Intensive care unit of a tertiary hospital. PATIENTS: All patients with severe sepsis or septic shock who required mechanical ventilation for > or =7 days who were considered ready to discontinue mechanical ventilation. INTERVENTIONS: Patients underwent a neurophysiologic evaluation at onset of weaning from mechanical ventilation. MEASUREMENTS AND MAIN RESULTS: Sixty-four critically ill septic patients were enrolled, and 34 developed critical illness polyneuropathy (53.1%; 95% confidence interval, 40.2-65.7%). Length of mechanical ventilation was significantly higher in patients who had developed critical illness polyneuropathy (median 34 days vs. 14 days, p < .001). The duration of the weaning period was also significantly greater in patients with critical illness polyneuropathy (median 15 days vs. 2 days, p < .001) even though factors suspected to influence the weaning process did not differ between these two groups. Multiple logistic regression analysis indicated that critical illness polyneuropathy was the only risk factor independently associated with weaning failure (odds ratio, 15.4; 95% confidence interval, 4.55, 52.3; p < .001). Lengths of intensive care unit and hospital stays were significantly higher in patients with critical illness polyneuropathy. CONCLUSIONS: In critically ill septic patients, critical illness polyneuropathy significantly increases the duration of mechanical ventilation and prolongs the lengths of intensive care unit and hospital stays.     

抑酸治疗在应激溃疡中预防性治疗的作用及不良反应

应激性溃疡（SU）是指机体在各类严重创伤、危重疾病等严重应激状态下,发生的急性消化道糜烂、溃疡等病变,最后可导致消化道出血、穿孔,并使原有病变恶化。有文献报道,危重症患者发病1-3d,使用胃镜检查可发现大约75%至100%的患者出现胃黏膜损伤〔1〕。而以隐性出血（粪隐血试验     

Stress-related mucosal disease in the intensive care unit: an update on prophylaxis

Gastric ulcers have been known to develop in critically ill patients secondary to physiological stress since the 19th century. It is only relatively recently that stress ulcer prophylaxis has become an established routine practice in the intensive care unit. Numerous terms have been used to describe stress ulcers, but stress-related mucosal disease (SRMD) is commonly used. Significant morbidity and mortality in critically ill patients is caused by SRMD and related bleedings, but the incidence depends on the definition of bleeding. Pathophysiology of SRMD is multifactorial and involves a complex set of interactions that causes a breakdown of mucosal proactive defenses, leading to ulceration. Critically ill patients are at an increased risk for developing SRMD and subsequent bleeding secondary to several risk factors. To minimize stress-related mucosal bleeding, several regimens have been used. This article presents an update on the incidence, pathophysiology, risk factors, and prophylaxis of SRMD.