Risk Factors Related to Outcome of Patients with Severe Massive Hemorrhage in Intensive Care Unit
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摘要:
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。 Abstract: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 whom 78 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 from emergency 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. -
Key words:
- severe massive hemorrhage /
- outcome /
- risk factor /
- surgical hemostasis /
- intensive care unit
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表 1 全部严重大出血患者生存组和死亡组比较
项目 生存组(n=78) 死亡组(n=63) P值 年龄(M,岁) 56 (41 ~68) 59 (52 ~69) 0.121 性别(男/女,例) 47/31 45/18 0.213 基础疾病(有/无,例) 心血管系统疾病 29/49 26/37 0.621 呼吸系统疾病 6/72 2/61 0.298 肾病 6/72 8/55 0.323 肝病 10/68 3/60 0.100 神经系统疾病 2/76 6/57 0.139 血液病 2/76 7/56 0.078 糖尿病 7/71 12/51 0.082 总输RBC量(M,U) 25 (22 ~34) 28 (22 ~36) 0.194 ICU输RBC量(M,U) 10 (4 ~22) 20 (12 ~37) 0.002 出血原因(手术/非手术,例) 44/34 19/44 0.002 科室来源[例(%)] 内科 13(16.7) 10(15.9) 0.899 手术科室 52(66.7) 24(38.1) 0.001 急诊 8(10.3) 17(27.0) 0.010 输RBC前基线资料 Hb(g/L) 75.0(67 ~93) 74.0(68 ~85) 0.906 PLT(×109/L) 102.0(60 ~153) 65.0(43 ~106) 0.004 ALT(U/L) 20.0(11.3~42.8) 29.0(15 ~94.5) 0.008 TBIL(μmol/L) 18.7(10.3~32.8) 26.0(11.9~73.7) 0.021 DBIL(μmol/L) 7.0(3.6~17.7) 12.9(5.1~48.8) 0.013 PT(s) 14.5(13.2~16.6) 14.3(12.8~17.8) 0.774 APTT(s) 39.8(32.3~48.3) 44.2(34.2~59.2) 0.043 Cr(μmol/L) 70.5(50.3~139) 117.0(74.5~185.5) 0.007 BUN(mmol/L) 9.6(4.9~18.2) 11.0(6.3~11.0) 0.367 治疗措施[例(%)] 药物止血 58(74.4) 51(81.0) 0.353 介入栓塞止血 2(2.6) 5(7.9) 0.242 手术止血 15(19.2) 7(11.1) 0.187 内镜止血 3(3.8) 0(0) 0.502 止血后再次出血[例(%)] 38(48.7) 28(44.4) 0.613 出血距止血治疗间隔(d) 1(1~3) 1(1~4.5) 0.807 RBC:红细胞;ICU:重症医学科病房;Hb:血红蛋白;PLT:血小板;ALT:丙氨酸氨基转移酶;TBIL:总胆红素;DBIL:直接胆红素;PT:凝血酶
原时间;APTT:活化部分凝血活酶时间;Cr:肌酐;BUN:尿素氮表 2 非手术相关大出血患者生存组和死亡组比较
项目 生存组(n=34) 死亡组(n=44) P值 年龄(M,岁) 58 (50 ~68) 59.5(54.3~74.3) 0.461 性别(男/女,例) 25/9 30/14 0.608 基础疾病(有/无,例) 心血管系统疾病 14/20 18/26 0.981 呼吸系统疾病 4/30 2/42 0.395 肾病 5/29 7/37 0.884 肝病 3/31 1/43 0.312 神经系统疾病 1/33 5/39 0.224 血液病 2/32 6/38 0.454 糖尿病 2/32 8/36 0.172 总输RBC量(M,U) 22 (21 ~34) 25 (21 ~36) 0.452 ICU输RBC量(M,U) 17 (8 ~23) 20 (16 ~24) 0.278 出血原因[例(%)] 感染 3(8.8) 15(34.1) 0.009 血液病 9(26.5) 12(27.3) 0.937 应激性溃疡 12(35.3) 7(15.9) 0.048 创伤 3(8.8) 4(9.1) 1.000 肿瘤 4(11.8) 3(6.8) 0.693 其他 3(8.8) 3(6.8) 1.000 出血部位(消化道/非消化道,例) 17/17 18/26 0.423 科室来源[例(%)] 急诊 7(20.6) 15(34.1) 0.189 基本外科 6(17.6) 8(18.2) 0.951 ICU 5(14.7) 8(18.2) 0.683 心外科 3(8.8) 3(6.8) 1.000 肝脏外科 2(5.9) 0(0) 0.187 风湿免疫科 2(5.9) 0(0) 0.187 骨科 2(5.9) 0(0) 0.187 血液内科 1(2.9) 3(6.8) 0.628 肾内科 0(0) 2(4.5) 0.502 其他 6(17.6) 5(11.3) 0.519 输RBC前基线资料 Hb(g/L) 72.0(62.3~81.0) 74.0(69 ~82) 0.476 PLT(×109/L) 119.0(74.3~166) 65.0(42 ~124) 0.003 ALT(U/L) 21.0(12 ~50.8) 22.0(15 ~89) 0.230 TBIL(μmol/L) 17.6(9.2~30.9) 26.0(10 ~62.2) 0.216 DBIL(μmol/L) 6.4(3.5~18.3) 11.9(4.5~38.3) 0.095 PT(s) 14.0(13.2~16.0) 14.3(12.8~17.4) 0.829 APTT(s) 36.7(31.8~47.2) 42.1(34.3~58.7) 0.051 Cr(μmol/L) 83.0(55.5~220.8) 126.0(75 ~201) 0.386 BUN(mmol/L) 9.6(6.0~16.7) 12.9(5.6~18.4) 0.587 治疗措施[例(%)] 药物止血 24(70.6) 38(86.4) 0.087 手术止血 6(17.6) 1(2.3) 0.039 介入栓塞止血 1(2.9) 5(11.4) 0.224 内镜止血 3(8.8) 0(0) 0.079 止血后再次出血[例(%)] 12(35.3) 16(36.4) 1.000 出血距止血治疗间隔(d) 1.5(1~3) 1(1~2) 0.642 RBC、ICU、Hb、PLT、ALT、TBIL、DBIL、PT、APTT、Cr、BUN:同表 1 表 3 非手术大出血患者中消化道大出血和非消化道大出血患者生存组和死亡组治疗措施比较
组别 消化道大出血患者 非消化道大出血患者 例数 治疗措施[例(%)] 例数 治疗措施[例(%)] 药物止血 手术止血 介入栓塞止血 内镜止血 药物止血 手术止血 介入栓塞止血 生存组(n=34) 17 9(52.9) 5(29.4) 1(5.9) 2(11.8) 17 15(88.2) 1(5.9) 0(0) 死亡组(n=44) 18 15(83.3) 0(0) 3(16.7) 0(0) 26 23(88.5) 1(3.8) 2(7.7) P值 0.053 0.019 0.603 0.229 1.000 1.000 0.511 表 4 手术相关大出血患者生存组和死亡组比较
项目 生存组(n=44) 死亡组(n=19) P值 年龄(x±s,岁) 52±18 56±15 0.365 性别(男/女,例) 22/22 10/9 0.320 基础疾病(有/无,例) 心血管系统疾病 15/29 8/11 0.544 呼吸系统疾病 2/42 0/19 1.000 肾病 1/43 1/18 0.516 肝病 7/37 2/17 0.711 神经系统疾病 1/43 1/18 0.516 血液病 0/44 1/18 0.302 糖尿病 5/39 4/15 0.434 总输RBC量(M,U) 26(22~34) 33(28~42) 0.057 ICU输RBC量(M,U) 14(2~14) 16(8~28) 0.019 出血部位[例(%)] 腹盆腔 29(65.9) 13(68.4) 1.000 胸腔和肺泡 6(13.6) 1(5.3) 0.664 心包纵膈 4(9.1) 3(15.8) 0.422 肢体血管 3(6.8) 0(0) 0.547 消化道 2(4.5) 2(10.5) 0.578 科室来源[例(%)] 基本外科 11(25.0) 7(36.8) 0.102 妇产科 8(18.1) 0(0) 0.093 肝脏外科 5(26.3) 5(26.3) 0.153 心外科 5(11.4) 2(10.5) 1.000 泌尿外科 4(9.1) 0(0) 0.306 骨科 3(6.8) 0(0) 0.547 其他 7(15.9) 5(26.3) 0.274 输RBC前基础资料 Hb(g/L) 77.5(70.8~86.3) 76.0(65.8~93.3) 0.940 PLT(×109/L) 89.5(55.3~141.3) 65.5(43.2~99.8) 0.187 ALT(U/L) 18.5(8.0~42.3) 54.5(17.3~244) 0.008 TBIL(μmol/L) 18.8(11.3~34.3) 27.5(18.9~95.2) 0.015 DBIL(μmol/L) 7.6(4.4~18.3) 14.3(8.0~68.5) 0.030 PT(s) 14.9(13.2~17.1) 14.5(12.6~19.4) 0.822 APTT(s) 41.3(33.3~49.6) 47.1(33.4~47.1) 0.226 Cr(μmol/L) 64.5(37.8~116.3) 99.5(70.5~183.8) 0.040 BUN(mmol/L) 9.3(4.5~32.6) 8.6(6.6~19.7) 0.468 治疗措施[例(%)] 药物止血 34(77.3) 13(68.4) 0.533 手术止血 9(20.5) 6(31.6) 0.353 介入栓塞止血 1(2.3) 0(0) 1.000 术后再次出血[例(%)] 26(59.1) 12(63.2) 0.762 出血距止血治疗间隔(d) 1(1~3) 1(1~6) 0.881 RBC、ICU、Hb、PLT、ALT、TBIL、DBIL、PT、APTT、Cr、BUN:同表 1 表 5 全部严重大出血患者死亡危险因素Logisctic回归分析结果
项目 B SE Wald P值 OR值 95% CI 输RBC前肾功能损伤 0.156 0.425 0.134 0.714 1.169 (0.508, 2.687) 输RBC前凝血功能紊乱 1.279 0.523 5.982 0.014 3.594 (1.289, 10.017) 输RBC前肝功能损伤 0.740 0.483 2.353 0.125 2.096 (0.814, 5.398) 入ICU后仍存在活动性大出血 0.986 0.440 5.020 0.025 2.680 (1.131, 6.350) 出血原因为手术出血 -0.779 0.462 2.848 0.091 0.459 (0.185, 1.134) 来源科室为手术科室 -0.466 0.498 0.874 0.350 0.628 (0.236, 1.667) 来源科室为急诊 0.254 0.612 0.173 0.678 1.289 (0.389, 4.276) RBC、ICU:同表 1 -
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