重症监护室医院获得性肺炎发病及预后危险因素分析

Incidence, risk and prognostic factors of pneumonia acquired at intensive care units

目的了解教学医院监护室（ＩＣＵ）内获得性肺炎的发病及预后危险因素，为制定相应防治措施作参考。方法以近２年上海中山医院外科监护室（ＳＩＣＵ）、呼吸监护室（ＲＩＣＵ）及华山医院综合监护室（ＧＩＣＵ）１０８例医院获得性肺炎及同期各ＩＣＵ未发生肺炎的５０例患者为对象，采用回顾性病例对照分析，用ＳＰＳＳ软件，作Ｌｏｇｉｓｔｉｃ回归，筛选和分析ＩＣＵ相关危险因素。结果综合分析医院内获得性肺炎（ＨＡＰ）发病危险因素，筛选出恶性肿瘤、应用制酸剂、意识障碍、留置导尿、机械通气５个发病危险因素，其发病相对危险度分别为６７２８、５５７４、３３０４、１０６６、１０４９。比较各ＩＣＵ的发病危险度，ＧＩＣＵ中意识障碍和机械通气者发病危险度增高。ＲＩＣＵ发病危险因素为慢性阻塞性肺疾病（ＣＯＰＤ）、制酸剂和机械通气。ＳＩＣＵ以前期呼吸道感染为发病危险因素。ＨＡＰ死亡相对危险度则随意识障碍加重、存在前期呼吸道感染、有吸烟史及机械通气时间延长而加大。结论各ＩＣＵ其发病危险因素有所不同。考虑为各ＩＣＵ收治的病种不同和相应诊疗措施有别所致。不同类型ＩＣＵ应根据各自的特点和发病危险因素，采用相应的预防措施。制酸剂作为ＨＡＰ发病的重要危险因?

Objective To estimate the incidence of pneumonia acquired in the intensive care unit, and to define risk factors for developing such an event. Method A total of 158 patients were retrospectively analyzed and 108 of them acquied pneumonia at ICU of Zhongshan Hospital (surgical ICU and respiratory ICU) and Huashan Hospital (general ICU) from January 1996 to November 1997. Statistical analysis was made using SPSS, odds ratios and stepwise logistic regression analysis were used to determine the interrelationships between multiple variables. Statistical significance was predetermined to include p values of <0.05. Result The following five factors were significantly (P<0.05) associated with HAP: cancer [OR=6.73, 95% CI=1.58 to 28.59], treatment with H2blockers (OR=5.5742, CI=1.94 to 15.99), decreased consciousness (OR=3.30, CI=1.52 to 7.18), use of urethral catheters (OR=1.07, CI=1.01 to 1.13), and mechanical ventilation (OR=1.05, CI=1.00 to 1.01). The risk facors for HAP were different among different ICU. The risk of developing pneumonia increased when depressed level of consciousness and mechanical ventilation were present at general ICU. Factors significantly predisposing to HAP were underlying COPD, using H2blockers and mechanical ventilation at respiratory ICU, and previously lower respiratory tract infection was the risk factor for HAP in surgical ICU. The following factors were associated with a signficantly higher fatality rate in HAP patients: depressed level of consciousness (P=0.02), previously lower respiratory tract infection (P=0.001), and longtime mechanical ventilation (P=0.03). Conclusion The risk factors for HAP were different among different ICU, which may be related to the difference of patients with an ultimately or a rapidly fatal underlying illness admitted to these units. 