机械通气患者并发消化道出血的危险因素分析

Risk Factors of Gastrointestinal Bleeding in Patients Receiving Mechanical Ventilation

目的探讨机械通气患者并发消化道出血的危险因素。方法回顾2007年1月~2009年12月在我院ICU住院的91例机械通气（≥48 h）并发消化道出血的临床资料,配对选取91例同期住院的性别相同、年龄差距不超过2岁的机械通气但无消化道出血的患者作为对照组。结果机械通气患者消化道出血的发生率为12.4%（91/736）,logistic回归分析显示镇静不充分（OR=3.728,95%CI=1.377~10.093）、血小板减少（OR=2.269,95%CI=0.876~5.588）、休克（OR=2.25,95%CI=1.109~4.959）为机械通气患者发生消化道出血的三项独立危险因素。根据出血程度将消化道出血分为轻度出血（显性出血）67例（73.4%）,重度出血（临床严重出血）24例（26.6%）。轻度出血组镇静不充分比例明显高于对照组（22.4%vs.6.6%,P=0.004）,病死率与对照组无显著差异（P=0.264）。重度出血组APACHⅡ评分高于对照组[（20.5±7.5）分vs.（17.5±5.4）分,P=0.024],肾功能衰竭（45.8%vs.11.0%,P=0.000）、休克（45.8%vs.15.4%,P=0.003）、血小板减少（33.3%vs.8.8%,P=0.005）等发生比例均明显高于对照组,病死率明显增高（58.3%vs.7.7%,P=0.000）。结论镇静不充分,血小板减少,休克为机械通气患者发生消化道出血的三项独立危险因素,其中镇静不充分在轻度出血中较为突出。重度出血与肾功能衰竭、休克、血小板减少有关,为病情笃重的标志,预后差,死亡风险明显增高。

Objective To identify risk factors of gastrointestinal bleeding（GI bleeding） in patients receiving mechanical ventilation.Methods A retrospective study was conducted at the ICU,Peking University Third Hospital.We reviewed the medical records of the patients with GI bleeding who received mechanical ventilation for more than 48 hours between January 2007 and December 2009.Data of 91 patients with GI bleeding were collected,and 91 patients without GI bleeding were set as a control group.Results The incidence of GI bleeding in patients receiving mechanical ventilation was 12.4%（91/736）.Logistic regression analysis showed that inadequate sedation（OR=3.728,95%CI=1.377-10.093）,thrombocytopenia（OR=2.269,95%CI=0.876-5.588）,and shock（OR=2.25,95%CI=1.109-4.959） were three independent risk factors for GI bleeding.We divided all the bleeding population into 2 groups according to its effect on patient＇s hemodynamic state： mild bleeding（overt bleeding,67 cases,73.4%） and severe bleeding（clinically important bleeding,24 cases,26.6%）.The overt bleeding group had significantly higher incidence of inadequate sedation than the control group（22.4% vs.6.6%,P=0.004）,but no significant difference in mortality between the two groups.The severe group showed significantly higher APACH Ⅱ score（20.5±7.5 vs.17.5±5.4,P=0.024） and higher incidence rates of renal failure（45.8% vs.11.0%,P=0.000）,shock（45.8% vs.15.4%,P=0.003）,thrombocytopenia（33.3% vs.8.8%,P=0.005）,and mortality（58.3% vs.7.7%,P=0.000） than the control group.Conclusions Inadequate sedation,thrombocytopenia and shock are three independent risk factors for GI bleeding in patients receiving mechanical ventilation.Inadequate sedation is especially prominent in mild bleeding patients.Severe bleeding is correlated with renal failure,shock and thrombocytopenia and can be a sign of deterioration of the disease and worse outcomes.