神经内科重症监护病房内医院获得性肺炎的危险因素：回顾性病例系列研究

Risk factors for hospital-acqtdred pneumonia in a neurological intensive care unit： a retrospective case series study

目的探讨神经内科重症监护病房（neurological intensive care unit，NICU）内医院获得性肺炎（hospital—acquired pneumonia，HAP）的危险因素。方法纳入2010年5月至2011年4月期间入住南方医院NICU≥48h且年龄≥18岁的患者，回顾性调查其一般资料、入住NICU24h内最差格拉斯哥昏迷量表（GlasgowComaScale，GCS）评分以及急性生理功能和慢性健康状况评分（Acute Physiologyand Chronic Health Evaluation，APACHE）1I、是否发生HAP、在研究时间范围内是否存在某些基础疾病或症状、使用特定药物治疗或侵袭性操作等可能的危险因素，同时记录连续性医疗干预措施的持续时间，并对连续型变量进行量化分层。结果共纳入243例患者，其中HAP50例（20．6％）。单变量分析显示，HAP组昏迷（44．0％对29．0％；X^2=4．091，P=0．043）和APACHEII评分≥15分（60．0％对38．9％；X^2=7．232，P=0．007）的比例显著高于非HAP组，两组间使用抗酸药（〈6d：38．0％对19．7％；≥6d：18．0％对25．9％；X^2=7．521，P=0．023）、使用镇静药（〈2d：30．0％对37．3％；≥2d：46．0％对28．O％；Y。=6．064，P=0．048）、使用血液制品（〈3d：24．0％对9．8％；≥3d：6．0％对7．3％；X^2=7．150，P=0．028）、气管插管（〈5d：24．0％对10．9％；≥5d：26．0％对15．5％；X^2=10．698，P=0．005）、机械通气（〈4d：6．0％对7．8％；≥4d：30．0％对7．8％，X^2=18．132，P=0．000）和留置鼻胃管（〈7d：56．O％对37．3％；≥7d：42．0％对44．6％；X^2=10．410，P=0．005）存在显著性差异。多变量logistic回归分析显示，机械通气≥4d[优势比（oddsratio，OR）6．481，95％可信区间（confidenceinterval，C／）2．522～16．654；JP=0．000]、留置鼻胃管〈7d（OR12．504，95％CI 1．614～96．869；P=0．016）和使用抗酸药〈6d（OR2．271，95％C／1．042～4．949；P=0．039）为NICU患者发生HAP的独立危险因素。结论机械通气、留置鼻胃管和使用抗酸药为NICU患者发生HAP的独立危险因素，需采取有针对性的措施。

Objective To investigate the risk factors for hospital-acquired pneumonia （HAP） in a neurological intensive care unit （NICU）. Methods The patients aged ≥ 18 years admitted in NICU of Nanfang Hospital for≥ 48 hours from May 2010 to April 2011 were enrolled. The possible risk factors, including the general information, the worst Glasgow Coma Scale （GCS） score, as well as Acute Physiology and Chronic Health Evaluation （APACHE） U scores within 24 hours in NICU, whether the occurrence of HAP, whether with some underlying disease or symptoms within the time of study and using specific drug therapy or invasive procedures were investigated retrospectively. The duration of continuous medical interventions was recorded at the same time, and the Continuous variables were quantified and stratified. Results A total of 243 patients were enrolled, and 50 （20. 6% ） of them developed HAP. Univariate analysis showed that the proportions of coma （44.0% vs. 29. 0%;X^2 =4.091, P=0.043） and APACHE Ⅱscore ≥15 （60.0% vs. 38.9%;X^2 =7.232, P = 0. 007） in the HAP group were significantly higher than those in the non-HAP group. There were significant differences in using antacids （ 〈6 d： 38. 0% vs. 19. 7% ; ≥6 d： 18. 0% vs. 25.9% ;X^2 =7. 521, P =0. 023）, sedatives （ 〈2 d： 30. 0% vs. 37. 3% ; ≥2 d： 46. 0% vs. 28. 0% ;X^2 =6. 064, P =0. 048）, blood products （ 〈 3 d： 24. 0% vs. 9. 8% ; I〉 3 d： 6. 0% vs. 7. 3% ; X^2 = 7. 150, P = 0. 028）, endotracheal intubation （ 〈 5 d： 24.0% vs. 10.9%; ≥5d： 26.0% vs. 15.5%;Xz= 10.698, P=0.005）, mechanical ventilation （〈4 d： 6. 0% vs. 7. 8% ; ≥ 4 d： 30. 0% vs. 7. 8% ; X^2 =, P = 0. 000） and indwelling nasogastric tube （ 〈 7 d： 56. 0% vs. 37. 3% ; ≥7d： 42. 0% vs. 44. 6% ;X^2 = 10. 410, P =0. 005） between the two groups. Multivariate logistic regression analysis showed that mechanical ventilation 1〉 4 d （odds ratio [ OR] 6. 481, 95% confidence interval [ CI] 2. 522 - 16. 654; P =0. 000）, indwelling nasogastric tube 〈 7 d （OR 12. 504, 95% CI 1. 614 - 96. 869; P =0. 016） and using antacids 〈 6 d （OR 2. 271, 95% CI 1. 042 - 4. 949; P = 0. 039） were the independent risk factors for HAP in NICU patients. Condusions Mechanical ventilation, indwelling nasogastric tube and using antacids are the independent risk factors for HAP in NICU patients, and thus it needs to take targeted measures.