外科重症加强治疗病房患者15年死亡原因统计及高危因素分析

Statistics of causes of death and analysis of risk factors in a surgical intensive care unit

目的 分析外科重症加强治疗病房（SICU）患者住院期间的死亡原因及高危因素.方法 回顾性分析1999年12月至2015年2月15年期间第四军医大学附属西京医院SICU死亡患者的相关资料,对比1999年12月至2007年7月（第一时间段）和2007年8月至2015年2月（第二个时间段）两个时间段之间死亡患者的性别、年龄、入院原因、入院时间、入SICU时间、既往史、是否急诊入院、转入科室、是否手术、死亡时间、主要死亡原因、急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分,是否行机械通气、连续性肾脏替代治疗（CRRT）、抗真菌等治疗,以及体温＞39℃、白细胞计数（WBC） ＞10x109/L、血小板计数（PLT）＜100x109/L、白蛋白＜35 g/L的患者比例.同时对比201例SICU住院存活患者的相关资料,采用logistic回归分析死亡的高危因素.结果 1999年12月至2015年2月15年期间SICU共收治4 317例患者,死亡186例,病死率为4.3％;1999年12月至2007年7月第一时间段收治1 356例患者中死亡109例,病死率为8.0％;2007年8月至2015年2月第二时间段收治2 961患者中死亡77例,病死率为2.6％,两个时间段病死率比较差异有统计学意义（x2=66.707, P=0.001）.与第一时间段死亡患者比较,第二时间段死亡患者急诊入院的比例较小[51.9％ （40/77）比79.8％ （87/109）,x2=16.181,P=0.001],白蛋白＜35 g/L的比例较大[59.7％ （46/77）比41.3％ （45/109）,x2=6.151,P=0.017].15年期间所有患者前3位死亡原因分别是脓毒症（38.2％）、外伤（16.7％）、癌症术后（14.0％）;其中第一时间段前3位死亡原因分别是脓毒症（35.8％）、外伤（22.0％）、癌症术后（13.8％）,第二时间段前3位死亡原因是脓毒症（41.6％）、中枢神经系统受损（16.9％）、癌症术后（14.3％）.所有患者转入SICU前3位病因分别是外伤（29.03％）、急腹症（20.97％）和其他（18.82％）;患者转入SICU最多的前3位科室分别是急诊科（19.35％）、骨科（17.20％）、肝胆外科（16.13％）.Logistic回归分析显示：高龄[优势比（OR） =2.025,95％可信区间（95％CI）=1.500 - 2.734,P=0.000]、机械通气（OR=3.514,95％CI=1.701 -7.259, P=0.001）、CRRT （OR=5.604, 95％CI=3.003- 10.459, P=0.000）、体温＞39℃（OR=1.992, 95％CI=1.052- 3.771,P=0.034）为SICU住院患者死亡的高危因素.结论 脓毒症、严重创伤是引起SICU重症患者死亡的主要原因,对合并高危因素的患者应给予足够的重视.

Objective To summarize the causes of death and to analyze the risk factors in a surgical intensive care unit （SICU）.Methods The relevant information of patients died in the SICU of Xijing Hospital of Fourth Military Medical University in past 15 years （from December 1999 to February 2015） was retrospectively analyzed.The gender,age, reason and date of hospitalization, date of transfer SICU, past medical history, whether or not admitted directly from emergency department, or transferred from other department, operated or not, date of death, the main cause of death, acute physiology and chronic health evaluation Ⅱ （APACHE Ⅱ） score, the history of undergoing mechanical ventilation, continuous renal replacement therapy （CRRT）, or antifungal therapy, as well as the ratio of the patients with body temperature higher than 39 ℃, white blood cell （WBC） count higher than 10 x 109/L, platelet （PLT） count below 100x 109/L, albumin （Alb） below 35 g/L of two periods, namely from December 1999 to July 2007 （the first period）,and from August 2007 to February 2015 （the second period） were compared.The above parameters were compared with those of 201 survivors in SICU, and the risk factors leading to death were analyzed by logistic regression.Results From December 1999 to February 2015, 4 317 patients were taken care of in the SICU.Among them, the number of death was 186, and the mortality rate was 4.3%.In the first time period （from December 1999 to July 2007）, the total number of patients was 1 356, and the number of death were 109 （the mortality rate was 8.0%）.In the second period, i.e.from August 2007 to February 2015, the number of SICU patients was 2 961, and 77 died （the mortality rate was 2.6%）.The difference of mortality rate between the two periods was statistically significant （x2 =66.707, P =0.001）.The death rate of patients transferred directly from emergency department in tle first period was 79.8% （87/109）, and it was lower in the second period （51.9%, 40/77, x2 =16.181, P =0.001）.The death rate of the patients with blood Alb below 35 g/L in the second period （59.7%, 46/77） was higher than that of the first period （41.3%, 45/109, x2 =6.151, P =0.017）.The top three causes of death from December 1999 to February 2015 were sepsis （38.2%）, trauma （16.7%）, and operation for cancer （14.0%）.In the first period, the top three causes of death were sepsis （35.8%）, trauma （22.0%）,and operation for cancer （13.8%）.In the second period, the top three causes of death were sepsis （41.6%）, damage of the central nervous system （16.9%）, and operation for cancer （14.3%）.Top three reasons for SICU admission were trauma （29.03%）, abdominal pain （20.97%） and other reasons （18.82%）.Top three departments from which the patients were transferred were the emergency department （19.35%）, orthopedics department （17.20%）, and hepatobiliary department （16.13%）.Logistic regression analysis showed that age [odds ratio （OR） =2.025, 95% confidence interval （95%CI） =1.500-2.734, P =0.000], mechanical ventilation （OR =3.514, 95%CI =1.701-7.259, P =0.001）, CRRT （OR =5.604,95%CI =3.003-10.459, P =0.000）, body temperature higher than 39 ℃ （OR =1.992, 95%CI =1.052-3.771, P =0.034） were the risk factors of death in SICU patients.Conclusion Sepsis and severe trauma are the leading causes of death in severe SICU patients, to whom with risk factors of death enough attention should be given.