急性胃肠穿孔继发脓毒症的临床特征和预后影响因素评价

Evaluation of clinical features and factors affecting prognosis in patients with secondary sepsis of acute gastrointestinal perforation

目的 观察胃肠穿孔继发脓毒症患者的临床特征,评价影响其预后的危险因素.方法 采用回顾性队列研究方法,选择2014年1月1日至2017年4月30日徐州医科大学附属沭阳人民医院普外科收治的胃肠穿孔患者,按其是否发生脓毒症分为胃肠穿孔伴脓毒症组和胃肠穿孔不伴脓毒症组.比较两组性别、年龄、发病至发生脓毒症时间、感染情况、体温、心率、呼吸频率、白细胞计数（WBC）、全身炎症反应综合征（SIRS）符合标准、C-反应蛋白（CRP）、血糖、平均动脉压（MAP）、乳酸、腹腔镜手术治疗例数、序贯器官衰竭评分（SOFA）和快速SOFA（qSOFA）、格拉斯哥昏迷评分（GCS）、重症加强治疗病房（ICU）住院时间、总住院时间的差异;采用格拉斯哥预后评分（GOS）评价患者30 d生存和预后情况.将两组中有统计学意义的指标纳入Cox回归模型,分析影响患者预后的独立危险因素.结果 58例胃肠穿孔患者纳入本研究.其中,22例继发脓毒症（胃肠穿孔伴脓毒症组,单器官和多器官衰竭各占50.0%,只符合0-1个SIRS标准者占81.8%,继发脓毒症患者病死率达31.8%）;未发生脓毒症（胃肠穿孔不伴脓毒症组）36例.胃肠穿孔伴脓毒症组年龄、血糖、乳酸、SOFA评分、qSOFA评分、ICU住院时间均明显高于胃肠穿孔不伴脓毒症组〔年龄（岁）：68.7±15.9比56.1±17.2,血糖（mmol/L）：6.9±2.3比5.9±1.2,乳酸（mmol/L）：2.9±1.3比1.2±0.7,SOFA（分）：5.6±3.2比0.5±0.4,qSOFA评分（分）：1.0±0.9比0.3±0.1,ICU住院时间（d）：1.0（0-4.0）比0.1（0-2.0）,均P〈0.05〕,而MAP、GCS评分、GOS评分均明显低于胃肠穿孔不伴脓毒症组〔MAP（mmHg,1 mmHg=0.133 kPa）：83.6±18.7比100.0±14.3,GCS（分）：12.8±3.5比14.5±0.5,GOS（分）：3.5±1.9比4.9±0.2,均P〈0.01〕.Cox多变量回归分析显示,低MAP和低GCS评分是胃肠穿孔患者伴脓毒症死亡的独立危险因素,相对危险度（RR）分别为0.896〔95%可信区间（95%CI）=0.815-0.984,P=0.022〕和0.585（95%CI=0.395-0.866,P=0.007）.结论 胃肠穿孔患者有较高的脓毒症发病率和更多的风险因素,而只有低MAP和低GCS评分与死亡高风险密切相关.

Objective To observe the clinical features and evaluate the risk factors affecting prognosis in patients with secondary sepsis of gastrointestinal perforation （GIP）. Methods A retrospective cohort study was conducted, and the patients with GIP admitted to the Department of General Surgery of Affiliated Shuyang People＆#39;s Hospital of Xuzhou Medical University from January 1, 2014 to April 30, 2017 were enrolled, according to the presence or absence of sepsis occurrence, they were divided into GIP with and GIP without sepsis groups. The difference of gender, age, the time between the onset of GIP and the occurrence of sepsis, infection situation, body temperature, heart rate, respiratory frequency, white blood cell count （WBC）, systemic inflammatory response syndrome （SIRS） in accord with standard, C-reactive protein （CRP）, blood sugar, mean arterial pressure （MAP）, lactic acid, number of cases having undergone laparoscopic surgery, sequential organ failure score （SOFA） and quick sequential organ failure score （qSOFA）, Glasgow coma score（GCS）, length of stay in intensive care unit （ICU）, the total length of stay in hospital were compared;the status of survival and prognosis was assessed on day 30 by the Glasgow Outcome Scale （GOS）. The indicators with statistical significance in the two groups were brought into the Cox regression model to analyze the independent risk factors affecting the prognosis of the patients. Results Fifty-eight patients with GIP were enrolled in this study. Among them, 22 cases developed secondary sepsis （GIP with sepsis group, there were 50.0% cases with single organ failure and 50.0% cases with multiple-organ failure, cases only in accord with 0-1 SIRS criteria accounting for 81.8%, and the mortality of secondary sepsis being 31.8%）. No sepsis occurred in 36 patients （GIP without sepsis group）. In GIP with sepsis group, the age, blood glucose, lactic acid, SOFA score, qSOFA, and the length of stay in ICU were significantly higher than those of GIP without sepsis group [age （years）： 68.7±15.9 vs. 56.1±17.2, blood glucose （mmol/L）： 6.9±2.3 vs. 5.9±1.2, lactic acid （mmol/L）： 2.9±1.3 vs. 1.2±0.7, SOFA score： 5.6±3.2 vs. 0.5±0.4, qSOFA score： 1.0±0.9 vs. 0.3±0.1, the length of stay in ICU （days）： 1.0 （0-4.0） vs. 0.1 （0-2.0）, all P〈 0.05], while MAP, GCS, and GOS scores in GIP with sepsis group were significantly lower than those in GIP without sepsis group [MAP （mmHg, 1 mmHg =0.133 kPa）： 83.6±18.7 vs. 100.0±14.3, GCS score： 12.8±3.5 vs. 14.5±0.5, GOS score： 3.5±1.9 vs. 4.9±0.2, all P 〈 0.01]. Cox multivariable regression analysis showed： only low MAP and low GCS score were the independent risk predictors of death outcome for GIP with sepsis, the relative risk （RR） was 0.896 [95% confidence interval （CI） = 0.815-0.984, P = 0.022] and 0.585 （95%CI = 0.395-0.866, P = 0.007） respectively. Conclusion Patients with secondary sepsis following GIP have relatively high morbidity and much more risk factors, but only low MAP and low GCS score are closely associated with its high risk of death.