重型颅脑损伤并发医院获得性肺炎的相关因素分析

Severe traumatic brain injury and hospital acquired pneumonia： A study of correlation factors

目的 探讨重型颅脑损伤（TBI）患者治疗期间医院获得性肺炎（HAP）的发生率及其相关影响因素.方法 回顾性分析首都医科大学附属北京天坛医院神经外科2016年3月至2017年3月收治的114例重型TBI患者的临床资料.治疗过程中37例患者行气管插管,其中24例在插管后行气管切开术;4例直接行气管切开术.根据气管切开时间,将患者分为早切开组（损伤时间≤7 d,18例）和晚切开组（损伤时间〉7d,10例）.所有患者出院时行格拉斯哥预后评级（GOS）.统计治疗期间HAP的发生率,分析影响重型TBI患者发生HAP的危险因素,进一步分析气管早切开与晚切开对患者疗效的影响.结果 114例患者中,23.7％（27/114）诊断为HAP.经治疗后73.7％（84/114）的患者预后较好（GOSⅢ-Ⅴ级）,26.3％（30/114）预后不良（GOS Ⅰ-Ⅱ级）.多因素分析结果显示,既往合并肺部疾病、气管插管或气管切开、伴有颅内感染及弥漫性轴索损伤是发生HAP的独立危险因素（均P 〈0.05）.伤后行气管早切开组的患者在颅骨骨折比例、住院时间及治疗费用方面显著优于晚切开组（均P〈0.05）.结论 既往合并肺部疾病、气道方面操作、颅内感染及弥漫性轴索损伤可增加重型TBI患者HAP的发生率,且损伤后7d内行气管切开术,可减少患者的颅骨骨折比例、住院时间和治疗费用.

Objective To investigate the incidence and risk factors of hospital acquired pneumonia （HAP） among patients with severe traumatic brain injury （TBI）.Methods The clinical and imaging data of 114 adult patients diagnosed as severe TBI were retrospectively reviewed who underwent treatment at Department of Neurosurgery,Beijing Tiantan Hospital,from March 2016 to March 2017.Factors analyzed included the age,gender,mechanisms of injury,CT scan before admission,GCS （Glasgow Coma Scale） scores,pupil changes,tracheal intubation or tracheostomy,central nervous system （CNS） infection,duration of mechanical ventilation and antibiotic drug use.Comparison of variables between groups with tracheal intubation and tracheostomy,early and late tracheostomy were conducted.Results The incidence of HAP after admission was 23.8%.Past history of pulmonary diseases,tracheal manipulation,CNS infection,diffuse axonal injury were considered as risk factors of HAP.Patients in tracheal intubation group had significantly fewer days of ventilator use and shorter stay at hospital,lower incidence of HAP compared with tracheostomy group.Patients with early tracheostomy had lower incidence of skull fracture,shorter hospital stay and less expenses,while their incidence of HAP and outcomes were not significantly different from those with late tracheostomy.Conclusions Pulmonary diseases,related tracheal manipulation,CNS infection and diffuse axonal injury could be the risk factors for HAP in patients with severe TBI.Early tracheostomy might not reduce the risk of HAP,while it could significantly decrease the incidence of skull fracture,the length of hospital stay,antibiotic usage and medical expenses.