多中心神经外科重症患者应激性溃疡出血的危险因素分析

Risk factors for stress ulcer bleeding in neurocritical patients ： A multi-center study

目的 调查多中心神经重症患者应激性溃疡（SU）出血的发生率和相关危险因素.方法 回顾性分析中国医学科学院北京协和医学院北京协和医院等中国12个医学中心神经外科2014年1月至12月收治的颅脑损伤后≤14 d的成年人神经重症患者的临床资料,共1 416例.采集患者的年龄、诊断、既往史等基本信息,以及机械通气时间,消化道溃疡或出血病史,入院24h内的格拉斯哥昏迷评分（GCS）,手术时间,颅内感染,卒中,脑外伤,脑出血,脑肿瘤手术,心、脑、肺复苏后,休克,肝功能衰竭,肾功能衰竭,多器官功能衰竭,酸碱平衡失调,应用大剂量糖皮质激素,应用抗凝或抗血小板聚集药物等17个与溃疡出血可能有关的潜在危险因素.采用Log-rank法行单因素分析,Cox比例风险模型行多因素分析.结果 1 416例患者中,182例发生SU出血,发生率为12.9％ （95％CI：11.2-14.7）,其中10例为有重要临床意义的出血,发生率为0.7％ （95％ CI：0.3-1.3）.潜在的危险因素中,机械通气〉48 h（RR=0.526,95％ CI：0.381-0.726,P〈0.0001）、使用抗凝剂或抗血小板聚集药物（RR=0.458,95％ CI：0.327 -0.643,P〈0.0001）是影响SU出血的独立危险因素;有消化道溃疡或出血病史（RR=0.082,95％ CI：0.016 -0.411,P=0.0023）的患者出血风险较高.结论 成年人神经重症患者SU出血并不少见,应当重视预防,尤其要重视存在危险因素的患者.

Objective To explore the incidence and related risk factors for stress ulcer （SU） bleeding in neurocritical patients at multiple centers.Methods We retrospectively analyzed the data of neurocritical patients at Department of Neurosurgery of 12 hospitals in China,which consisted of the patient＇s age,diagnosis,past medical history and 17 potential associated risk factors including duration of mechanical ventilation,gastrointestinal （GI） ulcer or bleeding history,GCS （Glasgow coma scale）,duration of neurosurgical operation,intracranial infection,stroke,traumatic brain injury,intracerebral hemorrhage,history of brain tumor operation,resuscitation of heart,lung and brain,shock,hepatic failure,renal failure,multiple organ failure,acid base imbalance,high dose of corticosteroids,administration of anticoagulant and antiplatelet drugs.Univariate analysis was conducted with Log-rank and multivariate analysis was performed using the Cox proportional hazard model.Results A total of 1 416 patients were enrolled into this study,among whom 182 cases （12.9%,95% CI：11.2-14.7） developed SU.The incidence of GI bleeding （10 cases） was 0.7% （95% CI：0.3-1.3）.Multivariate analysis showed that mechanical ventilation lasting over 48 hours （RR =0.526,95% CI：0.381-0.726,P 〈 0.0001） and use of anticoagulants （RR =0.458,95% CI：0.327-0.643,P 〈 0.0001） were independent risk factors for SU bleeding in neurocritical patients.The patients with history of GI ulcer or bleeding （RR =0.082,95% CI：0.016-0.411,P =0.0023） had higher chance of developing SU bleeding.Conclusion SU bleeding is not uncommon in neurocritical patients and cautions should be warranted particularly for those with risk factors.