“八二”昆山工厂铝粉尘爆炸事故13例特重度烧伤合并重度吸入性损伤患者的临床特征分析

Analysis on clinical characteristics of 13 extremely severe burn patients complicated with severe inhalation injury in August 2nd Kunshan factory aluminum dust explosion accident

目的探讨粉尘爆炸所致特重度烧伤合并重度吸入性损伤患者的临床特征。方法回顾性分析苏州大学附属第一医院于2014年8月2日救治的＂八二＂昆山工厂铝粉尘爆炸事故13例特重度烧伤合并重度吸入性损伤患者的病历资料。统计患者以下指标：（1）入院后24 h的急性生理与慢性健康评估Ⅱ（APACHEⅡ）评分和序贯性器官衰竭评估（SOFA）评分。（2）预后、死亡时间、死亡原因及不同性别患者死亡情况。（3）行气道电子支气管镜检查次数、气道特征性表现及其出现的相应时间。（4）在白斑形成期，病灶组织微生物培养次数及结果；存在和不存在气道黏膜白斑患者铜绿假单胞菌检出情况。对不同性别患者死亡情况行Fisher确切概率法检验，对出现白斑及检出铜绿假单胞菌的关联性行Kappa检验。结果（1）本组患者入院后24 h的APACHEⅡ评分为（19±3）分，SOFA评分为（12±3）分。（2）8例患者存活；5例患者死亡，死亡时间为伤后19~46（34±10）d，死亡原因主要为严重感染继发的多器官功能障碍综合征。7例男性患者中1例死亡，6例女性患者中4例死亡，但不同性别患者死亡情况差异无统计学意义（P〉0.05）。（3）本组患者行气道电子支气管镜检查4~25（10±5）次。13例患者伤后2~3周内均存在气道黏膜充血、水肿；5例患者伤后2~4周气道黏膜出现溃疡；7例患者伤后4~14周气道黏膜出现白斑；7例患者伤后10~15周气道黏膜肉芽形成并影响气道通畅，予以局部夹除或更换加长型气管套管后改善。（4）在白斑形成期，共行19例次气道病灶组织微生物培养，检出铜绿假单胞菌15例次、鲍氏不动杆菌5例次、粘质沙雷菌2例次，以及嗜麦芽窄食单胞菌、洋葱伯克霍尔德菌、奇异变形杆菌各1例次。7例存在气道黏膜白斑患者中6例检出铜绿假单胞菌，6例不存在气道黏膜白斑患者中1例检出铜绿假单胞菌，白斑的出现和铜绿假单胞菌的检出具有一致性（Kappa=0.69，P〈0.05）。结论本次粉尘爆炸致特重度烧伤合并重度吸入性损伤患者大部分存活，病死率无明显性别差异；电子支气管镜检查观察到气道黏膜早期表现为充血、水肿，随后出现不同程度的糜烂、溃疡、白斑、肉芽形成等；白斑形成可能与铜绿假单胞菌感染相关。

Objective To investigate the clinical characteristics of extremely severe burn patients complicated with severe inhalation injury caused by dust explosion.MethodsThe medical records of 13 extremely severe burn patients complicated with severe inhalation injury in August 2nd Kunshan factory aluminum dust explosion accident, who were admitted to the First Affiliated Hospital of Soochow University on August 2nd, 2014, were retrospectively analyzed. The following indicators were collected： （1） Acute Physiology and Chronic Health Evaluation Ⅱ （APACHE Ⅱ） score and Sequential Organ Failure Assessment （SOFA） score at post admission hour （PAH） 24. （2） Prognosis, death time, causes of death, and the mortality of patients with different sexes. （3） The number of times of airway electronic bronchoscopy, airway characteristics, and the corresponding onset time. （4） The number and result of microorganism culture of lesion tissue during the leukoplakia formation stage. Detection of Pseudomonas aeruginosa in patients with and without leukoplakia in airway mucosa. Fisher′s exact probability test was used to detect the mortality of patients with different sexes. Kappa test was used to detect the relevancy between leukoplakia and Pseudomonas aeruginosa.Results（1） The APACHE Ⅱ score of patients of this group at PAH 24 was （19±3） points, and the SOFA score was （12±3） points. （2） Eight patients survived, while 5 patients died, and the time of death was 19-46 （34±10） d after injury. The main cause of death was multiple organ dysfunction syndrome, which was secondary to severe infection. One of the 7 male patients and 4 of the 6 female patients died, but there was no significantly statistical difference in mortality between patients of the two sexes （P〉0.05）. （3） Airway electronic bronchoscopy was performed 4-25 （10±5） times among patients of this group. Hyperemia and edema were found in the airway mucosa of all the 13 patients 2-3 weeks after injury; ulcer was found in the airway mucosa of 5 patients 2-4 weeks after injury; leukoplakia was found in the airway mucosa of 7 patients 4-14 weeks after injury; granulation formed in the airway mucosa of 7 patients 10-15 weeks after injury, and airway patency was affected, which was solved after local clamping or replacement of lengthened tracheal cannula. （4） During the leukoplakia formation stage, 19 cases of microorganism culture were performed basing on airway lesion tissue, and the results were 15 cases of Pseudomonas aeruginosa, 5 cases of Acinetobacter baumannii, 2 cases of Serratia marcescens, as well as 1 case of Stenotrophomonas maltophilia, Burkholderia cepacia, and Proteus mirabilis each. Among 7 patients with airway mucosa leukoplakia, 6 patients were detected with Pseudomonas aeruginosa. Among 6 patients without airway mucosa leukoplakia, 1 patient was detected with Pseudomonas aeruginosa. The appearance of leukoplakia was consistent with the detection of Pseudomonas aeruginosa （Kappa=0.69, P〈0.05）.Conclusions Most of these extremely severe burn patients complicated with severe inhalation injury caused by dust explosion survived, and there was no significant gender difference in mortality. Electronic bronchoscopy showed that the early manifestations of airway mucosa were hyperemia and edema, followed by varying degrees of erosion, ulcer, leukoplakia, and granulation formation, etc. Leukoplakia may be relevant to Pseudomonas aeruginosa infection.