机械通气患者ICU获得性肌无力早期发病率及预后研究

Early incidence and prognosis of ICU-acquired weakness in mechanical ventilation patients

目的观察机械通气患者ICU获得性肌无力(ICU-AW)早期发病率,分析早期ICU-AW患者的危险因素及预后.方法采用前瞻性队列研究方法,连续选择2016年4月至2017年1月首都医科大学附属复兴医院重症加强治疗病房(ICU)收治的机械通气患者.于机械通气第(3±1)天对患者进行腓神经试验,阳性者行完整神经电生理检查,结果异常者纳入观察组;腓神经试验阴性或腓神经试验阳性但完整神经电生理检查正常者均纳入对照组.计算ICU-AW的早期发病率;对照组于10 d后复查腓神经试验,观察晚期ICU-AW发病情况.将患者死亡、转出ICU或ICU住院时间超过60 d设为观察终点.收集两组患者人口学资料、基础指标、药物使用情况、合并症、代谢相关指标及结局指标等资料,并进行组间比较;采用多因素Logistic回归分析筛选机械通气早期发生ICU-AW的危险因素.结果研究共纳入60例患者,观察组19例,对照组41例,ICU-AW早期发病率为31.7%;对照组有8例患者于10 d后完成腓神经试验复查,其中4例检查结果阳性,推测ICU-AW晚期发病率仍在50%左右.单因素分析显示,观察组患者年龄明显大于对照组〔岁:84(79,89)比81(65,85), P<0.05〕;而两组性别和体重指数(BMI)等人口学资料、基础疾病、急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、序贯器官衰竭评分(SOFA)、格拉斯哥昏迷评分(GCS)、机械通气主要原因等基础指标比较差异均无统计学意义.与对照组比较,观察组应用糖皮质激素及血管活性药物患者比例明显升高〔84.2%(16/19)比43.9%(18/41),100.0%(19/19)比75.6%(31/41),均P<0.05〕,血糖最高值明显升高(mmol/L :18.73±4.98比15.66±5.11,P<0.05),研究期间合并脓毒症及感染性休克发生率明显增加〔84.2%(16/19)比51.2%(21/41), P<0.05〕.将单因素分析中P<0.1的指标纳入多因素Logistic回归方程,结果显示,年龄是机械通气早期发生ICU-AW的独立危险因素〔优势比(OR)=1.086,95%可信区间(95%CI)=1.008~1.171,P=0.031〕.预后指标分析显示,与对照组比较,观察组患者ICU住院时间和机械通气时间均延长〔d :16(12,28)比13(8,31),h :306.0(143.0,376.0)比224.0(144.0,365.5)〕,总住院费用增加(万元:17.04±7.20比15.23±5.64),28 d病死率和60 d病死率均升高〔57.9%(11/19)比41.5%(17/41),68.4%(13/19)比43.9%(18/41)〕,但差异均无统计学意义(均P>0.05).结论 ICU-AW在机械通气患者中较常见,早期发病率高.年龄、APACHEⅡ评分、合并脓毒症及感染性休克、血糖最高值是ICU-AW早期发病的相关因素,其中年龄是独立危险因素.机械通气早期ICU-AW与患者短期预后无明显相关性.

Objective To observe the early morbidity of ICU-acquired weakness (ICU-AW) in mechanical ventilation patients, and to analyze the risk factors and prognosis of ICU-AW. Methods A prospective cohort study was conducted. The patients undergoing mechanical ventilation admitted to intensive care unit (ICU) of Fu Xing Hospital of Capital Medical University from April 2016 to February 2017 were enrolled. The peroneal nerve test was performed on (3±1) days of mechanical ventilation, and complete neuro-electrophysiological examination was performed next on the patients with positive result of peroneal nerve test. The abnormal cases were enrolled in the observation group, others were enrolled in the control group, then the early incidence of ICU-AW was obtained. The control group reviewed the peroneal nerve test after 10 days, and the late ICU-AW incidence was obtained. Death, ICU discharge, or over 60 days of ICU stay were set to the endpoints of observation. Demographic data, basic indicators, drug usage, comorbidities and metabolic markers during the study period, outcome data were collected and analyzed, and risk factors and of early ICU-AW in mechanical ventilation patients were identified by multivariate Logistic regression analysis. Results A total of 60 patients were enrolled in the study, with 19 patients in the observation group, and 41 in the control group, with the early ICU-AW incidence of 31.7%. In the control group, 8 patients reviewed the peroneal nerve test after 10 days, of which 4 were positive, so the late incidence of ICU-AW was about 50% finally. It was shown by univariate analysis that the age of the observation group was significantly higher than that of the control group [years old: 84 (79, 89) vs. 81 (65, 85), P < 0.05], other basic indicators such as gender, body mass index (BMI), basic diseases, acute physiology and chronic health evaluation Ⅱ(APACHEⅡ) score, sequential organ failure assessment (SOFA) score, Glasgow coma scale (GCS) score, the reason of mechanical ventilation etc. were similar. Compared with the control group, the ratios of glucocorticoid and vasoactive drugs usage in the observation group were significantly increased [84.2%(16/19) vs. 43.9%(18/41), 100.0%(19/19) vs. 75.6%(31/41), both P < 0.05], the highest blood glucose was significantly increased (mmol/L: 18.73±4.98 vs. 15.66±5.11, P < 0.05), the incidence of sepsis and septic shock during the study period was significantly increased [84.2%(16/19) vs. 51.2%(21/41), P < 0.05]. The indices of P < 0.1 in univariate analysis were included in multivariate Logistic regression equation. The results showed that age was an independent risk factor for ICU-AW in early stage of mechanical ventilation [odds ratio (OR)= 1.086, 95% confidence interval (95%CI)= 1.008-1.171, P = 0.031]. Analysis of prognostic indicators showed that compared with the control group, the length of ICU stay and duration of mechanical ventilation in the observation group were prolonged [days: 16 (12, 28) vs. 13 (8, 31), hours: 306.0 (143.0, 376.0) vs. 224.0 (144.0, 365.5)], the total cost of hospitalization was increased (ten thousand Yuan: 17.04±7.20 vs. 15.23±5.64), 28-day mortality and 60-day mortality were increased [57.9%(11/19) vs. 41.5%(17/41), 68.4%(13/19) vs. 43.9%(18/41)], but the differences were not statistically significant (all P > 0.05). Conclusions ICU-AW is more common in patients undergoing mechanical ventilation with high early incidence. Age, APACHEⅡ score, sepsis and septic shock, the highest blood glucose can be considered as the risk factors of ICU-AW, and age can be considered as an independent risk factor. There was no significant correlation between early onset ICU-AW and short-term prognosis in patients undergoing mechanical ventilation.