中国慢性危重症及外科相关慢性危重症的多中心横断面研究

A multicenter cross sectional study on chronic critical illness and surgery related chronic critical illness in China

目的了解中国慢性危重症(CCI)、尤其是外科相关CCI的患病率、临床病例特征和诊疗现状。方法采用多中心横断面研究的方法,收集53家医院2019年5月10日当天所有重症监护病房(ICU)住院的472例成年患者临床资料,包括患者基本信息、疾病相关资料、营养方案等。根据是否需要外科手段介入或疾病发生与外科手术直接相关的标准,进一步筛选出外科疾病相关ICU患者211例。本研究中CCI诊断标准为:(1)入住ICU时间>14 d;(2)合并有持续性脏器功能紊乱。记录分析53家单位外科相关ICU患者中CCI患病率、CCI患病分布情况、外科相关CCI患者疾病分布情况和治疗情况。采用Mann Whitney U检验、χ2检验或Fisher精确概率法检验进行比较分析。结果53家医院的472例ICU患者中,男性326例(69.1%),女性146例(30.9%),外科相关CCI的患病率为30.7%(145/472)。在211例外科疾病相关ICU患者中,CCI患者57例,患病率27.0%。与非CCI患者相比,外科相关CCI患者具有较高的急性生理改变及慢性健康评估系统评分(APACHEⅡ)[13.5(10.0,18.3)分比11.0(7.0,16.0)分,U=2970.000,P=0.007]、较高的查尔森合并症指数[4.0(2.0,7.0)分比3.0(1.0,5.0)分,U=3570.000,P=0.036]以及较高比例的呼吸、肾功能障碍[68.4%(39/57)比48.1%(74/154),χ2=6.939,P=0.008;42.1%(24/57)比18.2%(28/154),χ2=12.821,P<0.001];而两组序贯性脏器衰竭评分(SOFA)、格拉斯哥昏迷评分及其余系统脏器功能差异均无统计学意义(均P>0.05)。通过重症患者营养风险评分(NUTRIC)评估发现,外科相关CCI患者营养风险高于非CCI者[43.9%(25/57)比26.6%(41/154),U=5.750,P=0.016]。外科相关CCI患者使用机械通气比例更高[66.7%(38/57)比52.3%(79/154),χ2=3.977,P=0.046]。调查当日,50.2%(106/211)外科相关ICU患者的每日热量需求是依据成人标准热量摄入指标[(104.6~125.5)kJ·kg 1·d 1;1 kJ=0.239 kcal]得出,46.4%(98/211)患者由医师根据患者病情程度计算得出每日热量需求;60.2%(127/211)营养支持治疗为肠内营养(包括肠内、肠外营养联合使用),其余患者接受肠外营养(24.6%,52/211)、单纯葡萄糖输注(9.0%,19/211)、经口饮食(6.2%,13/211)。外科相关CCI患者每日目标热量104.6(87.9,125.5)kJ·kg 1·d 1,实际摄入热量占目标热量0.98(0.80,1.00);非CCI患者目标热量104.6(87.9,125.5)kJ·kg 1·d 1,实际摄入热量占目标热量0.91(0.66,1.00),差异均无统计学意义(P=0.248,P=0.150)。结论CCI及外科相关CCI患病率较高。外科相关CCI患者以合并症重,呼吸、肾功能障碍和机械通气为特征。入住ICU的外科患者存在高营养风险,积极、正确地营养支持对此类患者至关重要。

Objective To understand the prevalence,diagnosis and treatment of chronic critical illness(CCI)in China.Methods The clinical data of 472 adult patients admitted to ICU in 53 hospitals,including basic information,disease related data,nutrition program,etc.,were collected on May 10,2019,by means of multi center cross sectional study.If surgical intervention was needed or the occurrence of the disease was directly related to the surgery,ICU patients were regarded as surgical ICU cases(n=211).In this study,the diagnostic criteria for CCI were:(1)admission to ICU>14 days;(2)combined with persistent organ dysfunction.The prevalence,distribution and treatment of CCI and surgery related CCI were recorded and analyzed.The Mann Whitney U test,chi square test or Fisher exact test were used for comparative analysis.Results Among the 472 ICU patients from 53 hospitals,326 were male(69.1%)and 146 were female(30.9%).The prevalence of CCI was 30.7%(145/472).Among 211 surgery related ICU patients,57 developed CCI with a prevalence of 27.0%.As compared to non CCI patients,higher APACHE II score[median(IQR)13.5(10.0,18.3)vs.11.0(7.0,16.0),U=2970.000,P=0.007],higher Charlson comorbidity index[median(IQR)4.0(2.0,7.0)vs.3.0(1.0,5.0),U=3570.000,P=0.036]and higher ratio of breath dysfunction[68.4%(39/57)vs.48.1%(74/154),χ2=6.939,P=0.008]and renal dysfunction[42.1%(24/57)vs.18.2%(28/154),χ2=12.821,P<0.001]were found in surgery related CCI patients.While SOFA score,Glasgow coma score and other visceral function were not significantly different between surgery related CCI and non CCI patients(all P>0.05).NUTRIC score showed that surgery related CCI patients had higher nutritional risk[43.9%(25/57)vs.26.6%(41/154),U=5.750,P=0.016]and higher ratio of mechanical ventilation[66.7%(38/57)vs.52.3%(79/154),χ2=3.977,P=0.046]than non CCI patients.On the survey day,the daily caloric requirements of 50.2%(106/211)of surgery related ICU patients were calculated according to the standard adult caloric intake index(104.6 to 125.5 kJ·kg 1·d 1,1 kJ=0.239 kcal),and the daily caloric requirements of 46.4%(98/211)of patients were calculated by physicians according to the severity of the patient′s condition.60.2%(127/211)of nutritional support therapy was enteral nutrition(including a combination of enteral and parenteral nutrition),while the remaining patients received parenteral nutrition(24.6%,52/211),simple glucose infusion(9.0%,19/211),or oral diet(6.2%,13/211).The target calorie of CCI group was 104.6(87.9,125.5)kJ·kg 1·d 1,and the actual calorie intake accounted for 0.98(0.80,1.00)of the target calory.In the non CCI group,the target calorie was 104.6(87.9,125.5)kJ·kg 1·d 1,and the actual calorie consumed accounted for 0.91(0.66,1.00)of the target calorie.There was no statistically significant difference between two groups(P=0.248,P=0.150).Conclusion The prevalence of CCI and surgery related CCI in ICU is high,along with severe complications,respiratory and renal dysfunction and mechanical ventilation.Surgical patients admitted to ICU are at high nutritional risk,and active and correct nutritional support is essential for such patients.