重症新型冠状病毒肺炎患者的临床特点及其死亡的影响因素研究

Clinical Characteristics and Death Risk Factors of Patients with Severe COVID-19

背景新型冠状病毒肺炎(COVID-19)传播性极强,较2003年非典型肺炎疫情更为严重,多数患者死于严重呼吸困难,目前关于重症COVID-19的研究较少。目的分析重症COVID-19患者的临床特征及其死亡的影响因素,以为临床诊疗提供参考。方法回顾性分析2020年2月1日—3月11日黄冈市中心医院黄冈大别山区域医疗中心重症监护室(ICU)收治的重症COVID-19患者46例,均采用常规方案治疗。收集患者临床资料,并根据转归将所有患者分为死亡组(n=12)和好转组(n=34),比较两组患者性别、年龄、呼吸频率、心率、平均动脉压(MAP)、体温、合并症、血气分析、凝血功能、多层螺旋CT(MSCT)评分、肝功能、肾功能、心脏相关主要指标、发病至入ICU时间、血常规、C反应蛋白、降钙素原(PCT)、红细胞沉降率、气管插管情况,采用多因素Logistic回归分析重症COVID-19患者死亡的影响因素。结果46例重症COVID-19患者中,男36例(78.3%),女10例(21.7%);年龄<30岁2例(4.3%),30~49岁12例(26.1%),50~69岁20例(43.5%),70岁及以上12例(26.1%);合并症:低钾血症14例(30.4%),心血管系统疾病13例(28.3%),内分泌系统疾病11例(23.9%),呼吸系统疾病7例(15.2%),神经系统疾病3例(6.5%),肿瘤2例(4.3%);临床症状:咳嗽28例(60.9%),发热26例(56.5%),胸闷13例(28.3%),腹泻3例(6.5%),乏力2例(4.3%),咽喉不适2例(4.3%),无症状2例(4.3%),鼻塞流涕1例(2.2%);体温:36.0~37.2℃18例(39.1%),37.3~38.0℃12例(26.1%),38.1~39.0℃14例(30.4%),39.1~41.0℃2例(4.3%);MSCT评分:0~4分6例(13.1%),5~8分18例(39.1%),9~12分15例(32.6%),13~16分7例(15.2%);治疗方法:高流量给氧22例(47.8%),无创机械通气11例(23.9%),有创机械通气13例(28.3%),体外膜肺氧合(ECMO)支持治疗2例(4.3%);转归:死亡12例(26.1%),好转34例(73.9%);实验室检查指标:白细胞计数升高14例(30.4%),中性粒细胞分数升高37例(80.4%),淋巴细胞分数下降42例(91.3%),红细胞沉降率升高44例(95.7%),PCT升高13例(28.3%),C反应蛋白升高33例(71.7%);血气分析:动脉血二氧化碳分压(PaCO2)>50 mm Hg(1 mm Hg=0.133 kPa)7例(15.2%),动脉血氧分压(PaO2)<60 mm Hg 9例(19.6%);脏器功能损伤:肾功能异常27例(56.7%),心肌酶异常24例(52.2%),肝功能异常13例(28.3%),凝血功能异常13例(28.3%)。死亡组患者年龄大于好转组,心率、MSCT评分、丙氨酸氨基转移酶(ALT)、天冬氨酸氨基转移酶(AST)、总胆红素、直接胆红素、尿素氮、白细胞计数、血小板计数、中性粒细胞分数及气管插管率高于好转组,淋巴细胞分数低于好转组(P<0.05)。多因素Logistic回归分析结果显示,MSCT评分、尿素氮及气管插管是重症COVID-19患者死亡的独立危险因素(P<0.05)。结论重症COVID-19以中老年男性为主,临床症状以咳嗽、低热为主,且淋巴细胞分数较低,并伴有多器官功能损伤,且入院48 h内MSCT评分、尿素氮及气管插管是重症COVID-19患者死亡的独立危险因素。

Backgroud The COVID-19 is more serious than SARS epidemic in 2003.Most of COVID-19 patients died of severe dyspnea.However,there is few studies on severe COVID-19.Objective To investigate the clinical characteristics and death risk factors in patients with severe COVID-19,to provide a reference for clinical diagnosis and treatment of this disease.Methods A retrospective study was conducted on the clinical data of 46 severe COVID-19 patients who received routine treatment from the ICU,Dabieshan Medical Center,Huanggang Central Hospital from February 1 to March 11,2020.According to the outcome,the patients were divided into death group(n=12)and survival group(n=34),and intergroup differences in terms of gender ratio,age,respiratory rate,heart rate,MAP,temperature,complications,results of arterial blood gas analysis,coagulation function,MSCT score,liver function,renal function,main cardiac function indicators,time from onset to the ICU,and routine blood test,CRP,PCT,erythrocyte sedimentation rate and use of endotracheal intubation were analyzed.The influencing factors of death were identified by multivariate Logistic regression analysis.Results Among the participants,gender distribution:78.3%(36/46)were male and 21.7%(10/46)were female.Age-related prevalence of severe COVID-19:4.3%(2/46),26.1%(12/46),43.5%(20/46),26.1%(12/46)of the participants aged less than 30 years,30-49 years old,50-69 years old,and 70 years or over,respectively.Complications:14(30.4%)had hypokalemia,13(28.3%)had cardiovascular system disease,11(23.9%)had endocrine system disease,7(15.2%)had respiratory disease,3(6.5%)had nervous system disease,and 2(4.3%)had tumor.Clinical symptoms:28(60.9%)had cough,26(56.5%)had fever,13(28.3%)had chest distress,3(6.5%)had diarrhoea,2(4.3%)had fatigue,2(4.3%)had throat discomfort,2(4.3%)were asymptomatic,and 1(2.2%)had stuffy running nose.Temperature:temperature was 36.0-37.2℃for 18 cases(39.1%),37.3-38.0℃for 12(26.1%),38.1-39.0℃for 14(30.4%),and 39.1-41.0℃for 2(4.3%).MSCT score:MSCT score was 0-4 for 6(13.1%),5-8 for 18(39.1%),9-12 for 15(32.6%),and 13-16 for 7(15.2%).Treatment:high-flow oxygen therapy,noninvasive mechanical ventilation,invasive mechanical ventilation and ECMO were given to 47.8%(22/46),23.9%(11/46),28.3%(13/46),and 4.3%(2/46)of the participants,respectively.Outcome:12(26.1%)died and 34(73.9%)were improved.Laboratory indices:14(30.4%)had elevated WBC,37(80.4%)had elevated percentage of neutrophils,42(91.3%)had decreased lymphocyte percentage,44(95.7%)had elevated erythrocyte sedimentation rate,13(28.3%)had elevated PCT,and 33(71.7%)had elevated CRP.Arterial blood gas analysis:PaCO2 was greater than 50 mm Hg for 7 cases(15.2%);PaO2 was less than 60 mm Hg for 9 cases(19.6%).Organ damage:abnormal renal function,abnormal myocardial enzyme,abnormal liver function and abnormal coagulation function were found in 27 cases(56.7%),24 cases(52.2%),13 cases(28.3%),and 13 cases(28.3%),respectively.Compared to survival group,the death group showed greater average age,higher average heart rate,MSCT score,ALT,AST,total bilirubin,direct bilirubin,urea nitrogen,WBC,lymphocyte count,and percentage of neutrophils,and higher rate of endotracheal intubation but lower average lymphocyte percentage(P<0.05).Multivariate Logistic regression analysis showed that,elevated MSCT score and urea nitrogen and requiring endotracheal intubation were independently associated with death(P<0.05).Conclusion Middle-aged and elderly men account for the largest percentage of severe COVID-19 patients.The major clinical symptoms for severe COVID-19 are cough,low fever,low lymphocyte percentage and multiple organ function damage.Elevated MSCT score within 48 hours after admission,elevated urea nitrogen and requiring endotracheal intubation are independent risk factors for death.