脓毒症继发慢性重症患者临床特征分析

Analysis of clinical characteristics of patients with chronic critical illness after sepsis

目的探讨脓毒症继发慢性重症(CCI)患者的临床特征。方法选取2019年4月至2020年10月深圳市宝安区中心医院重症医学科首次入院的脓毒症存活患者,依据临床转归分为CCI组〔重症监护病房(ICU)住院时间≥14 d,存在持续的器官功能障碍〕和快速康复(RAP)组,收集并比较两组患者的入院基本情况和临床结局。所有患者入院后均取血,测定血清白细胞介素(IL-6、IL-10)水平及外周血淋巴细胞计数(LYM);比较两组入院1、7、14 d上述指标的差异,并观察两组180 d累积生存率。结果①纳入脓毒症继发CCI患者22例,RAP患者28例,两组患者性别、感染部位比较差异无统计学意义。CCI组的年龄、年龄≥65岁患者比例、入院当天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)、感染性休克比例及住院期间机械通气时间、ICU住院时间、总住院时间及继发感染比例均要高于RAP组〔年龄(岁):61.0±13.8比50.3±13.9,年龄≥65岁患者比例:54.5%(12/22)比25.0%(7/28),APACHEⅡ评分(分):20.5±4.4比14.4±4.3,SOFA评分(分):10(7,12)比5(3,8),感染性休克比例:40.9%(9/22)比17.9(5/28),机械通气时间(d):18.5(12.0,28.0)比5.0(3.0,7.0),ICU住院时间(d):26(18,46)比8(6,12),总住院时间(d):31(26,51)比14(12,17),继发感染比例:72.7%(16/22)比7.1%(2/28),均P<0.05〕。②CCI组在各时间点(入院1、7、14 d)的IL-6水平均明显高于RAP组(ng/L:1 d为176.86±103.54比113.32±71.34,7 d为84.72±46.06比54.98±26.61,14 d为44.28±20.20比17.76±4.70,均P<0.05);入院1 d、7 d,两组IL-10、LYM水平差异无统计学意义;入院14 d CCI组IL-10水平明显高于RAP组(ng/L:15.09±3.61比8.92±1.98,P<0.05),LYM则较RAP组明显降低〔×10^(9)/L:0.62(0.43,1.02)比1.17(0.93,1.71),P<0.05〕。③Kaplan-Meier生存曲线的Log-Rank检验结果显示,CCI组180 d累积生存率显著低于RAP组(63.6%比96.4%;Log-Rank检验:χ^(2)=9.024,P=0.007)。结论高龄及APACHEⅡ评分、SOFA评分高的脓毒症患者易继发CCI并导致住院时间延长,继发感染率高,预后差。CCI的发生可能与持续的促炎介质表达及后续免疫抑制状态有关。

Objective To investigate the clinical characteristics of patients who develop chronic critical illness(CCI)after sepsis.Methods The survival patients with sepsis admitted to the department of critical medicine of Baoan Central Hospital of Shenzhen for the first time from April 2019 to October 2020 were enrolled.According to clinical outcomes,patients were divided into CCI group[intensive care unit(ICU)stay≥14 days,with persistent organ dysfunction]and rapid recovery(RAP)group.The baseline characteristic on admission and clinical outcomes of patients in the two groups were collected and compared.Blood samples were collected to measure serum interleukins(IL-6,IL-10)levels and peripheral blood lymphocyte count(LYM)count were obtained from all patients after admission.The differences of above indexes on the 1st,7th and 14th day in ICU between the two groups were compared,the 180 day cumulative survival rate of the two groups was observed.Results①Twenty-two septic patients developed CCI and 28 patients with RAP were included.There were no significant differences in gender and infection site between the two groups.The age,acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ),sequential organ failure assessment(SOFA),proportion of septic shock,mechanical ventilation time,length of ICU stay,total length of hospital stay and proportion of secondary infection of CCI patients were higher than those in RAP group[age(years old):61.0±13.8 vs.50.3±13.9,proportion of patients aged≥65 years old:54.5%(12/22)vs.25.0%(7/28),APACHE Ⅱ score:20.5±4.4 vs.14.4±4.3,SOFA score:10(7,12)vs.5(3,8),septic shock ratio:40.9%(9/22)vs.17.9%(5/28),time of mechanical ventilation(days):18.5(12.0,28.0)vs.5.0(3.0,7.0),length of ICU stay(days):26(18,46)vs.8(6,12),total length of hospital stay(days):31(26,51)vs.14(12,17),secondary infection ratio:72.7%(16/22)vs.7.1%(2/28),all P<0.05].②The IL-6 levels of CCI group were higher than that of RAP group at all time points(ng/L:176.86±103.54 vs.113.32±71.34 on the 1st day,84.72±46.06 vs.54.98±26.61 on the 7th day,44.28±20.20 vs.17.76±4.70 on the 14th day,all P<0.05).On the 1st and 7th day of admission,there were no significant differences in IL-10 and LYM levels between the two groups.On the 14th day of admission,IL-10 levels in CCI group were higher than that in RAP group(ng/L:15.09±3.61 vs.8.92±1.98,P<0.05),while LYM was relatively lower[×10^(9)/L:0.62(0.43,1.02)vs.1.17(0.93,1.71),P<0.05].③The Log-Rank test results of Kaplan-Meier survival curve showed that the 180-day cumulative survival rate of CCI group was significantly lower than that of RAP group(63.6%vs.96.4%,Log-Rank:χ^(2)=9.024,P=0.007).Conclusions Septic patients with advanced age,high APAHCEⅡscore and high SOFA score are prone to secondary CCI,resulting in long hospital stay,high secondary infection rate and poor prognosis.The occurrence of CCI may be related to the continuous expression of proinflammatory mediators and subsequent immunosuppression.