神经外科术后患者拔除引流管后高热的危险因素分析

Analysis of risk factors of hyperpyrexia suffered by post neurosurgical patients after removal of drainage tube

目的分析神经外科术后患者拔除引流管后出现高热的危险因素。方法回顾分析2019年1月至2021年7月北京大学第三医院危重医学科收治的146例神经外科术后留置引流管患者临床资料。按拔除引流管后24 h内是否出现体温≥39℃将患者分为高热组和非高热组。收集两组患者一般临床资料及临床结局,基于格拉斯哥昏迷评分(GCS)对高热组和非高热组进行倾向性评分匹配,分析匹配后队列患者的年龄、性别、入院诊断、合并症、入院时急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、GCS评分、引流管留置天数和留置位置、拔除引流管前微生物培养结果、拔除引流管前后白细胞计数(WBC)和中性粒细胞比例(NEU%)及临床结局,主要临床结局为住院病死率,次要临床结局为重症监护病房(ICU)住院天数。结果①146例神经外科术后患者中28例拔除引流管后出现高热,高热组患者入院时GCS评分明显低于非高热组,高血压和糖尿病比例明显高于非高热组。②基于GCS评分进行倾向性评分匹配,两组各得28例,两组间性别、年龄、GCS评分及高血压和糖尿病比例比较差异均无统计学意义。患者入院时诊断以脑出血为主〔53.6%(30/56)〕。高热组患者脑室引流管留置比例和腰椎穿刺比例均明显高于非高热组〔32.1%(9/28)比7.1%(2/28),25.0%(7/28)比0(0/28),均P<0.05〕,但引流管留置位置比较差异均无统计学意义;高热组拔除引流管前1 d WBC〔×10^(9)/L:13.0(9.5,15.2)比11.5(8.8,13.3)〕、拔除引流管后NEU%〔0.892(0.826,0.922)比0.843(0.809,0.909)〕及引流液或引流管尖端培养阳性率〔7.1%(2/28)比0%(0/28)〕均较非高热组有所升高,但差异均无统计学意义;两组间拔除引流管前肺部感染、泌尿系感染及血流感染比例比较差异亦无统计学意义。临床结局方面,与非高热组比较,高热组ICU住院天数显著延长〔d:17.0(8.0,32.3)比8.5(1.0,16.8),P<0.05〕,住院病死率显著升高〔35.7%(10/28)比10.7%(3/28),P<0.05〕。高热组患者住院期间耐碳青霉烯细菌培养阳性率明显高于非高热组〔32.1%(9/28)比3.6%(1/28),P<0.05〕。结论神经外科术后留置引流管患者拔除引流管后出现高热可显著延长其ICU住院时间、增加住院病死率;其原因可能与留置颅内引流管继发感染及拔除时造成细菌颅内扩散,以及引流管导致颅内多重耐药细菌感染有关。

Objective To analyze the risk factors of hyperthermia after removal of drainage tubes in patients after neurosurgery.Methods The clinical data of 146 patients after neurosurgery with indwelling drainage tubes admitted to the department of critical care medicine of Pecking University Third Hospital from January 2019 to July 2021 were analyzed retrospectively.The patients were divided into hyperthermia group(body temperature≥39℃)and non-hyperthermia group(body temperature<39℃)according to whether their body temperatures within 24 hours after removal of drainage tubes.General clinical data and outcomes of the two groups were collected,and different tendentious scores were matched with the hyperthermia group and non-hyperthermia group based on Glasgow coma score(GCS),respectively.After such matching,the clinical baseline characteristics[age,gender,admission diagnosis,major complications,acute physiology and chronic health evaluationⅡ(APACHEⅡ)at admission,GCS],number of days of drainage tubes retention,location of drainage tubes,microbial culture results before removal of drainage tubes,white blood cell(WBC)and neutrophil ratio(NEU%)before and after removal of drainage tubes as well as clinical outcomes of the cohort patients were analyzed.The primarily outcome was in-hospital mortality,and then the length of intensive care unit(ICU)stay.Results A total of 146 patients after neurosurgery were included,28 of which developed hyperthermia after removal of drainage tubes.The GCS scores at admission in the hyperthermia group were significantly lower than that in the non-hyperthermia group,while the proportion of hypertension and diabetes in the hyperthermia group was significantly higher than that in the non-hyperthermia group.Based on GCS scores,the two groups,each of which included 28 patients,were matched with tendentious scores,and there was no significant difference in gender,age,GCS scores and the proportion of hypertension and diabetes between the two groups.The main disease for patients upon admission was cerebral hemorrhage(53.6%,30/56).The proportion of indwelling ventricular drainage tube retention in the hyperthermia group was significantly higher than that in the non-hyperthermia group[32.1%(9/28)vs.7.1%(2/28),P<0.05],but there was no significant difference in the location of other drainage tubes between the two groups.The proportion of lumbar puncture in the hyperthermia group was also significantly higher than that in the non-hyperthermia group[25.0%(7/28)vs.0(0/28),P<0.05].Compared with the non-hyperthermia group,WBC[×10^(9)/L:13.0(9.5,15.2)vs.11.5(8.8,13.3)]of 1 day before removal of drainage tubes,NEU%[0.892(0.826,0.922)vs.0.843(0.809,0.909)]after removal of drainage tubes and positive rate of drainage-fluid culture or drainage-tube-tip culture[7.1%(2/28)vs.0%(0/28)]in the hyperthermia group increased,but there were not significant differences.There was no significant difference in the proportion of pulmonary,urinary system and blood flow infection before removal of drainage tubes in the two groups.In terms of primary outcomes,compared with the non-hyperthermia group,the length of ICU stay[days:17.0(8.0,32.3)vs.8.5(1.0,16.8),P<0.05]in the hyperthermia group was significantly prolonged,and the in-hospital mortality[35.7%(10/28)vs.10.7%(3/28),P<0.05]in the hyperthermia group was obviously increased.The positive rate of carbapenem-resistant bacteria culture[32.1%(9/28)vs.3.6%(1/28),P<0.05]in the hyperthermia group during hospitalization was significantly higher than that in the non-hyperthermia group.Conclusions Hyperthermia after removal of drainage tubes for patients after neurosurgery can significantly prolong the length of ICU stay and increase the in-hospital mortality,which may be related to the secondary infection caused by indwelling intracranial drainage tubes and the intracranial spread of bacteria caused by removal of drainage tubes,as well as the intracranial multidrug-resistant bacterial infection caused by the drainage tubes.