重型颅脑损伤患者术后发生呼吸机相关性肺炎的影响因素分析

Influencing factors for postoperative ventilator-associated pneumonia in patients with severe traumatic brain injuries

目的 分析重型颅脑损伤患者术后发生呼吸机相关性肺炎(VAP)的影响因素。方法 回顾性分析2018年1月—2022年1月河北北方学院附属第一医院收治的240例行开颅手术治疗的重型颅脑损伤患者临床资料,男性135例,女性105例;年龄42~68岁,平均53.2岁;道路交通伤156例,机械损伤64例,其他损伤20例。根据术后是否发生VAP分为感染组(63例)和未感染组(177例)。对两组患者的临床资料单因素分析,采用Logistic回归分析重型颅脑损伤患者术后发生VAP的危险因素,绘制ROC曲线分析血清降钙素原(PCT)、CRP、可溶性髓系细胞触发受体-1(sTREM-1)、肾上腺髓质素前体(pro-ADM)对重型颅脑损伤患者术后发生VAP的预测价值。结果 感染组性别(36/27)、年龄(54.4±11.1)岁、BMI(23.7±2.8)kg/m2和未感染组性别(99/78)、年龄(53.0±12.9)岁、BMI(23.1±3.6)kg/m2等一般资料比较差异无统计学意义(P>0.05);两组患者二次手术、机械通气时间≥14d、术后第3天血清PCT、CRP、sTREM-1、pro-ADM水平比较差异有统计学意义(P<0.05);Logistic回归分析结果显示,二次手术、机械通气时间≥14d、PCT≥0.58ng/mL、CRP≥66.04mg/mL、sTREM-1≥63.65pg/mL、pro-ADM≥45.19pg/mL是重型颅脑损伤患者术后发生VAP的危险因素(OR=2.136、2.281、2.512、2.446、2.279、2.252,95%CI=1.322~3.451、1.176~4.424、1.348~4.681、1.225~4.884、1.372~3.786、1.319~3.845,P<0.05)。ROC曲线分析结果显示PCT≥0.58ng/mL、CRP≥66.04mg/mL、sTREM-1≥63.65pg/mL、pro-ADM≥45.19pg/mL是重型颅脑损伤患者预测术后VAP的最佳截断值。结论 二次手术、机械通气时间≥14d、PCT≥0.58ng/mL、CRP≥66.04mg/mL、sTREM-1≥63.65pg/mL、pro-ADM≥45.19pg/mL是重型颅脑损伤术后VAP的危险因素,术前临床可借助上述危险因素及最佳截断值评估重型颅脑损伤术后VAP发生的风险并积极干预,改善患者预后。

Objective To analyze the incidence of postoperative ventilator-associated pneumonia(VAP)in patients with severe traumatic brain injuries(TBI).Methods A retrospective analysis was conducted on the clinical data of 240 patients with severe TBIs and treated with craniotomy in our hospital from Jan.2018 to Jan.2022.There were 135 males and 105 females aged 42-68(mean 53.2)years,with 156 road traffic injuries,64 me-chanical injuries,and 20 others.According to whether VAP occurred after surgery,patients were divided into infected group(63 cases)and uninfected group(177 cases).Univariate analysis was conducted on clinical data of two groups,and Logistic stepwise regression was further adopted to analyze the risk factors.ROC curves were drawn to analyze the predictive value of serum procalcitonin(PCT),C-reactive protein(CRP),soluble triggering receptor ex-pressed on myeloid cell-1(sTREM-1),and proadrenomedullin(pro-ADM)for postoperative incidence of VAP in se-vere TBI patients.Results There was no statistically significant difference between the infected and uninfected groups in gender,age,BMI(all P>0.05),but much higher proportions of patients with secondary surgery and≥14 d mechanical ventilation,and much higher levels of serum PCT,CRP,sTREM-1,and pro-ADM levels on the post-operative 3rd day were figured out in the infected group(all P<0.05).Further Logistic regression analysis showed the risk factors for postoperative VAP in severe TBI patients:secondary surgery(OR=2.136,95%CI=1.322-3.451,P=0.002),mechanical ventilation time≥14 d(OR=2.281,95%CI=1.176-4.424,P=0.015),PCT≥0.58 ng/mL(OR=2.512,95%CI=1.348-4.681,P=0.004),CRP≥66.04 mg/mL(OR=2.446,95%CI=1.225-4.884,P=0.011),sTREM-1≥63.65 pg/mL(OR=2.279,95%CI=1.372-3.786,P=0.001),pro-ADM≥45.19 pg/mL(OR=2.252,95%CI=1.319-3.845,P=0.003).ROC curve analysis showed that to predict postoperative VAP in severe TBI patients,the optimal cutoff values were 0.58 ng/mL by PCT,66.04 mg/mL by CRP,63.65 pg/mL by sTREM-1,and 45.19 pg/mL by pro-ADM.Conclusion Secondary surgery,mechanical ventilation time≥14 d,PCT≥0.58 ng/mL,CRP≥66.04 mg/mL,sTREM-1≥63.65 pg/mL,and pro-ADM≥45.19 pg/mL are risk factors for postoperative VAP in severe TBI patients.Monitoring of these risk factors and protective use of the optimal cutoff with active intervention may improve patient prognosis.