多发伤患者住院期间发生脓毒症的危险因素分析

Risk factors of sepsis during hospitalization in patients with multiple trauma

目的观察多发伤患者住院期间脓毒症的发生情况,探讨多发伤患者住院期间发生脓毒症的危险因素。方法2021年1月-2023年12月青岛市市立医院诊治多发伤患者816例,根据住院期间(入院28 d内)是否发生脓毒症分为脓毒症组252例和非脓毒症组564例。比较2组受伤原因、受伤部位、受伤至入院时间,入院24 h内首次急性生理学和慢性健康状况评估Ⅱ(APACHEⅡ)评分、格拉斯哥昏迷评分(GCS)、创伤严重程度评分(ISS)、序贯器官衰竭评估(SOFA)评分及血乳酸、C反应蛋白(CRP)、降钙素原(PCT)等指标。采用1∶1倾向性评分匹配,匹配的协变量包括性别、年龄、受伤原因、受伤部位,匹配后比较2组临床评分、实验室检查等指标。采用多因素logistic回归分析多发伤患者住院期间发生脓毒症的影响因素。结果匹配后,脓毒症组受伤至入院时间[24(13,24)h]、活化部分凝血活酶时间[34.72(26.09,44.59)s]均长于非脓毒症组[19(8,24)h、28.90(22.51,36.87)s](Z=-3.108,P=0.003;Z=-4.694,P<0.001),APACHEⅡ评分[17.0(14.0,22.0)分]、ISS评分[25.0(21.0,28.0)分]、SOFA评分[9.0(6.0,13.0)分]、机械通气比率(92.5%)、白细胞计数[11.06×10^(9)/L(9.36×10^(9)/L,13.03×10^(9)/L)]、中性粒细胞/淋巴细胞比值[2.87(2.27,3.40)]及血乳酸[2.80(2.34,3.33)mmol/L]、CRP[58.35(34.54,90.57)mg/L]、PCT[0.81(0.62,2.24)μg/L]水平均高于非脓毒症组[14.0(11.0,17.0)分、23.0(20.0,23.5)分、5.5(4.0,9.0)分、66.3%、10.37×10^(9)/L(8.95×10^(9)/L,12.33×10^(9)/L)、2.03(1.63,2.40)、1.96(1.76,2.19)mmol/L、40.70(22.11,59.82)mg/L、0.41(0.24,0.60)μg/L](Z=-6.501、-4.969、-9.087,χ^(2)=52.775,Z=-3.608、-13.143、-15.649、-7.387、-12.185;P均<0.05),GCS评分[5.0(4.0,8.0)分]、红细胞计数[(3.29±0.89)×1012/L]、血小板计数[(122.00±65.64)×10^(9)/L]均低于非脓毒症组[8.5(5.0,12.0)分、(3.65±0.97)×1012/L、(157.21±69.51)×10^(9)/L](Z=-8.464,t=-4.295、-5.846;P均<0.05)。受伤至入院时间(OR=1.088,95%CI:1.014~1.167,P=0.018)、APACHEⅡ评分(OR=1.431,95%CI:1.216~1.684,P<0.001)、GCS评分(OR=0.767,95%CI:0.640~0.918,P=0.004)、ISS评分(OR=1.352,95%CI:1.140~1.604,P=0.001)、SOFA评分(OR=1.513,95%CI:1.248~1.833,P<0.001)、血乳酸(OR=2.037,95%CI:1.454~2.852,P=0.003)、CRP(OR=1.041,95%CI:1.020~1.064,P<0.001)、PCT(OR=3.106,95%CI:1.410~6.842,P=0.005)是多发伤患者住院期间发生脓毒症的影响因素。结论受伤至入院时间长,APACHEⅡ评分、ISS评分、SOFA评分及血乳酸、CRP、PCT水平高,GCS评分低的多发伤患者住院期间发生脓毒症的风险较高。

Objective To observe the incidence of sepsis during hospitalization in patients with multiple trauma and to explore its risk factors.Methods Totally 816 patients with multiple trauma were diagnosed and treated in Qingdao Municipal Hospital from January 2021 to December 2023,and were divided into sepsis group(n=252)and non-sepsis group(n=564)according to whether sepsis occurred during hospitalization(within 28 d after admission).The cause of trauma,location of trauma,time from injury to admission,and the first Acute Physiology and Chronic Health EvaluationⅡ(APACHEⅡ)score,Glasgow Coma Scale(GCS),Injury Severity Score(ISS),Sequential Organ Failure Assessment(SOFA)score,blood lactate,C-reactive protein(CRP),procalcitonin(PCT),and other indicators within 24 h after admission were compared between two groups.Propensity score matching with a 1:1 ratio was used,with covariates including gender,age,and cause and location of trauma.After matching,the clinical scores,laboratory tests and other indicators were compared between two groups.Multivariate logistic regression was used to assess the influencing factors of sepsis during hospitalization in patients with multiple trauma.Results After matching,the time from trauma to admission and activated partial thromboplastin time were longer in sepsis group[24(13,24)h,34.72(26.09,44.59)s]than those in non-sepsis group[19(8,24)h,28.90(22.51,36.87)s](Z=-3.108,P=0.003;Z=-4.694,P<0.001).The APACHEⅡscore,ISS,SOFA score,mechanical ventilation ratio,white blood cell count,neutrophil/lymphocyte ratio,blood lactate,CRP and PCT were higher in sepsis group[17.0(14.0,22.0),25.0(21.0,28.0),9.0(6.0,13.0),92.5%,11.06×10^(9)/L(9.36×10^(9)/L,13.03×10^(9)/L),2.87(2.27,3.40),2.80(2.34,3.33)mmol/L,58.35(34.54,90.57)mg/L,0.81(0.62,2.24)μg/L]than those in non-sepsis group[14.0(11.0,17.0),23.0(20.0,23.5),5.5(4.0,9.0),66.3%,10.37×10^(9)/L(8.95×10^(9)/L,12.33×10^(9)/L),2.03(1.63,2.40),1.96(1.76,2.19)mmol/L,40.70(22.11,59.82)mg/L,0.41(0.24,0.60)μg/L](Z=-6.501,Z=4.969,Z=-9.087,χ^(2)=52.775,Z=-3.608,Z=-13.143,Z=-15.649,Z=-7.387,Z=-12.185;all P values<0.05).The GCS,red blood cell count and platelet count were lower in sepsis group[5.0(4.0,8.0),(3.29±0.89)×10^(12)/L,(122.00±65.64)×10^(9)/L]than those in non-sepsis group[8.5(5.0,12.0),(3.65±0.97)×10^(12)/L,(157.21±69.51)×10^(9)/L](Z=-8.464,t=-4.295,t=-5.846;all P values<0.05).Time from trauma to admission(OR=1.088,95%CI:1.014-1.167,P=0.018),APACHEⅡscore(OR=1.431,95%CI:1.216-1.684,P<0.001),GCS(OR=0.767,95%CI:0.640-0.918,P=0.004),ISS(OR=1.352,95%CI:1.140-1.604,P=0.001),SOFA score(OR=1.513,95%CI:1.248-1.833,P<0.001),blood lactate level(OR=2.037,95%CI:1.454-2.852,P=0.003),CRP level(OR=1.041,95%CI:1.020-1.064,P<0.001),and PCT level(OR=3.106,95%CI:1.410-6.842,P=0.005)were the influencing factors of sepsis during hospitalization in patients with multiple trauma.Conclusion Long time from trauma to admission,high APACHEⅡscore,high ISS,high SOFA score,high blood lactate level,high CRP level,high PCT level,and low GCS indicate a high risk of sepsis during hospitalization in patients with multiple trauma.