摘要
目的探讨重症加强治疗病房（ICU）长期机械通气患者发生便秘的相关因素及其对预后的影响。方法采用前瞻性观察性队列研究方法，选择2013年10月1日至2015年9月30日青岛大学附属医院综合ICU收治的机械通气（MV）时间≥6d的患者，按入住ICU后排便时间分为早期排便组（〈6d）和延迟排便组（≥6d）C数据收集期间，患者的营养支持方案按常规进行，记录患者的性别、年龄、急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分、病例来源、MV原因、应用乳果糖和吗啡类药物以及肾上腺素／去甲肾上腺素情况、最高呼气末正压（PEEP）、最低氧合指数（PaO2／FiO2）、最低收缩压等；采用多元回归方法分析影响首次排便时间的相关因素。观察早期排便组和延迟排便组患者ICU病死率、ICU住院时间、MV时间、中心静脉导管（CVC）留置时间、ICU获得性细菌感染和呼吸机相关性肺炎（VAP）发生率及MV不同时间点Logistic器官功能障碍评分（LOD）和每日胃残留量。结果入选189例患者，排除39例不符合纳入标准和13例中途放弃治疗或转院患者，最终共137例患者纳入分析，其中延迟排便组83例，早期排便组54例。两组患者性别、年龄、APACHEⅡ评分、病例来源、MV1dLOD评分、MV原因、MV5d内发生呕吐和每日胃残留量、营养支持、MV5d内肝性脑病患者乳果糖治疗及血液净化治疗等差异均无统计学意义（均P〉0．05）。与早期排便组比较，延迟排便组首次排便为稀便或水样便比例更低（15．7％（13／83）比33．3％（18／54）]，应用吗啡类药物和应用肾上腺素／去甲肾上腺素〉24h比例更高[48．2％（40／83）比40．7％（22／54），42．2％（35／83）比29．6％（16／54）]，呼吸机最高PEEP水平更高[cmH2O（1cmH2O=0．098kPa）：7．9±3．7比6．7±3．5]，最低收缩压更低[mmHg（1mmHg=0．133kPa）：74．8±28．1比88．9±30．2]，低氧血症（PaO2／FiO2〈150mmHg）患者更多[54．2％（45／83）比44．4％（24／53）]，差异均有统计学意义（均P〈0．05）。将单因素分析中有统计学意义的指标纳入多元回归分析，结果显示，PaO2／FiO2〈150mmHg和收缩压〈90mmHg是影响长期MV患者首次排便时间的独立危险因素[PaO2／FiO2〈150mmHg：风险比（HR）=1．415，95％可信区间（95％CI）=1．061—1．590，P=0．026；收缩压70—89mmHg：HR=1．461，95％CI=1．164—1．788，P=0．002；收缩压≤69mmHg：HR=1．273，95％CI=1．010—1．587，P=0．034]。延迟排便组ICU病死率、ICU住院时间、MV时间、CVC留置时间、ICU获得性细菌感染发生率及MV7d后VAP发生率均明显高于早期排便组[ICU病死率：15．7％（13／83）比7．4％（4／54），ICU住院时间（d）：17．0（14．0，23．0）比15．0（13．8，20．0），MV时间（d）：14．0（10．0，20．0）比11．0（9．8，15.3），CVC留置时间（d）：12．0（10．0，14．0）比10．0（9．0，11．3），ICU获得性细菌感染发生率：60．2％（50／83）比14．8％（8／54），VAP发生率：32．5％（27／83）比14．8％（8／54），均P〈0．05]。两组MV1dLOD评分无明显差异；MV4d和9d延迟排便组LOD评分则较早期排便组明显升高（分：6．41±4．37比5．21±3．12，4．33±2．20比3．50±2．90，均P〈0．01）。结论MV5d内PaO2/FiO2〈150mmHg、收缩压〈90mmHg是ICU长期MV患者延迟排便的独立危险因素；延迟排便会影响长期MV患者的ICU结局。
Objective To explore the factors associated with delayed defecation in long-term ventilated patients in intensive care unit （ICU） and their potential effect on prognosis. Methods A prospective observational cohort study was conducted. The patients admitted to general ICU of the Affiliated Hospital of Qingdao University from October 1st in 2013 to September 30th in 2015 who underwent mechanical ventilation （MV） for ≥ 6 days were enrolled, and they were divided into early defecation group （〈 6 days） and late defecation group （ ≥ 6 days）. At admission, clinical nutritional support were given as usual, and gender, age, acute physiology and chronic health evaluation Ⅱ （APACHE Ⅱ ） score, admission reasons, MV reasons, the usage of morphine and epinephrine/norepinephrine, the highest positive end-expiratory pressure （PEEP）, the lowest oxygenation index （PaO2/FiO2） and the lowest systolic blood pressure were collected. Logistic regression analysis was used to analyze the influencing factors of the first defecation time. ICU mortality, the length of ICU stay, central venous catheter （CVC） indwelling time, duration of MV, ICU acquired bacterial infection rate, and the incidence of ventilator associated pneumonia （VAP） were compared between early defecation group and late defecation group. Logistic organ dysfunction system （LOD） scores and gastric residual volume per day were recorded at the different time of MV. Results Totally 189 patients were enrolled, 39 patients did not satisfied the inclusion criteria and 13 patients gave up treatment or referrals were excluded. Finally 137 patients were enrolled in the analysis, 83 patients in late defecation group and 54 in early defecation group. There were no significant differences in the baseline characteristics such as gender, age, APACHE Ⅱ score, LOD score at 1 day of MV, admission reasons, MV reasons, disgorging and gastric residual volume per day during the first 5 days of MV, enteral nutrition, lactulose treatment in patients with hepatic encephalopathy during the first 5 days of MV, and blood purification treatment between the two groups （all P 〉 0.05）. Compared with the early defecation group, late defecation group had less patients with loose stools or watery stool at first time [15.7% （13/83） vs. 33.3% （18/54）], more patients using morphine and the usage of epinephrine/norepinephrine more than 24 hours [48.2% （40/83） vs. 40.7% （22/54）, 42.2%（35/83） vs. 29.6% （16/54）], higher the maximum PEEP level [cmH2O （1 cmH2O = 0.098 kPa）： 7.9 ± 3.7 vs. 6.7 ± 3.5], lower the minimal systolic blood pressure [mmHg （1 mmHg = 0.133 kPa）： 74.8 ± 28.1 vs. 88.9 ± 30.2] and more severe of hypoxemia [PaO2/FiO2 〈 150 mmHg, 54.2% （5/83） vs. 44.4% （24/53）], all of which had significant differences （all P 〈 0.05）. Factors found statistical significances by single factor analysis were enrolled in the muhiple regression analysis, which showed that PaO2/FiO2 〈 150 mmHg and systolic blood pressure 〈 90 mmHg were independently associated with a delay in defecation in patients undergoing long-term MV [PaO2/FiO2 〈 150 mmHg： adjusted hazard rate： 1.415, 95% confidence interval （95%CI） = 1.061-1.590, P =0.026; systolic blood pressure 70-89 mmHg： HR = 1.461, 95%CI = 1.164-1.788, P = 0.002; systolic blood pressure ≤ 69 mmHg： adjusted hazard rate = 1.273, 95%01 = 1.010-1.587, P = 0.034）. ICU mortality, the length of ICU stay, CVC indwelling time, duration of MV, ICU acquired bacterial infection rate, and the incidence of VAP at 7 days of MV in late defecation group were significantly higher than those of early defecation group [ICU mortality rate： 15.7% （13/83） vs. 7.4% （4/54）, the length of ICU stay （day）： 17.0 （14.0, 23.0） vs. 15.0 （13.8, 20.0）, CVC indwelling time （days）： 12.0 （10.0, 14.0） vs. 10.0 （9.0, 11.3）, duration of MV （days）： 14.0 （10.0, 20.0） vs. 11.0 （9.8, 15.3）, ICU acquired bacterial infections rate： 60.2% （50/83） vs. 14.8% （8/54）, the incidence of VAP： 32.5% （27/83） vs. 14.8% （8/54）; all P 〈 0.05]. There was no significant difference in LOD score between both groups. The LOD scores at 4 days and 9 days of MV in late defecation group were significantly higher than those of early defecation group （6.41± 4.37 vs. 5.21± 3.12, 4.33 ± 2.20 vs. 3.50 ± 2.90, both P 〈 0.01）. Conclusions PaO2/FiO2 〈 150 mmHg and systolic blood pressure 〈 90 mmHg during the first 5 days of MV were independently associated with a delay in defecation in patients undergoing long-term MV. The results suggest that constipation is associated with adverse outcomes in long-term ventilated patients.
出处
《中华危重病急救医学》
CAS
CSCD
北大核心
2017年第1期75-80,共6页
Chinese Critical Care Medicine
基金
中国博士后科学基金资助项目（2015M582058）
关键词
便秘
重症加强治疗病房
机械通气
预后
Constipation
Intensive care unit
Mechanical ventilation
Prognosis
