摘要
目的 探讨儿科重症监护中新发功能障碍的高危因素。方法 采用回顾性病例对照研究方法分析2015年1月至2016年1月中国医科大学附属盛京医院儿科重症监护病房收治的患儿906例，在入院时和出院时分别进行功能状态评分（FSS），根据新发功能障碍诊断标准分为新发功能障碍组、非新发功能障碍组，统计并比较2组性别、糖皮质激素应用时间、机械通气时间、镇静时间、神经肌肉阻滞剂应用时间、入院时清蛋白、丙氨酸氨基转氨酶、门冬氨酸氨基转氨酶、肌酸激酶、肌酸激酶同工酶、白细胞、血红蛋白、C反应蛋白是否存在差异。应用多因素Logistic回归分析筛选出导致新发功能障碍的高危因素。根据高危因素将所有患儿分为高危因素组、非高危因素组，比较2组在入院、出院时FSS、ΔFSS及出院神志FSS、感觉FSS、沟通FSS、运动FSS、喂养FSS、呼吸FSS的变化和入院、出院时的功能状态。结果 906例患儿中男547例，女359例；年龄（28.1±1.9）个月。新发功能障碍组81例，非功能障碍组825例。新发功能障碍组与非功能障碍组机械通气时间[（3.7±0.5） d比（1.1±0.1） d]、糖皮质激素应用时间[（3.2±0.6） d比（1.7±0.1） d]、镇静时间[（4.7±0.7） d比（1.7±0.1） d]、神经肌肉阻滞剂应用时间[（0.7±0.3） d比（0.1±0.03） d]、清蛋白[（35.6±0.8） g/L比（40.5±0.2） g/L]、肌酸激酶同工酶[（75.8±12.4） U/L比（49.7±2.6） U/L]比较差异均有统计学意义（均P〈0.05）。多因素Logistic回归分析显示机械通气时间〉7 d、糖皮质激素应用时间〉7 d、镇静时间〉7 d、低清蛋白血症是儿童重症监护中发生新发功能障碍的独立危险因素[OR＝0.69（95%CI：0.62～0.78）、OR＝0.84（95%CI：0.75～0.94）、OR ＝0.76（95%CI：0.68～0.84）、OR＝1.10（95%CI：1.06～1.16），均P〈0.05]。机械通气〉7d组出院FSS、出院神志FSS、出院感觉FSS、出院沟通FSS、出院运动FSS、出院喂养FSS、出院呼吸与机械通气≤7 d组比较差异均有统计学意义（均P〈0.05）。糖皮质激素应用〉7 d组出院FSS、出院神志FSS、出院感觉FSS、出院沟通FSS与糖皮质激素应用≤7 d比较差异均有统计学意义（均P〈0.05）。镇静时间〉7 d组出院FSS、出院神志FSS、出院感觉FSS、出院沟通FSS、出院运动FSS与镇静时间≤7 d比较差异均有统计学意义（均P〈0.05）。结论 机械通气时间〉7 d、糖皮质激素应用〉7 d、镇静时间〉7 d主要累及神志、感觉、沟通、运动功能，不仅增加了在院期间的新发功能障碍的发生率，对住院患儿的认知功能和肌肉功能造成损伤，影响预后。
Objective To investigate the high risk factors of new dysfunction in Pediatric Intensive Care Unit.Methods A retrospective cohort case control analysis was performed in order to investigate the 906 patients admitted to the Pediatric Intensive Care Unit of Shengjing Hospital of China Medical University from January 2015 to January 2016.Assessment of Functional Status Scale（FSS） was performed at both admission and discharge.According to the new dysfunction diagnostic criteria, all cases were divided into new dysfunction group and control group.The 2 groups were compared in gender, glucocorticoids application time, mechanical ventilation application time, sedation application time, neuromuscular blockers application time, albumin, alanine aminotransferase, aspartate aminotransferase, creatine kinase, creatine kinase isoenzyme, leukocyte, hemoglobin and C-reactive protein.Multivariate Logistic regression was used to screen the risk factors leading to new dysfunction.All cases were divided into high risk factors group and control group according to the risk factors.The 2 groups were compared in initial FSS, FSS of discharge, ΔFSS and the discharge FSS of mental status domain, FSS of sensory domain, FSS of communication domain, FSS of motor domain, FSS of feeding domain, and FSS of respiratory domain.Results Among the 906 cases, 547 cases were male and 359 cases were female, and average age was （28.1±1.9） months.There were 81 cases in new dysfunction group and 825 cases in control group.Factors such as mechanical ventilation application time[（3.7±0.5） d vs.（1.1±0.1） d], glucocorticoid application time [ （3.2±0.6） d vs.（1.7±0.1） d], sedation application time[（4.7±0.7） d vs.（1.7±0.1） d], neuromuscular blockers application time [（0.7±0.3） d vs.（0.1±0.03） d], albumin[（35.6±0.8） g/L vs.（40.5±0.2） g/L], creatine kinase isoenzyme [（75.8±12.4） U/L vs.（49.7±2.6） U/L] had significant diffe-rences between the new dysfunction group and the control group（all P〈0.05）. Multivariate Logistic regression analysis revealed that more than 7 days of mechanical ventilation, more than 7 days of glucocorticoids application, more than 7 days of sedation application, hypoalbuminemia were risk factors to develop new dysfunction[OR=0.69 （95% CI： 0.62-0.78）, OR=0.62 （95% CI： 0.75-0.94）, OR=0.75 （95% CI： 0.68-0.84）, OR=0.68 （95% CI： 1.06-1.16）, all P〈0.05]. In the more than 7 days of mechanical ventilation group, FSS at discharge, FSS of mental status, FSS of sensory, FSS of communication, FSS of motor, FSS of feeding, FSS of respiratory were significantly diffe-rent from those of the mechanical ventilation application time≤7 d group（all P〈0.05）. In the more than 7 days of glucocorticoids application group, FSS of mental status, FSS of sensory, FSS of communication were significantly different from those of the glucocorticoids application time≤7 d group（all P〈0.05）. In the more than 7 days of sedation application group, FSS at discharge, FSS of mental status, FSS of sensory, FSS of communication, FSS of motor were significantly different from those of the sedation application time≤7 d group（all P〈0.05）.Conclusion More than 7 days of mechanical ventilation, glucocorticoids application and sedation application not only increase the incidence of new dysfunction, but also affect mental, sensory, communication, motor function, the muscle and cognitive function at discharge and prognosis.
出处
《中华实用儿科临床杂志》
CSCD
北大核心
2017年第18期1393-1397,共5页
Chinese Journal of Applied Clinical Pediatrics
基金
国家自然科学基金（81372039）
辽宁省科学技术计划项目（2014225017）
