摘要
目的观察脓毒症相关胆汁淤积性黄疸患者临床特征并分析死亡危险因素。方法收集2011年8月-2019年8月四川省医学科学院·四川省人民医院重症医学中心SICU收治的脓毒症相关胆汁淤积性黄疸患者139例,分为存活组(n=62)和死亡组(n=77)。记录患者年龄、性别、急性生理和慢性健康评分(APACHEⅡ)以及感染部位;记录5个时间点TBil、DBil、IBil、PT、国际标准化比值(INR)、AST、ALT、WBC、中性粒细胞(NEU)、降钙素原(PCT)、乳酸(Lac)数值;同时记录TBil、DBil、IBil峰值,以及血管活性药物时间、机械通气时间、人工肝血浆置换次数、重症监护病房(ICU)住院时间、Child-Pugh分级、黄疸分级。符合正态性和方差齐性的计量资料两组间比较采用独立样本t检验;不符合正态性和方差齐性的计量资料两组间比较采用Mann-Whitney U检验。计数资料两组间比较采用χ2检验。采用二元logistic多因素回归分析进行死亡危险因素分析。结果脓毒症相关胆汁淤积性黄疸患者病死率55.4%。存活组TBil、DBil以及IBil在14 d、21 d、28 d以及峰值水平均显著低于死亡组(TBil:Z值分别为-3.230、-8.197、-9.281,t=-5.371;DBil:Z值分别为-4.708、-8.633、-9.579、-8.238;IBil:Z值分别为-2.402、-6.522、-8.113、-5.300,P值均<0.01);存活组中度黄疸比例高,而死亡组重度黄疸比例高,两组比较差异有统计学意义(χ2=57.633,P<0.01);存活组PT和INR在所有时点(诊断时、7 d、14 d、21 d、28 d)均低于死亡组(PT:Z值分别为-3.173、-3.467、-2.660、-2.261、-3.120;INR:Z值分别为-3.141、-2.754、-3.230、-2.560、-3.229,P值均<0.05);AST在7 d、14 d、21 d及28 d明显低于死亡组(Z值分别为-2.484、-3.200、-3.298、-4.277,P值均<0.05);ALT在14 d、21 d及28 d明显低于死亡组(Z值分别为-2.635、-2.667、-4.656,P值均<0.01);存活组WBC、NEU在7 d、14 d、21 d均显著低于死亡组(WBC:Z值分别为-3.229、-2.987、-4.537;NEU:t=-3.332、Z=-3.107、Z=-4.485,P值均<0.01);存活组PCT诊断时、14 d、21 d和28 d明显低于死亡组(Z值分别为-4.844、-2.215、-2.869、-7.442,P值均<0.05);Lac在所有时点(诊断时、7 d、14 d、21 d、28 d)均明显低于死亡组(Z值分别为-4.316、-2.913、-3.068、-8.578、-9.341,P值均<0.01);存活组血管活性药物(Z=-6.421)、机械通气时间(Z=-2.005)、人工肝时间(Z=-4.822)和ICU住院时间(t=-3.005)均明显低于死亡组(P值均<0.05)。TBil(OR=0.959,95%CI:0.929~0.991)、DBil(OR=1.056,95%CI:1.009~1.105)、IBil(OR=1.071,95%CI:1.006~1.140),WBC 7 d(OR=31.365,95%CI:2.878~41.761)、14 d(OR=5.859,95%CI:1.073~31.999),NEU 7 d(OR=0.007,95%CI:0.003~0.409)、14 d(OR=0.132,95%CI:0.023~0.765),PCT诊断时(OR=1.062,95%CI:1.017~1.110)、7 d(OR=0.920,95%CI:0.855~0.990)、28 d(OR=12.711,95%CI:3.532~45.745),血管活性药物时间(OR=1.657,95%CI:1.337~2.053),机械通气时间(OR=0.783,95%CI:0.634~0.967)以及人工肝持续时间(OR=1.534,95%CI:1.065~2.208)是脓毒症相关胆汁淤积性黄疸患者死亡的独立危险因素(P值均<0.05)。结论脓毒症相关胆汁淤积性黄疸患者病死率高。与死亡患者相比,存活患者胆红素及其峰值水平在疾病的中后期更低,中度黄疸比例居多,而死亡患者重度黄疸比例居多。存活患者凝血障碍更轻,肝酶学AST、ALT更低,感染指标WBC、NEU及PCT更低,灌注指标Lac更低。存活患者血管活性药物使用时间、人工肝时间、机械通气时间和ICU住院时间均明显优于死亡患者。胆红素水平,感染指标WBC、NEU及PCT,血管活性药物,机械通气时间和人工肝持续时间是脓毒症相关胆汁淤积性黄疸患者死亡的独立危险因素。
Objective To investigate the clinical features of patients with sepsis-induced cholestatic jaundice and the risk factors for death.Methods A retrospective analysis was performed for the clinical data of 139 patients with sepsis-induced cholestatic jaundice who were admitted to Surgical Intensive Care Unit,Critical Care Medicine Center,Sichuan Academy of Medical Sciences&Sichuan Provincial People’s Hospital,from August 2011 to August 2019,and the patients were divided into survival group with 62 patients and death group with 77 patients.Age,sex,Acute Physiology and Chronic Health Evaluation II(APACHEII)score,and infection sites were recorded;related laboratory data at five time points were recorded,including total bilirubin(TBil),direct bilirubin(DBil),indirect bilirubin(IBil),prothrombin time(PT),international normalized ratio(INR),aspartate aminotransferase(AST),alanine aminotransferase(ALT),white blood cell count(WBC),neutrophils(NEU),procalcitonin(PCT),and lactic acid(Lac);the peak values of TBil,DBil,and IBil were also recorded,as well as duration of use of vasoactive agent,duration of mechanical ventilation,number of times of artificial liver plasma exchange,length of stay in the intensive care unit(ICU),Child-Pugh class,and jaundice grade.The independent samples t-test was used for comparison of normally distributed continuous data with homogeneity of variance between groups,and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data with heterogeneity of variance between groups;the chi-square test was used for comparison of categorical data between groups;a binary logistic regression analysis was used to investigate the risk factors for death.Results The mortality rate of patients with sepsis-induced cholestatic jaundice was 55.4%.Compared with the death group,the survival group had significantly lower levels of TBil,DBil,and IBil on days 14,21,and 28 and significantly lower peak values of TBil,DBil,and IBil(TBil:Z=-3.230,-8.197,and-9.281,t=-5.371,all P<0.01;DBil:Z=-4.708,-8.633,-9.579,and-8.238,P<0.01;IBil:Z=-2.402,-6.522,-8.113,and-5.300,all P<0.01).The survival group had a higher proportion of patients with moderate jaundice,while the death group had a higher proportion of patients with severe jaundice(χ2=57.633,P<0.01).Compared with the death group,the survival group had significantly lower PT and INR at all time points(at diagnosis and on days 7,14,21,and 28)(PT:Z=-3.173,-3.467,-2.660,-2.261,and-3.120,all P<0.05;INR:Z=-3.141,-2.754,-3.230,-2.560,and-3.229,all P<0.05)and significantly lower levels of AST on days 7,14,21,and 28(Z=-2.484,-3.200,-3.298,and-4.277,all P<0.05)and ALT on days 14,21,and 28(Z=-2.635,-2.667,and-4.656,all P<0.01).Compared with the death group,the survival group had significantly lower levels of WBC and NEU on days 7,14,and 21(WBC:Z=-3.229,-2.987,and-4.537,all P<0.01;NEU:t=-3.332,Z=-3.107 and-4.485,all P<0.01),as well as significantly lower PCT at diagnosis and on days 14,21,and 28(Z=-4.844,-2.215,-2.869,and-7.442,all P<0.05)and Lac at all time points(at diagnosis and on days 7,14,21,and 28)(Z=-4.316,-2.913,-3.068,-8.578,and-9.341,all P<0.01).Compared with the death group,the survival group had significantly shorter duration of use of vasoactive agent(Z=-6.421,P<0.01),duration of mechanical ventilation(Z=-2.005,P<0.05),duration of artificial liver(Z=-4.822,P<0.01),and length of stay in the ICU(t=-3.005,P<0.01).TBil(odds ratio[OR]=0.959,95%confidence interval[CI]:0.929-0.991,P<0.05),DBil(OR=1.056,95%CI:1.009-1.105,P<0.05),IBil(OR=1.071,95%CI:1.006-1.140,P<0.05),WBC on day 7(OR=31.365,95%CI:2.878-41.761,P<0.05),WBC on day 14(OR=5.859,95%CI:1.073-31.999,P<0.05),NEU on day 7(OR=0.007,95%CI:0.003-0.409,P<0.05),NEU on day 14(OR=0.132,95%CI:0.023-0.765,P<0.05),PCT at diagnosis(OR=1.062,95%CI:1.017-1.110,P<0.05),PCT on day 7(OR=0.920,95%CI:0.855-0.990,P<0.05),PCT on day 28(OR=12.711,95%CI:3.532-45.745,P<0.05),duration of use of vasoactive agent(OR=1.657,95%CI:1.337-2.053,P<0.05),duration of mechanical ventilation(OR=0.783,95%CI:0.634-0.967,P<0.05),and duration of artificial liver(OR=1.534,95%CI:1.065-2.208,P<0.05)were independent risk factors for death in patients with sepsis-induced cholestatic jaundice.Conclusion Patients with sepsis-induced cholestatic jaundice have a high mortality rate.The survival group has significantly lower levels and peak values of bilirubin than the death group in the middle and late stages of the disease,and there is a higher proportion of patients with moderate jaundice in the survival group and a higher proportion of patients with severe jaundice in the death group.Compared with the death group,the survival group has significantly lower degree of coagulation disorder,levels of AST and ALT,infection indices WBC,NEU,and PCT,and perfusion index Lac.Compared with the death group,the survival group has significantly better duration of use of vasoactive agent,duration of artificial liver support,duration of mechanical ventilation,and length of stay in the ICU.Bilirubin levels,infection indices WBC,NEU,and PCT,vasoactive agent,duration of mechanical ventilation,and duration of artificial liver support are independent risk factors for death in patients with sepsis-induced cholestatic jaundice.
作者
雷雨
黎嘉嘉
刘蓉安
曾帆
李贵森
兰蕴平
LEI Yu;LI Jiajia;LIU Rongan(Department of Nephrology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China)
出处
《临床肝胆病杂志》
CAS
北大核心
2020年第5期1065-1071,共7页
Journal of Clinical Hepatology
基金
四川省卫生和计划生育委员会科研课题(17PJ137)。
