目的 探讨影响重症加强治疗病房(ICU)患者预后的相关因素.方法 采用回顾性队列研究方法,收集2005年1月至2016年12月入住北京老年医院ICU患者的临床资料,根据ICU预后分为死亡组和存活组,观察研究期间ICU病死率随年份、年龄的变化趋势.以存活和死亡作为因变量;以性别、年龄、入ICU原因、急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、是否行有创机械通气、有创机械通气原因、有创机械通气时间、是否成功撤机、是否发生ICU院内感染、是否发生医院获得性肺炎(HAP)、是否发生中央导管相关性血流感染(CLABSI)、是否发生急性肾损伤(AKI)、是否行连续性血液净化(CBP)、是否发生脓毒性休克、是否行有创血流动力学监测、是否输血以及ICU住院时间作为自变量,先分别对临床资料进行单因素分析,将分析得到的影响因变量的自变量进行logistic回归分析,筛选影响ICU患者预后的危险因素.结果 研究期间共收治患者1325例,剔除资料缺失者26例,最终入组1299例.其中存活组865例,死亡组434例;男性占比(67.7%)和年龄跨度(16~105岁)较大;不同年份ICU病死率比较差异无统计学意义(χ2=16.712,P=0.117);而随年龄增长,ICU病死率呈升高趋势(χ2=16.399,P=0.022).单因素分析显示:ICU患者死亡与性别无关,而与年龄、APACHEⅡ评分、有创机械通气、有创机械通气原因、有创机械通气时间、成功撤机、ICU院内感染、HAP、CLABSI、AKI、脓毒性休克、行CBP或有创血流动力学监测、输血、入ICU原因、ICU住院时间均有关(均P<0.05).将单因素分析中有统计学意义的相关因素进行logistic回归分析,结果显示,是否成功撤机〔优势比(OR)=0.016,95%可信区间(95%CI)=0.010~0.025〕,以及是否发生AKI(OR=3.917,95%CI=2.331~6.582)或脓毒性休克(OR=2.808,95%CI=1.604~4.915)3个自变量对死亡或存活有影响(均P=0.000).其中是否成功撤机回归系数(β 值)为-4.155,提示未成功撤机患者死亡的可能性大;是否发生AKI或脓毒性休克的β 值分别为1.365、1.033,提示发生AKI或脓毒性休克的患者死亡的可能性大.结论 是否成功撤机及是否发生AKI或脓毒性休克是影响ICU患者预后的独立危险因素,临床上采取有针对性的预防措施可能改善患者的预后.%Objective To explore the prognostic factors of intensive care unit (ICU) patients. Methods A retrospective cohort study was conducted. The clinical data of patients admitted to ICU of Beijing Geriatric Hospital from January 2005 to December 2016 were collected. According to the prognosis, the patients were divided into death group and survival group, and the mortality trend with time and age was observed. Survival and death were treated as dependent variables, while the gender, age, reason of ICU admission, acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) score, whether undergoing invasive mechanical ventilation (MV), invasive MV reason, duration of invasive MV, whether successful weaning, whether ICU nosocomial infection, hospital acquired pneumonia (HAP), central line-associated bloodstream infection (CLABSI), acute kidney injury (AKI) occurred, whether undergoing continuous blood purification (CBP), whether septic shock occurred, whether undergoing invasive hemodynamic monitoring or blood transfusion and length of ICU stay were used as the independent variables. First, the clinical data was analyzed by univariate analysis. Second, the independent variables influencing the dependent variable were analyzed by logistic regression analysis to screen out prognostic factors of ICU patients. Results During the study period, 1325 patients were treated, 26 patients with missing data, 1299 patients in final group, 865 patients in survival group, and 434 in death group. The proportion of men in the patients was larger (67.7%), and the age span was larger (16-105 years old). The mortality rate in different years showed no significant difference (χ2 = 16.712, P = 0.117), and with the increase of age, the mortality rate of ICU showed an upward trend (χ2 = 16.399, P = 0.022). The univariate analysis showed that ICU deaths were unrelated to gender, but associated with age, APACHE Ⅱ score, invasive MV, invasive MV reason, duration of invasive MV, successful weaning, ICU nosocomial infection, HAP, CLABSI, AKI, septic shock, whether CBP or invasive hemodynamic monitoring, blood transfusion, the reason of ICU admission and the length of ICU stay (all P < 0.05). The relevant factors with statistical difference found in univariate analysis were analyzed in logistic regression analysis, which showed that whether successful weaning [odds ratio (OR) = 0.016, 95% confidence interval (95%CI) = 0.010-0.025], and whether AKI (OR = 3.917, 95%CI = 2.331-6.582) or septic shock occurred (OR = 2.808, 95%CI = 1.604-4.915) were the dependent variables of death or survival (all P = 0.000). Regression coefficient (β value) of successful weaning was -4.155, suggesting that unsuccessful weaning patients were likely to die. The β value of AKI and septic shock was 1.365 and 1.033, suggesting that the patients with AKI or septic shock were more likely to die. Conclusions Whether the success of weaning, whether the occurrence of AKI or septic shock are independent prognostic factors for the prognosis of ICU patients. Measures for the prevention of the above three aspects could improve the prognosis of ICU patients.
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