大面积烧伤患者继发持续炎症-免疫抑制-分解代谢综合征的危险因素分析

汤文彬; 陈宾; 欧莎莉; 李欣滢; 肖逵; 王思思; 李孝建

doi:10.3760/cma.j.cn501225-20220214-00028

大面积烧伤患者继发持续炎症-免疫抑制-分解代谢综合征的危险因素分析

doi: 10.3760/cma.j.cn501225-20220214-00028

暨南大学附属广州红十字会医院烧伤整形科，广州　　510220

基金项目:

广州市科技计划项目 202102010058

广州市卫生健康科技项目一般引导项目 20221A010016

广州市科学技术局2022年基础研究计划项目 202201020003

详细信息

通讯作者:
李孝建，Email：lixj64@163.com

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出版历程
- 收稿日期: 2022-02-14

Analysis of the risk factors of persistent inflammation-immunosuppression-catabolism syndrome in patients with extensive burns

Department of Burns and Plastic Surgery, Guangzhou Red Cross Hospital of Jinan University, Guangzhou 510220, China

Funds:

Guangzhou Science and Technology Plan Project 202102010058

General Guidance Project of Guangzhou Health Science and Technology Project 20221A010016

The 2022 Basic Research Plan of Guangzhou Science and Technology Office 202201020003

More Information

Corresponding author: Li Xiaojian, Email: lixj64@163.com

摘要

摘要: 目的探讨大面积烧伤患者继发持续炎症-免疫抑制-分解代谢综合征（PICS）的危险因素和治疗结局。方法采用回顾性病例系列研究方法。2017年1月—2021年12月，暨南大学附属广州红十字会医院收治220例符合入选标准的大面积烧伤患者，其中男168例、女52例，年龄18~84（43±14）岁。按照PICS发生情况，将患者分为PICS组（84例）和非PICS组（136例）。收集并分析2组患者性别、年龄、入院时合并基础疾病情况和急性生理学和慢性健康状况评价Ⅱ（APACHEⅡ）评分、入院时和入院14 d脓毒症相关性器官功能衰竭评价（SOFA）评分、治疗期间行机械通气超过48 h比例等一般资料，烧伤总面积、Ⅲ度烧伤面积、伤后48 h内入院比例、伤后30 d深度创面暴露面积等专科情况，住院天数、住院总费用、手术次数以及死亡情况等结局指标。对数据行独立样本 t检验、Mann-Whitney U检验、 χ ²检验。对除结局指标外2组比较差异有统计学意义的指标行多因素logistic回归分析，筛选大面积烧伤患者继发PICS的独立危险因素。结果 PICS组患者入院时APACHEⅡ评分和SOFA评分、治疗期间行机械通气超过48 h比例均明显高于非PICS组（ t=6.78， Z=-4.75， χ ²=4.74， P<0.05）；2组患者其余一般资料比较，差异均无统计学意义（ P>0.05）。PICS组患者烧伤总面积、Ⅲ度烧伤面积、伤后30 d深度创面暴露面积均明显大于非PICS组（ t=6.29， Z=-7.25， Z=-8.73， P<0.05），其中PICS组、非PICS组患者伤后30 d深度创面暴露面积分别为25%（15%，35%）体表总面积（TBSA）、8%（0，13%）TBSA；但伤后48 h内入院比例明显低于非PICS组（ χ ²=6.13， P<0.05）。PICS组患者住院天数、住院总费用、手术次数均明显多于非PICS组（ Z值分别为-7.12、-8.48、-6.87， P<0.05），但2组患者死亡情况相近（ P>0.05）。入院时APACHEⅡ评分、伤后30 d深度创面暴露面积均是大面积烧伤患者继发PICS的独立危险因素（比值比分别为1.15、1.07，95%置信区间分别为1.06~1.25、1.05~1.10， P<0.05）。结论入院时APACHEⅡ评分、伤后30 d深度创面暴露面积是大面积烧伤患者继发PICS的独立危险因素。继发PICS的患者预后良好，但手术干预和住院天数更多、住院总费用更高。
- 烧伤 /
- 预后 /
- 危险因素 /
- 持续炎症-免疫抑制-分解代谢综合征
Abstract: Objective To investigate the risk factors and treatment outcome of persistent inflammation-immunosuppression-catabolism syndrome (PICS) in patients with extensive burns. Methods A retrospective case series study was conducted. From January 2017 to December 2021, 220 patients with extensive burns who were admitted to Guangzhou Red Cross Hospital of Jinan University met the inclusion criteria, including 168 males and 52 females, aged 18-84 (43±14) years. According to the occurrence of PICS, the patients were divided into PICS group (84 patients) and non-PICS group (136 patients). The general data such as sex, age, complication of underlying diseases and acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score on admission, sepsis-related organ failure evaluation (SOFA) scores on admission and 14 days post admission, and proportion of patients with mechanical ventilation over 48 h during treatment, special conditions such as total burn area, full-thickness burn area, proportion of patients admitted within 48 h post injury, and exposed deep wound area at the 30 ^th day post injury, outcome indicators such as hospitalization day, total cost of hospital stay, number of surgeries, and death of patients in the 2 groups were collected and analyzed. Data were statistically analyzed with independent sample t test, Mann-Whitney U test, and chi-square test. The multivariate logistic regression analysis was performed on the indicators with statistically significant differences between the two groups except for outcome indicators, and the independent risk factors influencing secondary PICS in patients with extensive burns were screened. Results The APACHE Ⅱ and SOFA scores on admission, and proportion of patients with mechanical ventilation over 48 h during treatment of patients in PICS group were significantly higher than those in non-PICS group ( t=6.78, Z=-4.75, χ ²=4.74, respectively, P<0.05). There were no statistically significant differences in the rest of general data of patients between the two groups ( P>0.05). The total burn area, full-thickness burn area, and exposed deep wound area at the 30 ^th day post injury in PICS group were significantly greater than those in non-PICS group ( t=6.29, Z=-7.25, Z=-8.73, P<0.05), the exposed deep wound areas at the 30 ^th day post injury in PICS group and non-PICS group were respectively 25% (15%, 35%) total body surface area (TBSA) and 8% (0, 13%) TBSA, while the proportion of patients admitted within 48 h post injury was significantly lower than that in non-PICS group ( χ ²=6.13, P<0.05). The hospitalization day, total cost of hospital stay, and number of surgeries of patients in PICS group were significantly higher than those in non-PICS group (with Z values of -7.12, -8.48, and -6.87, respectively, P<0.05), while the deaths of patients in the 2 groups were similar ( P>0.05). The APACHE Ⅱ score on admission and exposed deep wound area at the 30 ^th day post injury both were the independent risk factors for PICS in patients with extensive burns (with odds ratios of 1.15 and 1.07, 95% confidence intervals of 1.06-1.25 and 1.05-1.10, respectively, P<0.05). Conclusions The APACHE Ⅱ score on admission and exposed deep wound area at the 30 ^th day post injury are the independent risk factors for PICS in patients with extensive burns. The patients with secondary PICS had good prognosis with more surgical intervention and hospitalization day, and higher total cost of hospital stay.
- Burns /
- Prognosis /
- Risk factors /
- Persistent inflammation-immunosuppression-catabolism syndrome
汤文彬：统计分析、论文撰写；陈宾：数据整理、统计分析；欧莎莉、李欣滢、肖逵、王思思：数据采集与整理；李孝建：研究指导、论文修改、经费支持

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参考文献(14)

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表1 2组大面积烧伤患者一般资料比较

组别	例数	性别［例（%）］		年龄［例（%）］		入院时合并基础疾病［例（%）］		入院时APACHEⅡ评分（分， x ¯ ± s ）	入院时SOFA评分［分， M（ Q ₁， Q ₃）］	入院14 d SOFA评分［分， M（ Q ₁， Q ₃）］	治疗期间行机械通气超过48 h［例（%）］
组别	例数	男	女	<65岁	≥65岁	糖尿病	高血压	入院时APACHEⅡ评分（分， x ¯ ± s ）	入院时SOFA评分［分， M（ Q ₁， Q ₃）］	入院14 d SOFA评分［分， M（ Q ₁， Q ₃）］	治疗期间行机械通气超过48 h［例（%）］
PICS组	84	65（77.4）	19（22.6）	80（95.2）	4（4.8）	3（3.6）	10（11.9）	11±5	4（3，5）	3（2，4）	46（54.8）
非PICS组	136	103（75.7）	33（24.3）	128（94.1）	8（5.9）	4（2.9）	8（5.9）	7±4	2（1，3）	2（1，3）	54（39.7）
统计量值		χ ²=0.08		χ ²<0.01		χ ²<0.01	χ ²=2.50	t=6.78	Z=-4.75	Z=-1.90	χ ²=4.74
P值		0.780		0.960		1.000	0.113	<0.001	<0.001	0.057	0.029
注：PICS为持续炎症-免疫抑制-分解代谢综合征，APACHEⅡ为急性生理学和慢性健康状况评价Ⅱ，SOFA为脓毒症相关性器官功能衰竭评价

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表2 2组大面积烧伤患者专科情况比较

组别	例数	烧伤总面积（%TBSA， x ¯ ± s ）	Ⅲ度烧伤面积［%TBSA， M（ Q ₁， Q ₃）］	伤后48 h内入院［例（%）］	伤后30 d深度创面暴露面积［%TBSA， M（ Q ₁， Q ₃）］
PICS组	84	73±20	56（36，80）	57（67.9）	25（15，35）
非PICS组	136	55±20	29（6，43）	112（82.4）	8（0，13）
统计量值		t=6.29	Z=-7.25	χ ²=6.13	Z=-8.73
P值		<0.001	<0.001	0.013	<0.001
注：PICS为持续炎症-免疫抑制-分解代谢综合征，TBSA为体表总面积；深度创面暴露面积包括未行手术治疗的深Ⅱ度和Ⅲ度烧伤创面、暴露的肉芽组织创面、植皮区/供皮区感染创面面积

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表3 2组大面积烧伤患者结局指标比较

组别	例数	住院天数［d， M（ Q ₁， Q ₃）］	住院总费用［万元， M（ Q ₁， Q ₃）］	手术次数［次， M（ Q ₁， Q ₃）］	死亡［例（%）］
PICS组	84	66（42，86）	85.3（48.1，110.6）	5（3，7）	2（2.4）
非PICS组	136	40（26，48）	35.7（13.0，47.8）	2（1，4）	3（2.2）
统计量值		Z=-7.12	Z=-8.48	Z=-6.87	χ ²<0.01
P值		<0.001	<0.001	<0.001	0.633
注：PICS为持续炎症-免疫抑制-分解代谢综合征

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表4 影响220例大面积烧伤患者继发PICS的多因素logistic回归分析阳性结果

因素	回归系数	标准误	比值比	95%置信区间	P值
入院时APACHEⅡ评分（分）	0.14	12.13	1.15	1.06~1.25	<0.001
伤后30 d深度创面暴露面积（%TBSA）	0.07	30.07	1.07	1.05~1.10	<0.001
注：PICS为持续炎症-免疫抑制-分解代谢综合征，APACHEⅡ为急性生理学和慢性健康状况评价Ⅱ，TBSA为体表总面积；深度创面暴露面积包括未行手术治疗的深Ⅱ度和Ⅲ度烧伤创面、暴露的肉芽组织创面、植皮区/供皮区感染创面面积