Epidemiological characteristics and risk factors of sepsis development and death in patients with extremely severe burns
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摘要:
目的 探讨特重度烧伤患者发生脓毒症与死亡的流行病学特点和危险因素。 方法 采用回顾性病例系列研究方法。2017年1月—2021年12月，浙江大学医学院附属第二医院烧伤与创面修复科收治135例符合入选标准的特重度烧伤患者，其中男100例、女35例，年龄18~84岁。统计所有患者脓毒症发病率与确诊时间、血液标本微生物培养阳性（以下简称血培养阳性）率、病死率以及血培养阳性患者脓毒症发病率、感染病原菌情况（行 χ 2检验或Fisher确切概率法检验）。根据是否发生脓毒症，将所有患者分为脓毒症组（58例）和非脓毒症组（77例），比较2组患者性别、年龄、身体质量指数、高血压史、糖尿病史、合并吸入性损伤情况、烧伤部位、烧伤类型、烧伤总面积、复合伤情况。根据转归情况，将所有患者分为死亡组（37例）和存活组（98例），比较2组患者前述根据脓毒症分组的资料以及休克期度过平稳情况、合并脓毒症情况。对前述2组间数据比较行独立样本 t检验、Wilcoxon秩和检验、Mann-Whitney U检验、 χ 2检验或Fisher确切概率法检验等单因素分析，选取 P<0.1的因素进行多因素logistic回归分析，筛选影响特重度烧伤患者发生脓毒症和死亡的独立危险因素。 结果 所有患者中脓毒症发病率为42.96%（58/135），脓毒症确诊时间为伤后14（7，24）d，血培养阳性率达62.22%（84/135），病死率为27.41%（37/135）。血培养阳性患者脓毒症发病率为69.05%（58/84）。血培养阳性的脓毒症患者检出率居前5的病原菌从高到低排列依次为鲍曼不动杆菌、肺炎克雷伯菌、铜绿假单胞菌、金黄色葡萄球菌和阴沟肠杆菌，其感染鲍曼不动杆菌比例明显高于血培养阳性的非脓毒症患者（ χ 2=7.49， P<0.05）。与非脓毒症组比较，脓毒症组患者合并吸入性损伤比例、会阴烧伤比例、烧伤总面积均明显增大（ χ 2值分别为11.08、17.47， Z=5.68， P<0.05），其余指标均无明显变化（ P>0.05）。多因素logistic回归分析显示，合并吸入性损伤、烧伤总面积≥80%体表总面积（TBSA）、会阴烧伤均为特重度烧伤患者发生脓毒症的独立危险因素（比值比分别为3.15、7.24、3.24，95%置信区间分别为1.07~9.29、1.79~29.34、1.21~8.68， P<0.05）。与存活组比较，死亡组患者合并吸入性损伤比例、会阴烧伤比例、合并脓毒症比例（ χ 2值分别为6.55、11.64、22.26， P值均<0.05）以及烧伤总面积（ Z=4.25， P<0.05）与休克期度过不平稳比例（ P<0.05）均明显增大，其余指标均无明显变化（ P>0.05）。多因素logistic回归分析显示，休克期度过不平稳与合并脓毒症均为特重度烧伤患者发生死亡的独立危险因素（比值比分别为4.87、3.45，95%置信区间分别为1.21~19.57、1.28~9.33， P<0.05）。 结论 特重度烧伤患者脓毒症发病率高、病死率高，脓毒症发病高峰期为伤后2周，感染病原菌以鲍曼不动杆菌最为突出。合并吸入性损伤、烧伤总面积≥80%TBSA和会阴烧伤是特重度烧伤患者并发脓毒症的独立危险因素，合并脓毒症和休克期度过不平稳是特重度烧伤患者死亡的独立危险因素。 Abstract:Objective To explore the epidemiological characteristics and risk factors of sepsis development and death in patients with extremely severe burns. Methods A retrospective case series study was conducted. From January 2017 to December 2021, 135 patients with extremely severe burns who met the inclusion criteria were admitted to the Department of Burn and Wound Repair of the Second Affiliated Hospital of Zhejiang University School of Medicine, including 100 males and 35 females, aged 18-84 years. The incidence and diagnosis time of sepsis, the rate of positive microbial culture of blood samples (hereinafter referred to as positive blood culture), and the mortality rate of all patients, as well as the incidence of sepsis and the pathogen of infection in patients with positive blood culture were recorded (statistically analyzed with chi-square test or Fisher's exact probability test). According to the occurrence of sepsis, all patients were divided into sepsis group (58 cases) and non-sepsis group (77 cases), and the gender, age, body mass index, history of hypertension, history of diabetes, combination of inhalation injury, burn site, burn type, total burn area, and combined injury of patients were compared between the two groups. According to the outcome, all patients were divided into death group (37 cases) and survival group (98 cases), and the aforementioned data grouped according to sepsis as well as the stability of shock period and the combination of sepsis of patients were compared between the two groups. The aforementioned data between two groups were statistically analyzed with univariate analysis of independent sample t test, Wilcoxon rank-sum test, Mann-Whitney U test, chi-square test, or Fisher's exact probability test. Factors with P<0.1 were selected for multivariate logistic regression analysis to screen independent risk factors of sepsis and death in patients with extremely severe burns. Results Among all patients, the incidence of sepsis was 42.96% (58/135), the diagnosis time of sepsis was 14 (7, 24) d after injury, the positive blood culture rate was 62.22% (84/135), and the mortality rate was 27.41% (37/135). The incidence of sepsis of patients with positive blood culture was 69.05% (58/84). The top 5 pathogenic bacteria in the detection rate of septic patients with positive blood culture were Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus, and Enterobacter cloacae, ranking from high to low, and the proportion of Acinetobacter baumannii infected was significantly higher than that of non-septic patients with positive blood culture ( χ 2=7.49, P<0.05). Compared with those in non-sepsis group, the proportion of combination of inhalation injury, the proportion of perineal burns, and the total burn area of patients in sepsis group increased significantly (with χ 2 values of 11.08 and 17.47, respectively, Z=5.68, P<0.05), while the other indicators did not change significantly ( P>0.05). Multivariate logistic regression analysis showed that combination of inhalation injury, total burn area ≥80% total body surface area (TBSA), and perineal burns were independent risk factors for patients with extremely severe burns developing sepsis (with odds ratios of 3.15, 7.24, and 3.24, respectively, with 95% confidence intervals of 1.07 to 9.29, 1.79 to 29.34, and 1.21 to 8.68, respectively, P<0.05). Compared with those in survival group, the proportion of combination of inhalation injury, the proportion of perineal burns, and the proportion of combination of sepsis (with χ 2 values of 6.55, 11.64, and 22.26, respectively, Pvalues all <0.05), total burn area ( Z=4.25, P<0.05), and proportion of instability of shock period ( P<0.05) of patients in death group all increased significantly, while the other indicators did not change significantly ( P>0.05). Multivariate logistic regression analysis showed that the instability of shock period and combination of sepsis were independent risk factors for death of patients with extremely severe burns (with odds ratios of 4.87 and 3.45, respectively, with 95% confidence intervals of 1.21 to 19.57 and 1.28 to 9.33, respectively, P<0.05). Conclusions Patients with extremely severe burns have a high incidence of sepsis and a high mortality rate. The peak period of sepsis onset is 2 weeks after injury, with Acinetobacter baumannii as the most prominent infectious pathogen. Combination of inhalation injury, total burn area ≥80% TBSA, and perineal burns are independent risk factors for extremely severe burn patients complicated with sepsis, and combination of sepsis and instability of shock period are independent risk factors for death of patients with extremely severe burns. -
Key words:
- Burns /
- Sepsis /
- Prognosis /
- Risk factors /
- Pathogen
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参考文献
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表1 血液标本微生物培养阳性特重度烧伤患者中发生脓毒症与未发生脓毒症者感染病原菌情况比较
类别 例数 鲍曼不动杆菌 肺炎克雷伯菌 铜绿假单胞菌 金黄色葡萄球菌 阴沟肠杆菌 表皮葡萄球菌 溶血葡萄球菌 粪肠球菌 大肠埃希菌 奇异变形杆菌 脓毒症患者 58 27 25 19 9 8 7 2 4 3 3 非脓毒症患者 26 4 9 7 6 2 3 3 1 0 0 χ 2值 7.49 0.54 0.29 — — — — — — — P值 0.006 0.464 0.593 0.538 0.717 >0.999 0.169 >0.999 0.549 0.549 注：“—”表示无此项 
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表2 脓毒症组和非脓毒症组特重度烧伤患者临床资料比较
组别 例数 性别（例） 年龄［岁， M（ Q 1 ，Q 3）］ 身体质量指数 （kg/m 2， 高血压（例） 糖尿病（例） 合并吸入性损伤情况（例） 男 女 是 否 脓毒症组 58 40 18 47.5（35.0，53.0） 24±3 5 2 51 7 非脓毒症组 77 60 17 48.0（39.0，56.0） 24±4 11 1 48 29 统计量值 χ 2=1.38 Z=-0.73 t=-0.38 χ 2=1.02 — χ 2=11.08 P值 0.240 0.466 0.702 0.313 0.577 <0.001 注：“—”表示无此项，TBSA为体表总面积
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表3 影响135例特重度烧伤患者发生脓毒症的多因素logistic回归分析结果
因素与分类 比值比 95%置信区间 P值 合并吸入性损伤情况 3.15 1.07~9.29 0.038 烧伤总面积 60%~79%TBSA与50%~ 59%TBSA比较 2.35 0.55~9.97 0.787 ≥80%TBSA与50%~59%TBSA比较 7.24 1.79~29.34 0.001 会阴烧伤 3.24 1.21~8.68 0.020 复合伤情况 4.94 0.81~30.18 0.084 注：TBSA为体表总面积
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表4 死亡组和存活组特重度烧伤患者临床资料比较
组别 例数 性别（例） 年龄［岁， M（ Q 1 ，Q 3）］ 身体质量指数 （kg/m 2， 高血压（例） 糖尿病（例） 合并吸入性损伤情况（例） 烧伤类型（例） 男 女 是 否 烧伤 烫伤 化学烧伤 死亡组 37 25 12 51.0（41.0，56.0） 24±3 3 1 33 4 33 1 3 存活组 98 75 23 46.5（37.0，54.0） 24±4 13 2 66 32 90 6 2 统计量值 χ 2=1.12 Z=1.03 t=-0.22 — — χ 2=6.55 — P值 0.289 0.307 0.822 0.556 >0.999 0.010 0.220 注：“—”表示无此项，TBSA为体表总面积
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表5 影响135例特重度烧伤患者预后的多因素logistic回归分析结果
因素与分类 比值比 95%置信区间 P值 合并吸入性损伤情况 2.84 0.67~11.54 0.145 烧伤总面积 60%~79%TBSA与50%~ 59%TBSA比较 3.31 0.36~30.65 0.496 ≥80%TBSA与50%~ 59%TBSA比较 4.29 0.46~39.76 0.212 会阴烧伤 2.32 0.65~8.26 0.192 休克期度过平稳情况 4.87 1.21~19.57 0.026 合并脓毒症情况 3.45 1.28~9.33 0.014
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