重症吉兰巴雷综合征患者机械通气及出院6个月预后影响因素分析

摘要

Objective To explore the predictors for mechanical ventilation (MV) management and long-term outcome in patients with severe Guillain-Barre syndrome(GBS),so as to provide a reference for clinical treatment of the disease.Methods A retrospective study was conducted in 50 patients with severe GBS,who admitted to the Neurocritical Care Unit (NCU),Xuanwu Hospital,Capital Medical University from January 1st,2009 to December 31st,2015.We collected the patients′ clinical data and Hughes GBS Disability Scale (H-GBS-DS) score before immunization therapy,at discharge from NCU,at the 6th month after discharge from the hospital,and divided them into MV group and non-MV group based on the status of undergoing MV,good treatment outcome group and poor treatment outcome group based on the status of outcome,and group with good outcome and group with poor outcome within 6 months after discharge based on the status of outcome at the 6th month after discharge.We analyzed the predictive effects of sex,age,history of infections before the onset of GBS,the duration from onset to admission,cranial nerve involvement,autonomic dysfunction,axonal degeneration/axonal degeneration and demyelination found in electromyography(EMG) on MV,the effects of above 7 factors combined with the duration from onset to the start of immunization treatment on the response to treatment,the effects of the above 7 factors combined with the duration from onset to the start of immunization treatment,status of MV management,more than 1 cycle of immunoglobulin (IVIG) treatment,the response to treatment,hypoalbuminemia,hyponatremia and length of stay in the NCU on the outcome at the 6th month after discharge.Results Of the 50 cases,2 died during hospitalization,7 were lost to follow-up,the rest 41 completed the 6-month follow-up,63.4% of whom (26/41) had a good prognosis.The proportion of GBS patients with autonomic dysfunction with MV management was higher than that of those without(P<0.05).Participants with good response to treatment were more likely to have infections before the onset of GBS than those with poor response to treatment (P<0.05).Compared with those with poor outcome at the 6th month after the discharge,participants with good outcome had better response to treatment,and shorter length of stay in the NCU (P<0.05).Multivariate Logistic regression analysis showed that autonomic dysfunction was an independent predictor for MV management 〔OR=5.573,95%CI(1.027,30.242),P<0.05〕;history of infections before the onset of GBS was an independent predictor for a good response to treatment〔OR=4.743,95%CI(1.003,22.442),P<0.05〕;the response to treatment〔OR=59.720,95%CI(4.411,809.698),P<0.05〕 and length of stay in the NCU were the independent predictors for the outcome at the 6th month after discharge 〔OR=1.069,95%CI(1.007,1.135),P<0.05〕.Conclusion More severe GBS patients with automatic dysfunction compared with that without would need MV;severe GBS patients who has preceding infections before onset of severe GBS compared with that without would have better response to treatment;severe GBS patients with good response to treatment would have a good 6-month outcome and severe GBS patients with longer stay in the NCU would have a poor 6-month outcome;the most of patients with severe GBS would have a good 6-month outcome after immunotherapy,MV and good supportive care in our NCU.%目的 分析重症吉兰巴雷综合征(GBS)患者机械通气及出院6个月预后的影响因素,为临床治疗提供帮助.方法 回顾性分析2009-01-01至2015-12-31首都医科大学宣武医院神经重症监护病房(NCU)收治的50例重症GBS患者的临床资料.分别收集免疫治疗前、出NCU时、出院6个月所有患者的GBS残障量表(H-GBS-DS)评分,按照是否进行机械通气、治疗效果是否良好、出院6个月预后是否良好进行分类,并分析性别、年龄、发病前感染性诱因情况、发病至入院时间、颅神经受累情况、自主神经功能障碍情况、肌电图表现为轴索型损害+混合型损害情况对重症GBS患者是否进行机械通气的影响;上述因素以及发病至免疫治疗时间对重症GBS患者治疗效果的影响;上述因素以及机械通气情况、免疫球蛋白(IVIG)治疗>1个疗程情况、治疗效果、低蛋白血症情况、低钠血症情况、住NCU时间对重症GBS患者出院6个月预后的影响.结果 50例重症GBS患者中,住院期间死亡2例,随访过程中失访7例,最终完成出院6个月随访41例,其中63.4%(26/41)预后良好.进行机械通气的重症GBS患者自主神经功能障碍率高于未进行机械通气的重症GBS患者(P<0.05);治疗效果良好的重症GBS患者发病前有感染性诱因率高于治疗效果不良的重症GBS患者(P<0.05);出院6个月预后良好的重症GBS患者治疗效果良好率高于出院6个月预后不良的重症GBS患者,住NCU时间短于出院6个月预后不良的重症GBS患者(P<0.05).多因素Logistic回归分析结果显示,自主神经功能障碍是重症GBS患者是否进行机械通气的独立影响因素〔OR=5.573,95%CI(1.027,30.242),P<0.05〕;发病前有感染性诱因是重症GBS患者治疗效果的独立影响因素〔OR=4.743,95%CI(1.003,22.442),P<0.05〕;治疗效果、住NCU时间是重症GBS患者出院6个月预后的独立影响因素〔OR=59.720,95%CI(4.411,809.698),P<0.05;OR=1.069,95%CI(1.007,1.135),P<0.05〕.结论 存在自主神经功能障碍的重症GBS患者需要机械通气概率更大;发病前有感染诱因较无感染诱因的重症GBS患者治疗效果良好;早期治疗效果良好的重症GBS患者出院6个月预后良好,而住NCU时间长的GBS患者出院6个月预后不良;重症GBS患者经过积极治疗,绝大多数预后良好.