摘要：
目的 探讨综合重症医学科(ICU)转出患者在普通病房发生病情变化的原因.方法 回顾性分析2013年1月至2018年12月连云港市第一人民医院综合ICU病情改善转入普通病房患者的临床资料.收集患者的一般情况,如性别、年龄、基础疾病、吸烟情况、24 h内急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)和格拉斯哥昏迷评分(GCS)、ICU住院时间、ICU内平均氧合指数和平均呼吸频率、转出当日氧合指数和呼吸频率、转出前GCS评分、是否为有创通气、有创通气时间、是否发生脓毒症、社区或院内获得性肺炎等情况及转出后病情变化分类.根据转科患者在普通病房是否发生病情变化分为病情变化组和病情稳定组,再根据是否发生呼吸系统并发症分为有呼吸系统并发症组和无呼吸系统并发症组;采用多因素Logistic回归分析导致病情变化的危险因素.结果 2013年1月至2018年12月本院综合ICU共收治2 451例患者,其中转至普通病房1 293例;发生病情变化628例.① 转出ICU患者发生病情变化的原因以呼吸系统并发症最为常见(345例,占54.9%),其次为心血管系统并发症(118例,占18.8%)和手术相关并发症(96例,占15.3%).② 病情变化组合并基础疾病和大量吸烟的比例显著高于病情稳定组〔24.4%(153/628)比7.8%(52/665),40.3% (253/628)比24.2%(161/665),均P＜0.05〕.与病情稳定组比较,病情变化组ICU住院期间平均氧合指数低〔mmHg(1 mmHg＝0.133 kPa):238.91±71.14比291.74±63.64〕,转出当日氧合指数低(mmHg:261.23±58.11比301.00±58.25),有创通气比例高〔64.2%(403/628)比47.4%(315/665)〕,有创通气时间长〔d:5(2～9)比3(2～7)〕,差异均有统计学意义(均P＜0.05).③ 与无呼吸系统并发症组比较,有呼吸系统并发症组ICU住院期间平均氧合指数低(mmHg :216.43±67.17比264.85±78.46)、转出当日氧合指数低(mmHg :250.72±74.93比274.87± 81.79)、有创通气比例高〔77.4%(267/345)比48.1%(136/283)〕,差异均有统计学意义(均P＜0.05).④ Logistic回归分析显示,合并基础疾病〔优势比(OR)＝1.522〕、大量吸烟(OR＝2.314)、平均氧合指数(OR＝1.821)是影响转出ICU患者发生病情变化的独立危险因素(均P＜0.05).结论 合并基础疾病、大量吸烟、住ICU期间氧合指数低、转出当日氧合指数低、有创通气且通气时间长的患者转至普通病房后更容易发生呼吸系统相关并发症;其中合并基础疾病、大量吸烟、氧合指数是影响转出ICU患者发生病情变化的独立危险因素.对于存在这些危险因素的患者转出ICU前后应加强病情评估与监护.%Objective To investigate the causes of disease condition changes after the patients' transfer from intensive care unit (ICU) into the general wards. Methods From January 2013 to December 2018, the patients with improvement of disease condition in comprehensive ICU were transferred into the general wards of the First People's Hospital of Lianyungang and their clinical data were retrospectively analyzed. The general information of patients was collected, such as gender, age, underlying diseases, heavy smoking, acute physiology and chronic health evaluationⅡ(APACHEⅡ) and Glasgow coma score (GCS) in 24 hours, length of stay in ICU, average levels of oxygenation index and respiratory rates during the stay in ICU and on the day transfer from ICU, GCS score on the day of transfer from ICU, presence or absence of invasive ventilation,the time of invasive ventilation, sepsis or its absence, the situation of community or hospital acquired pneumonia, etc, and the classification of the disease changes after transfer. The patients were divided into a disease situation change group (change group) and a disease situation stable group (stable group) according to whether there was any change in the disease situation in the general ward or not, the patients were divided into respiratory complications group and non-respiratory complications group. The risk factors that may influence the change of the disease condition were analyzed by multiple-factor Logistic regression. Results From January 2013 to December 2018, there were 2 451 patients treated in comprehensive ICU, of that 1 293 were transferred into the general wards for further treatment. Among the patients transferred to the general ward, 628 cases' conditions were changed.① The respiratory complications were the most common changes (345 cases, 54.9%) in patients after the transfer from ICU, followed by cardiovascular complications (118 cases, 18.8%) and surgery-related complications (96 cases, 15.3%).② The proportions of underlying diseases and heavy smoking in the change group were significantly higher than those in the stable group [24.4% (153/628) vs. 7.8% (52/665), 40.3% (253/628) vs. 24.2% (161/665), all P < 0.05]. Compared with the stable group, the average oxygenation index [mmHg (1 mmHg = 0.133 kPa): 238.91±71.14 vs. 291.74±63.64], and the turn-out day oxygenation index (mmHg: 261.23±58.11 vs. 301.00 ±58.25) were lower in the change group, while the proportion of applying invasive ventilation [64.2% (403/628) vs. 47.4% (315/665)], and the duration of invasive ventilation [days: 5 (2-9) vs. 3 (2-7)] were higher in the change group, the differences being all statistical significant (all P < 0.05). ③ Compared with the non-respiratory complications group, the average oxygenation index in the respiratory complications group was lower (mmHg: 216.43±67.17 vs. 264.85±78.46), the turn-out day oxygenation index was lower (mmHg: 250.72±74.93 vs. 274.87±81.79), and invasive ventilation ratio was higher [77.4% (267/345) vs. 48.1% (136/283)], the differences being statistically significant (all P < 0.05).④ Logistic regression analysis showed that the underlying diseases [odds ratio (OR) = 1.522], heavy smoking (OR = 2.314), and average oxygenation index (OR = 1.821) were the independent risk factors for patients in the general wards occurring disease situation changes after transfer from ICU (all P < 0.05). Conclusions The patients with following factors: underlying diseases, heavy smoking, low average oxygenation index during ICU stay, low oxygenation level on the day of transfer, application of invasive ventilation and long ventilation time are more easily to occur complications of respiratory system in the general wards after transfer from ICU; among the above related factors, the underlying diseases, heavy smoking and average oxygenation index are the independent risk factors for patients' occurrence of disease situation changes after transfer from ICU. Therefore, the patients with these risk factors, the evaluation and monitoring of the disease situation should be strengthened before and after patients' transfer from ICU. and the changes of patients' condition are mostly respiratory complications. Among them, combined underlying diseases, severe smoking and average oxygenation index are the independent risk factors for patients who have condition changes transferred from ICU. For patients with these risk factors, evaluation and monitoring should be strengthened before and after patients are transferred from ICU.
