摘要：
目的 探讨脓毒症患者重症监护病房获得性肌无力(ICUAW)的高危因素.方法 回顾性分析2015年1月1日至2017年9月30日入住昆明医科大学第二附属医院重症医学科(ICU)诊断为脓毒症合并多器官功能障碍综合征(MODS)并进行机械通气(MV)的164例患者的临床资料.收集患者的一般情况、基础疾病(高血压、糖尿病)、体重指数(BMI)、原发病、入ICU前白蛋白水平、MV时间、是否使用糖皮质激素和连续性肾脏替代治疗(CRRT)、营养供给情况(营养方式、营养启动时间、氨基酸/蛋白质供给情况、入ICU 3 d和7 d营养达标情况)、血肌红蛋白水平、ICU住院时间、总住院时间、急性生理学与慢性健康状况评分系统Ⅱ(APACHE Ⅱ)评分.分析脓毒症患者ICUAW的高危因素和发生率,并进一步进行多因素Logistic回归分析;用多元线性回归分析影响脓毒症患者高肌红蛋白水平的相关因素.结果 脓毒症合并MODS患者ICUAW发生率为25.6%(42/164).将单因素分析中有差异的危险因素纳入多因素Logistic回归分析显示,入ICU前白蛋白水平〔优势比(OR)=0.232,95%可信区间(95%CI)=0.061~0.885,P=0.032〕、MV时间(OR=0.380, 95%CI=0.154~0.935,P=0.035)、营养启动时间(OR=2.642,95%CI=1.100~6.346,P=0.030)、肌红蛋白水平(OR=4.129,95%CI=1.681~10.142,P=0.002)是脓毒症合并MODS患者发生ICUAW的独立危险因素.多元线性回归分析显示,肌红蛋白与APACHE Ⅱ评分呈正相关(β=38.297,P=0.000),与总住院时间呈负相关(β=-7.071,P=0.048),与MV时间及ICU住院时间无线性关系.结论 对肌肉功能的评价应成为ICU检查的常规部分;入ICU前白蛋白水平、MV时间、血肌红蛋白水平以及营养启动时间为脓毒症合并MODS患者发生ICUAW的独立危险因素;肌红蛋白水平可以作为评估病情严重程度的一个指标.%Objective To investigate high risk factors of intensive care unit-acquired weakness (ICUAW) in patients with sepsis. Methods A retrospective study was conducted. 164 patients with mechanical ventilation (MV) who were diagnosed sepsis and multiple organ dysfunction syndrome (MODS), admitted to intensive care unit (ICU) of the Second Affiliated Hospital of Kunming Medical University from January 1st, 2015 to September 30th, 2017 were enrolled. The general situation, the basic diseases (hypertension, diabetes), body mass index (BMI), protopathy diseases, the level of albumin before ICU admission, the MV time, whether to use glucocorticoid and continuous renal replacement therapy (CRRT) or not, nutrition supply (nutritional way, nutrition initiation time, amino acid/protein supply, nutritional status on ICU 3 days and 7 days), myoglobin, the length of ICU stay, the length of hospital stay, and acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ) score were collected. The high risk factors of ICUAW in patients with sepsis complicated with MODS were analyzed further using multi-factor Logistic regression analysis. Multiple linear regression analysis was used to analyze the myoglobin related factors in sepsis patients. Results The ICUAW incidence was 25.6% (42/164). The risk factors with differences in univariate analysis were included in the multivariate Logistic regression analysis, and it was shown that the level of albumin before ICU [odds ratio (OR) = 0.232, 95% confidence interval (95%CI) = 0.061-0.885, P = 0.032], the MV time (OR = 0.380,95%CI = 0.154-0.935, P = 0.035), nutrition initiation time (OR = 2.642, 95%CI = 1.100-6.346, P = 0.030), myoglobin (OR = 4.129, 95%CI = 1.681-10.142, P =0.002) were the independent risk factors for ICUAW in sepsis patients with MODS. The linear regression showed that the level of myoglobin was positively correlated with APACHE Ⅱ score (β= 38.297, P = 0.000), negatively correlated with the length of hospital stay (β= -7.071, P = 0.048), and it had nothing to do with the MV time and the length of ICU stay. Conclusions Evaluation of muscle function should be a routine part of ICU examination. The levels of albumin,MV time, hemoglobin and nutritional start-up time were independent risk factors for ICUAW in sepsis patients with MODS. Myoglobin levels can be used as an indicator of severity.
