急性ST段抬高型心肌梗死患者并发医院获得性肺炎的危险因素分析

doi:10.3969/j.issn.1006-7795.2013.01.018

摘要/Abstract

摘要：

目的研究急性ST段抬高型心肌梗死(acute ST-segment elevated myocardial infarction, STEMI)患者合并医院获得性肺炎(hospital-acquired pneumonia, HAP)的危险因素。方法回顾性分析2008年8月1日至2011年8月1日之间所有入北京通州区潞河医院的STEMI患者的病历资料,合并HAP的患者作为病例组,选取同期住院的STEMI但无HAP的患者作为对照。回顾性分析患者各项可能与HAP相关的临床指标,应用SPSS16.0软件进行数据分析。结果本研究共纳入病例组患者165例。单因素分析显示,病例组患者年龄、男性患者比例、合并慢性阻塞性肺病(chronic obstructive pulmonary disease, COPD)、长期服用激素、心脏功能差(Killip分级3级及以上)、卧床时间、大手术后、气管插管、机械通气、经鼻胃管、应用镇静、肌松药物比例明显高于对照组,病例组患者经皮冠状动脉介入(percutaneous coronary intervention, PCI)比例低于对照组,住院天数明显长于对照组,病死率显著高于对照组。行Logistic回归分析,STEMI并发HAP的独立危险因素包括:年龄大于75岁(OR=3.205,95% CI:1.314~7.813)、合并COPD(OR=8.264,95% CI:2.165~31.250)、卧床时间(OR=2.583, 95% CI:1.793~3.713)及未行PCI治疗(OR=0.361, 95% CI:0.213~0.613)。结论高龄(大于75岁),合并COPD,卧床时间、机械通气大于48 h及未行PCI治疗是发生HAP的独立危险因素。

关键词: 急性ST段抬高型心肌梗死, 医院获得性肺炎, 危险因素

Abstract:

Objective To investigate risk factors of hospital-acquired pneumonia(HAP) in patients with acute ST-segment elevated myocardial infarction(STEMI). Methods We reviewed all the STEMI with HAP cases diagnosed between August 1 st, 2008 and August 1 st, 2011. The data of these patients were collected as case group. We selected a control case that was admitted in the same unit at the same time as the case patient, but without HAP. Medical information studied included possible correlated variables. All statistical analyses were performed with SPSS version 16.0. Results Medical data of 165 HAP patients with STEMI were reviewed during the study period. There were obvious differences between the two groups about age, male sex, complicated with chronic obstructive pulmonary disease (COPD), steroids/immunosuppressive drugs intake, heart function(Killip class≥Ⅲ),restriction to bed,prior major surgery, endotracheal intubation/tracheostomy, mechanical ventilation more than 48 hours,nasogastric tubes, sedation/muscle relaxants, treatment with percutaneous coronary intervention(PCI) by univariate analyses. The hospital day was longer and mortality rate was higher in the HAP group. These variables selected by univariate analyses were further analyzed by multivariate logistic regression analyses, and elder patients(older than 75 years) (OR=3.205,95% CI:1.314-7.813),COPD(OR=8.264,95% CI:2.165-31.250), length of bed limitation(OR=2.583, 95% CI:1.793-3.713), and without PCI (OR=0.361, 95% CI:0.213-0.613)were independent risk factors for to HAP in patients with STEMI.Conclusion Elder patients(older than 75 years),COPD, length of bed limitation, and without PCI were independent risk factors for HAP in patients with STEMI.

Key words: acute ST-segment elevated myocardial infarction, hospital-acquired pneumonia prognostic factors, prognostic factors

中图分类号:

崔纳, 郭金城, 华琦. 急性ST段抬高型心肌梗死患者并发医院获得性肺炎的危险因素分析[J]. 首都医科大学学报, 2013, 34(1): 95-99.

CUI Na, GUO Jincheng, HUA Qi. Prognostic factors of hospital-acquired pneumonia in patients with acute ST-segment elevated myocardial infarction[J]. Journal of Capital Medical University, 2013, 34(1): 95-99.

参考文献

[1] Lichtman J H,Spertus J A,Reid K J,et al.Acute noncardiac conditions and in-hospital mortality in patients with acute myocardial infarction[J].Circulation,2007,116(17):1925-1930.

[2] 赵玉生,刘光华,尹巧香,等.80岁以上老年人急性心肌梗死近期预后多因素分析[J].实用老年医学, 2006,20(1):28-30.

[3] Chastre J, Fagon J Y. Ventilator-associated pneumonia[J]. Am J Respir Crit Care Med,2002,165(7):867-903.

[4] Fagon J Y, Chastre J, Hance A J, et al. Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay[J]. Am J Med,1993, 94:281-288.

[5] Rello J, Ollendorf D A, Oster G, et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database[J]. Chest, 2002, 122(6):2115-2221.

[6] Rello J, Ausina V, Ricart M, et al. Impact of previous antimicrobial therapy on the etiology and outcome of ventilator associated pneumonia[J]. Chest, 1993, 104(4):1230-1235.

[7] Heyland D K, Cook D J, Griffith L,et al. The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient[J]. Am J Respir Crit Care Med, 1999, 159(4 Pt1):1249-1256.

[8] 李晓英,赵玉生,王德水.急性心肌梗死住院患者并发肺炎的影响因素分析[J].中华老年多器官疾病杂志,2008,7(1):16-18.

[9] 中华医学会心血管病学分会,中华心血管病杂志编辑委员会. 急性ST段抬高型心肌梗死诊断和治疗指南[J].中华心血管病杂志, 2010, 38(8):675-690.

[10] 中华医学会呼吸病学分会. 医院获得性肺炎诊断和治疗指南(草案)[J]. 中华结核和呼吸杂志, 1999, 22(4): 201.

[11] Tablan O C, Anderson L J, Besser R, et al. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of the CDC and the Healthcare Infection Control Practices Advisory Committee[J]. MMWR Recomm Rep, 2004, 53(RR-3):1-36.

[12] 周庆涛,贺蓓.医院获得性肺炎的定义和诊治[J]. 军医进修学院学报,2011,32(7)682-697.

[13] 元鹏,胡亦新,黄宏艳,等.北京市部分老年人咽部机会致病菌的携带状况及临床意义[J].中华医院感染学杂志,2007,17(9):1079-1081.

[14] 王秋娟,何伟峰.布地奈德溶液雾化吸入在慢性阻塞性肺疾病合并急性肺部感染中的应[J].中国煤炭工业医学杂志,2012,15(11):1674-1675.

[15] 陈晖,贾三庆,严松彪,等.白细胞水平对接受急诊冠状动脉介入治疗的急性心肌梗死患者预后的影响[J].临床心血管病杂志, 2006,22(9):523-525.

[16] 肖暖,唐路宁,陈春红.急性心肌梗死择期PCI对左室重构及远期预后的影响[J].中国老年学杂志, 2007,27(3):270-273.

[17] Hirayama A, Kusoka H, Adachi T, et al. Comparison of time of reperfusion during anterior wall acute myocardial infarction to left ventricular volume one month and 20 months later[J]. Am J Cardiol, 2002, 89(12):1335-1340.

[18] Cannon C P,Mccabe C H, Wilcox R G, et al. Association of white blood cell count with increased mortality in acute myocardial infarction and unstable angina pectoris. OPUSTIMI-16 Investigators[J]. Am J Cardiol,2001, 87(5): 636-639.

[19] Wertheim H F, Vos M C, Ott A, et al. Risk and outcome of nosocomial Staphylococcus aureus bacteraemia in nasal carriers versus noncarriers[J]. Lancet, 2004, 364(9435): 703-705.