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"拯救脓毒症运动"1h Bundle依从性调查及对患者预后的影响--一项多中心前瞻性观察性队列研究 被引量:13

A 1-hour Bundle compliance survey of the"surviving sepsis campaign"and its impact on the prognosis of sepsis patients:a multicenter,prospective observational cohort study
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摘要 目的调查临床医生在治疗脓毒症3.0定义及诊断标准下的重症监护病房(ICU)脓毒症患者时,执行2018年"拯救脓毒症运动"(SSC)更新的1 h集束化治疗(1 h Bundle)的依从性,并分析其对患者预后的影响。方法采用多中心前瞻性观察性队列研究,选择2019年1月至2020年12月资阳市第一人民医院、资阳市人民医院、雁江区人民医院收治的符合脓毒症3.0定义及诊断标准的153例ICU患者,其中95例完全执行1 h Bundle的患者为Bundle依从组,58例未完成1 h Bundle的患者为Bundle未依从组。统计3家医院的病原菌分布情况和感染部位,以及1 h Bundle依从性执行情况和28 d生存情况。采用单因素分析影响两组脓毒症患者预后的危险因素;采用Cox回归模型绘制28 d生存曲线,评估两组脓毒症患者生存情况。结果3家医院153例脓毒症患者病原菌检出率为61.44%(94/153),以革兰阴性菌为主,占79.79%(75/94);感染部位前3位分别为呼吸系统、胃肠道和泌尿系统,分别占32.0%、28.1%、18.3%。3家医院能完全执行1 h Bundle的患者占62.09%(95/153),1 h Bundle中执行较差的指标为1 h血液微生物培养〔占77.78%(119/153)〕和1 h抗菌药物的应用〔占79.74%(122/153)〕。Bundle是否依从两组患者基线指标比较差异均无统计学意义。单因素分析显示,主要预后指标:Bundle依从组28 d生存率明显高于Bundle未依从组〔80.00%(76/95)比62.06%(36/58),χ^(2)=6.447,P=0.014〕;次要评价指标:Bundle依从组6 h和24 h平均动脉压(MAP)均明显高于Bundle未依从组〔mmHg(1 mmHg=0.133 kPa):78.22±11.25比69.86±14.04,79.78±11.45比75.35±12.90〕,Bundle依从组总住院时间中位数较Bundle未依从组明显延长〔d:13(17)比6(11),P<0.05〕。二元Logistic回归分析显示:6 h和24 h MAP是影响脓毒症患者预后的危险因素〔优势比(OR)和95%可信区间(95%CI)分别为1.064(0.994-1.102)、1.032(1.003-1.063),均P<0.05〕。结论资阳市3家医院ICU脓毒症患者1 h Bundle依从率为62.09%,依从性仍有待提高,特别是经验性抗菌药物使用和抗菌药物使用前留取微生物培养两项的依从性较差。Bundle依从组28 d生存率明显高于Bundle未依从组,说明1 h Bundle方案有助于改善脓毒症患者预后。 Objective To investigate clinicians'compliance with the 2018 Surviving Sepsis Campaign(SSC)update"1-hour sepsis Bundle therapy"(1-hour Bundle)when treating patients with Sepsis 3 in the intensive care unit(ICU),and to analyze its impact on patient outcomes.Methods A multicenter,prospective observational cohort study was conducted.A total of 153 ICU patients in Ziyang First People's Hospital,Ziyang People's Hospital and Yanjiang District People's Hospital who were diagnosed of sepsis by the definition and diagnostic criteria of Sepsis 3 from January 2019 to December 2020 were selected.Among them,95 patients who had completed 1-hour Bundle were divided into the Bundle compliance group.58 patients who did not complete the Bundle within 1 hours were classified as the Bundle non-compliance group.The distribution of pathogenic bacteria and infected sites,1-hour Bundle compliance and 28-day survival in the 3 hospitals were analyzed.Univariate analysis was used to analyze the risk factors affecting the prognostic between the two groups of sepsis patients.Cox regression model was used to draw a 28-day survival curve to evaluate the survival of the patients in the two groups.Results Among 153 sepsis patients in 3 hospitals,the detection rate of pathogenic bacteria was 61.44%(94/153),and Gram-negative bacteria accounted for 79.79%(75/94).The top 3 infection sites were respiratory system,gastrointestinal tract and urinary system,accounted for 32.0%,28.1%and 18.3%,respectively.In the 3 hospitals,62.09%(95/153)of patients fully implemented the 1-hour Bundle.The poorly implemented indicators in the 1-hour Bundle were 1-hour blood microbial culture[77.78%(119/153)]and 1-hour antimicrobial application[79.74%(122/153)].There was no significant difference in the baseline indicators between Bundle compliance and non-compliance groups.Univariate analysis showed that the main prognostic indicators:28-day survival rate in the Bundle compliance group was significantly higher than that in the Bundle non-compliance group[80.00%(76/95)vs.62.06%(36/58),χ^(2)=6.447,P=0.014].Secondary evaluation indicators:mean arterial pressure(MAP)at 6 hours and 24 hours in the Bundle compliance group were significantly higher than those in the Bundle non-compliance group[mmHg(1 mmHg=0.133 kPa):78.22±11.25 vs.69.86±14.04,79.78±11.45 vs.75.35±12.90].However,the median length of in hospital stay in the Bundle compliance group was significantly longer than that in the Bundle non-compliance group[days:13(17)vs.6(11)],with statistically significant differences(all P<0.05).Bivariate Logistic regression analysis showed that 6 hours and 24 hours MAP were risk factors affecting the prognosis of patients with sepsis[odds ratio(OR),95%confidence interval(95%CI):1.064(0.994-1.102),1.032(1.003-1.063),both P<0.05].Conclusions The 1-hour Bundle compliance rate of ICU patients with sepsis in 3 hospitals of Ziyang City was 62.09%,and the compliance is still to be improved,especially for the 2 aspects of empirical antimicrobial use and microbial culture retention before antimicrobial use.The 28-day survival rate in the Bundle compliance group was significantly higher than that in the Bundle non-compliance group,suggesting that the 1-hour Bundle regimen can improve the prognosis of patients with sepsis.
作者 邹燕群 廖兰凯 魏宗海 陈勇 张远军 王波 龚建 江惜彬 Zou Yanqun;Liao Lankai;Wei Zonghai;Chen Yong;Zhang Yuanjun;Wang Bo;Gong Jian;Jiang Xibin(Department of Critical Care,Ziyang First People's Hospital,Ziyang 641300,Sichuan,China;Department of Critical Care,West China Hospital,Sichuan University,Chengdu 610041,Sichuan,China;Department of Critical Care,Ziyang People's Hospital,Ziyang 641300,Sichuan,China;Department of Critical Care,Yanjiang District People's Hospital,Ziyang 641300,Sichuan,China)
出处 《中华危重病急救医学》 CAS CSCD 北大核心 2021年第6期671-675,共5页 Chinese Critical Care Medicine
基金 四川省医学科研课题(S18054)。
关键词 脓毒症3.0 1 h脓毒症集束化治疗 依从性 前瞻性队列研究 Sepsis 3 1-hour sepsis bundle Compliance Prospective cohort study
作者简介 通信作者:廖兰凯,Email:564701038@qq.com。
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