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中华实验和临床感染病杂志(电子版)

中华实验和临床感染病杂志(电子版) ›› 2020, Vol. 14 ›› Issue (05) : 406 -410. doi: 10.3877/cma.j.issn.1674-1358.2020.05.009

所属专题： 文献；

论著

气管切开不同时机对重型颅脑损伤患者肺部感染的影响
肖金红1,†(), 胡丙兰1, 黄忠明1, 王旭1, 刘海军2   
  1. 1. 519100　珠海市，遵义医科大学第五附属（珠海）医院神经外科
    2. 558000　贵州黔南布依族苗族自治州，贵州医科大学第三附属医院神经外科
  • 收稿日期:2019-10-28 出版日期:2020-10-20
  • 通信作者: 肖金红
  • 基金资助:
    珠海市医学科研基金项目(No. 20191207A010046)

Effect of tracheotomy at different opportunities on pulmonary infection of patients with heavy cranicerebral injury

Jinhong Xiao1,†(), Binglan Hu1, Zhongming Huang1, Xu Wang1, Haijun Liu2   

  1. 1. Department of Neurosurgery, Fifth Affiliated (Zhuhai) Hospital of Zunyi Medical University, Zhuhai 519100, China
    2. Department of Neurosurgery, Third Affiliated Hospital of Guizhou Medical University, Buyi and Miao Autonomous Prefecture 558000, China
  • Received:2019-10-28 Published:2020-10-20
  • Corresponding author: Jinhong Xiao
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引用本文：

肖金红, 胡丙兰, 黄忠明, 王旭, 刘海军. 气管切开不同时机对重型颅脑损伤患者肺部感染的影响[J]. 中华实验和临床感染病杂志(电子版), 2020, 14(05): 406-410.

Jinhong Xiao, Binglan Hu, Zhongming Huang, Xu Wang, Haijun Liu. Effect of tracheotomy at different opportunities on pulmonary infection of patients with heavy cranicerebral injury[J]. Chinese Journal of Experimental and Clinical Infectious Diseases(Electronic Edition), 2020, 14(05): 406-410.

目的

探究气管切开不同时机对重型颅脑损伤（HCI）患者肺部感染的影响，为更有效地治疗重型颅脑损伤提供临床依据。

方法

选取2016年1月至2018年12月遵义医科大学第五附属（珠海）医院收治的160例重型颅脑损伤患者为研究对象，按照气管切开的不同时机分为观察组（80例）和对照组（80例）。观察组和对照组患者分别于颅脑损伤24 h内（早期）和24 h后（晚期）实施气管切开救治方案，观察两组HCI合并肺部感染者的病原菌构成及感染控制的有效率，比较其疗效及手术前后的肺通气功能。

结果

观察组患者不良反应如肺部感染（33.75%）、皮下气肿（8.75%）、低氧血症（3.75%）、出血（10.00%）、食管气管瘘（6.25%）、气胸（6.25%）等发生率均显著低于对照组（61.25%、20.00%、13.75%、25.00%、21.25%和16.25%），差异具有统计学意义（χ2 = 12.13、P < 0.001，χ2 = 4.11、P = 0.040，χ2 = 4.10、P = 0.040，χ2 = 6.23、P = 0.010，χ2 = 7.59、P = 0.010，χ2 = 6.01、P = 0.010）。重型颅脑损伤患者肺部感染病原体主要分为革兰阴性菌（60.00%、51/85），以铜绿假单胞菌（25.88%、22/85）为主；革兰阳性菌（34.12%、29/85）中以金黄色葡萄球菌（23.53%、20/85）为主；真菌（5.88%、5/85）感染中以白假丝酵母菌（4.71%、4/85）为主。观察组患者HCI合并肺部感染的治疗有效率（77.28%、21/27）显著优于对照组（32.66%、16/49）（χ2 = 14.18、P < 0.001），且其整体的生存率（88.89%、24/27）亦高于对照组（67.36%、33/49）（χ2 = 4.38、P = 0.04），差异均有统计学意义。观察组中HCI合并肺部感染者PO2[（128.22 ± 11.79）mmHg]和SaO2[（96.55 ± 1.41）%]均显著高于对照组[（101.35 ± 10.27）mmHg和（94.26 ± 1.64）%]，差异有统计学意义（t = 15.37、9.47，P均< 0.001）。观察组中HCI合并肺部感染者PCO2[（35.79 ± 5.33）mmHg]低于对照组[（43.72 ± 6.06）mmHg]，差异有统计学意义（t = 8.77、P < 0.001）。

结论

重型颅脑损伤患者早期实施气管切开，能有效提高疗效，降低并发症发生率，改善患者预后。

关键词: 气管切开, 重型颅脑损伤, 肺部感染
Objective

To explore the influence of tracheotomy timing on pulmonary infection in patients with severe head injury (HCI), and to provide clinical basis for more effective treatment.

Methods

Total of 160 patients with severe craniocerebral injury admitted to the Fifth Affiliated Hospital (Zhuhai) of Zunyi Medical University from January 2016 to December 2018 were selected, and divided into observation group (80 cases) and control group (80 cases) according to the different timing of tracheotomy. The cases in observation group were given tracheotomy within 24 hours (early) of craniocerebral injury, while the cases in control group were given tracheotomy after 24 hours (late) of craniocerebral injury. The pathogenic bacteria composition and infection control of the two groups of patients with pulmonary infection were observed, and the clinical efficacy and pulmonary ventilation function before and after surgery were compared, respectively.

Results

The incidences of adverse reactions such as pulmonary infection (33.75%), subcutaneous emphysema (8.75%), hypoxemia (3.75%), hemorrhage (10.00%), esophago-tracheal fistula (6.25%) and pneumothorax (6.25%) of cases in observation group with early tracheotomy were significantly lower than those of the control group with late tracheotomy (61.25%, 20.00%, 13.75%, 25.00%, 21.25%, 16.25%), with significant differences (χ2 = 12.13, P < 0.001; χ2 = 4.11, P = 0.04; χ2 = 4.10, P = 0.04; χ2 = 6.23, P = 0.01; χ2 = 7.59, P = 0.01; χ2 = 6.01, P = 0.01). Gram-negative bacteria (60.00%, 51/85) were predominant in pulmonary infections of severe craniocerebral injury and Pseudomonas aeruginosa was predominant (25.88%, 22/85). Staphylococcus aureus (23.53%, 20/85) was predominant in Gram-positive bacteria (34.12%, 29/85) and Candida albicans (4.71%, 4/85) was predominant in fungal infection (5.88%, 5/85). The recovery rate of HCI pulmonary infection after early tracheotomy (77.28%, 21/27) was significantly higher than that of control group (32.66%, 16/49) and the overall survival rate (88.89%, 24/27) was also higher than that of control group (67.36%, 33/49), with significant differences (χ2 = 14.18, P < 0.001; χ2 = 4.38, P = 0.04). PO2 of patients in observation group [(128.22 ± 11.79) mmHg] and SaO2 [ (96.55 ± 1.41)%] were higher than those in control group with tracheotomy [ (101.35 ± 10.27) mmHg] and [ (94.26 ± 1.64)%], with significant differences (t = 15.37, P < 0.001; t = 9.47, P < 0.001). PCO2 of patients in observation group [ (35.79 ± 5.33) mmHg] was significantly lower than that of patients in control group [(43.72 ± 6.06) mmHg], with significant difference (t = 8.77, P < 0.001).

Conclusions

Early tracheotomy in patients with severe craniocerebral injury could effectively improve the clinical therapeutic effect, reduce complications and improve the prognosis of patients.

Key words: Tracheotomy, Severe cranicerebral injury, Pulmonary infection
表1 两组患者的不良反应[例（%）]
组别 例数 肺部感染 皮下气肿 低氧血症 出血 食管气管瘘 气胸
观察组 80 27（33.75） 7（8.75） 3（3.75） 8（10.00） 5（6.25） 5（6.25）
对照组 80 49（61.50） 16（20.00） 10（13.75） 20（25.00） 17（21.25） 13（16.25）
χ2值   12.13 4.11 4.10 6.23 7.59 6.01
P值   < 0.001 0.04 0.04 0.01 0.01 0.01
表2 76例HCI肺部感染者的病原菌分布
病原菌 株数（%）
革兰阳性菌 29（34.12）
  金黄色葡萄球菌 20（23.53）
  其他 9（10.59）
革兰阴性菌 51（60.00）
  铜绿假单胞菌 22（25.88）
  肺炎克雷伯菌 9（10.59）
  鲍曼不动杆菌 10（11.76）
  大肠埃希菌 3（3.53）
  其他 7（8.24）
真菌 5（5.88）
  白假丝酵母菌 4（4.71）
  其他 2（1.17）
合计 85（100.00）
表3 观察组和对照组HCI合并肺部感染者的感染控制[例（%）]
组别 例数 显著有效 有效 无效 死亡 总有效率 生存率
观察组 27 8（29.63） 13（48.15） 3（11.11） 3（11.11） 21（77.78） 24（88.89）
对照组 49 7（14.29） 9（18.37） 17（34.70） 16（32.64） 16（32.66） 33（67.36）
χ2值   2.59 7.51 4.99 4.31 14.18 4.38
p   0.11 0.01 0.03 0.04 < 0.001 0.04
表4 观察组和对照组中HCI合并肺部感染者的血气水平（± s）
分组 例数 PO2（mmHg） PCO2（mmHg） SaO2（%）
术前 术后 术前 术后 术前 术后
观察组 27 62.19 ± 8.12 128.22 ± 11.79 53.12 ± 6.44 35.79 ± 5.33 87.09 ± 2.00 96.55 ± 1.41
对照组 49 61.18 ± 5.82 101.35 ± 10.27 53.79 ± 6.72 43.72 ± 6.06 87.38 ± 1.94 94.26 ± 1.64
t值   0.90 15.37 0.65 8.77 0.93 9.47
P值   0.37 < 0.001 0.52 < 0.001 0.35 < 0.001
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