Effect of Tracheotomy Timing in Patients with Severe Cerebrovascular Disease
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摘要:
目的 评估不同时机气管切开对重症脑血管病患者的影响。 方法 对青岛大学附属青岛市中心医院2018年1 月至2020年12月进行气管切开的56例重症脑血管病患者进行回顾性分析。根据经口插管时间将患者分成早期气管切开ET组（≤ 10 d）共28例，晚期气管切开LT组（> 10 d）共28例，其中男38例，女18例，年龄44～86岁。观察2组患者的基础特征、气管切开后重症医学科（intensive care unit，ICU）住院时间、重症医学科总住院时间、呼吸机相关性肺炎（ventilator associated pneumonia，VAP）发生率，肺部感染患者抗生素使用时间，痰培养多重耐药（multidrug resistant，MDR）发生率及细菌培养的菌群分布等。 结果 2组患者在基础特征如年龄、性别、急性生理和慢性健康状况（acute physiology and chronic health evaluation Ⅱ，APACHEII）评分以及格拉斯哥昏迷（glasgow coma scale，GCS）评分比较，差异无统计学意义（P > 0.05），2组间气管切开后的ICU住院时间（中位数分别为7.5 d和7 d，P = 0.729）及VAP发生率（分别为39%和61%，P = 0.109）差异无统计学意义。但早期气管切开组的ICU总住院时间（中位数分别为15.5 d和22 d，P < 0.001），抗生素使用时间分别为[（11.8 ± 3.2） d和（17.1 ± 4.1） d，P < 0.001]及多重耐药发生率较晚期气管切开组均明显减少（分别为39%和79%，P = 0.003）。而且早期气管切开组肺炎克雷伯菌引起的肺部感染发生率更低（P = 0.029）。 结论 早期气管切开明显缩短重症脑血管病患者的ICU住院时间及肺部感染患者抗生素使用时间，减少多重耐药的发生率，但并没有减少VAP的发生率。而对于气管切开指征及时机仍需有效的手段进一步评估。 Abstract:Objective To evaluate the effect of tracheotomy at different time in patient with severe cerebrovascular disease. Methods A retrospective analysis was conducted on 56 patients with severe cerebrovascular disease who underwent tracheotomy in Qingdao Central Hospital Affiliated to Qingdao University from January 2018 to December 2020. All patients were divided into Early tracheotomy group [≤ 10 d Early tracheotomy （ET） group] and Late tracheotomy group [> 10 d Late tracheotomy （LT） group] based on the time of endotracheal intubation. Among them, 38 were male and 18 were female, aged 44-86 years. The basic characteristics, length of stay in intensive care unit （ICU） after tracheotomy, total length of stay in ICU, and the incidence of ventilator-associated pneumonia （VAP）, the duration of antibiotic use in patients with pulmonary infection, the incidence of multidrug resistance （MDR） in sputum culture and the distribution of bacterial flora in bacterial culture in the 2 groups were compared. Results There were no differences between the two groups in general characteristics, such as age, gender, acute physiology and chronic health evaluation Ⅱ（APACHEII）score and Glasgow coma scale （GCS） score （P > 0.05）. The incidence of VAP and the length of post-PDT ICU stay also showed no different between the two groups （P > 0.05）. However, in the early tracheotomy group, total ICU stay （median 15.5 and 22 d, respectively, P < 0.001）, duration of antibiotic use [（11.8±3.2） d and （17.1±4.1） d, respectively, P < 0.001] and the incidence of multiple drug resistance was significantly reduced compared with the late tracheotomy group （39% and 79%, respectively, P = 0.003）. The incidence of Klebsiella pneumoniae infection was lower in the early tracheotomy group （P = 0.029, respectively）. Conclusion ET in patients with severe cerebrovascular disease might contribute to a shorter duration of ICU length of stay, lower incidence of MDR, and shorter duration of antibiotic use. But ET does not reduce the incidence of VAP. Further assessment through effective methods is necessary for tracheotomy indication and timing. -
Key words:
- Tracheotomy timing /
- Severe cerebrovascular disease /
- Multidrug resistant
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表 1 2组患者一般特征的比较（
$\bar x \pm s $ ）Table 1. Comparison of general characteristics between the two groups （
$\bar x \pm s $ ）项目 ET（n = 28） LT（n = 28） t z χ2 P 年龄（岁） 63.1 ± 15.5 69.1 ± 11.9 1.599 0.116 男/女（n） 22/6 16/12 2.947 0.086 GCS（分） 3～8（5.5）* 3～8（5.5） −0.433 0.665 APACHE2（分） 9～33（20.0） 11～24（23.0） −1.672 0.094 卒中类型[（n）%] 出血性 18（64.0） 14（50.0） 1.167 0.28 缺血性 10（36.0） 14（50.0） 括号内为中位数。 
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表 2 2组患者预后等其他指标的比较（
$ \bar x \pm s$ ）Table 2. Comparison of prognosis and other indexes between the two groups （
$ \bar x \pm s$ ）项目 ET（n = 28） LT（n = 28） t z χ2 P PDT后ICU时间（d） 7.1 ± 2.5 8.7 ± 6.4 −0.346 0.729 ICU总住院时间（d） 15.1 ± 3.0 23.4 ± 7.1 −4.971 < 0.001* VAP[n（%）] 11（39.0） 17（61.0） 2.571 0.109 多重耐药[n（%）] 11（39.0） 22（79.0） 8.928 0.003* 抗生素时间（d） 11.8 ± 3.2 17.1 ± 4.1 5.21 < 0.001* 括号内为中位数。 *P < 0.05。
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表 3 2组患者痰细菌培养结果的比较[n（%）]
Table 3. Comparison of sputum bacterial culture results between two groups [n（%）]
细菌 ET（n = 28） LT（n = 28） χ2 P 肺炎克雷伯菌 7（25.0） 15（54.0） 4.791 0.029* 鲍曼不动杆菌 4（14.0） 5（18.0） — 铜绿假单胞菌 5（18.0） 5（18.0） — 产气肠杆菌 2（7.0） 1（4） — 嗜麦芽杆菌 1（4.0） 0（0） — 金黄色葡萄球菌 4（14.0） 0（0） 2.423 0.12 括号内为中位数。 *P < 0.05。
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