血清镁水平对老年重症患者预后的影响

【作者】 王芳；

【导师】 姚刚；

【作者基本信息】 南京医科大学 ， 老年医学科（专业学位）， 2017， 硕士

【摘要】 目的:本研究通过对入重症监护病房的322例患者的临床资料进行回顾性分析,总结重症患者的一般发病特点,血清镁水平与重症患者各临床指标之间的相互关系,探讨重症监护病房(ICU)危重患者低镁血症的发生情况及血清镁水平对患者预后的影响。方法:回顾性分析2013年1月至2016年7月在南京医科大学第二附属医院重症监护病房住院≥48h的重症患者322例,按入ICU24h内血清镁水平分成3组:(1)正常血镁组(血镁0.75～1.2mmol/L);(2)低血镁组(血镁<0.75mmol/L);(3)高血镁组(血镁>1.2mmol/L)。记录患者相关一般情况,包括性别、年龄、既往史、入ICU诊断、机械通气时间、住院时间、ICU24h内各项实验室指标(生化、血常规等)等,同时应用序贯器官衰竭评分(SOFA)和急性生理学与慢性健康状况评分系统II(APACHE II)评分对患者病情评估;记录胸片、超声或CT、磁共振成像(MRI)等影像学检查结果。采用Logistic回归分析筛选重症患者死亡的危险因素。结果:1)共纳入重症患者322例,其中低血镁组87例,正常血镁组213例,高血镁组22例,分别占总例数的27.02%、66.15%、6.80%,血镁水平分别为(0.62±0.06)、(0.88±0.13)、(1.39±0.21)mmol/L。2)在疾病组成上,低血镁组胸腹部手术后患者和严重脓毒症患者的比例显著高于正常血镁组(19.54%比 5.63%,χ2=16.351,P<0.001;16.09%比 2.35%,χ2=19.397,P<0.001),而高血镁组患者多伴随着不同程度的肾功能不全,正常血镁组以肺部感染(占31.92%)多见。3)与正常血镁组相比,低血镁组的APACHE Ⅱ评分(24.64±9.15比18.63±9.70,x2=4.956,P<0.01)更高、SOFA 评分(15.53±6.52 比 12.01±5.55,x2=4.715,P<0.01)更高、机械通气时间(x2=2.593,P=0.01)延长、ICU住院时间(8.80±7.30比7.15±3.58,x2=2.022,P=0.046)延长、死亡率(48.28%比32.86%,x2=6.271,P=0.012)更高。4)多因素回归分析示血清镁可以预测重症患者的预后。结论:1)近3年在ICU患者中低镁血症发生率及死亡率较高。2)疾病组成中,低血镁组以胸腹部手术后患者和严重脓毒症患者为主,高血镁组多伴有不同程度的肾功能不全,正常血镁组中肺部感染多见。3)与正常血镁组相比,低血镁组的死亡率、APACHE II评分以及SOFA评分更高、机械通气时间延长、ICU住院时间延长。4)血清镁水平是重症患者死亡的独立危险因素。目的:本研究通过对纳入重症监护病房的235例老年患者的临床资料进行回顾性分析,总结老年重症患者的一般发病特点,血清镁水平与老年重症患者各临床指标之间的相互关系,探讨重症监护病房(ICU)老年重症患者低镁血症的发生情况及血清镁水平对老年重症患者预后的影响。方法:回顾性分析2013年1月至2016年7月在南京医科大学第二附属医院ICU住院≥48h的老年重症患者235例,根据血清镁水平,血镁0.75～1.2mmol/L定义为正常血镁组;血镁<0.75mmol/L为低血镁组;血镁>1.2mmol/L为高血镁组。比较3组患者的临床资料,如机械通气时间、ICU住院时间、死亡率、24h实验室指标、CT、APACHE Ⅱ评分、SOFA评分等临床指标;血清镁水平与各临床指标之间的相互关系采用Pearson相关分析,采用Logistic回归分析筛选老年重症患者死亡的危险因素。结果:1)共纳入重症患者322例,中青年重症患者87例,老年重症患者235例,分别占 27.02%和 72.98%,血清镁水分别为(0.87±0.25)、(0.82±0.16)mmo1/L;且与中青年重症患者相比,老年重症患者的APACHE II评分(26.91±7.60比22.03±8.43,x2=-4.963,P<0.001)、SOFA 评分(14.26±6.31 比 11.95±5.69,x2=-2.983,P=0.003)、低镁发生率(32.86%比 19.54%,x2=5.326,P=0.021)及死亡率(55.74%比42.53%,x2=-2.186,P=0.030)更高、机械通气时间(d:8比6,Z=-3.345,P=0.001)更长。2)在疾病组成中,老年重症患者中肺部感染、脓毒症发生率显著高于中青年重症患者(30.21%比 6.90%,x2=19.300,P<0.001;5.96%比 0%,x2=5.419,P=0.020)。胸腹部术后患者多见于中青年重症患者(19.54%比8.09%,x2=8.390,P=0.004),老年重症患者合并慢性基础疾病数目多于中青年重症患者。3)老年重症患者中,低血镁组80例、正常血镁组141例、高血镁组14例,分别占 34.04%、60.00%和 5.96%;血镁水平分别为(0.66±0.06)、(0.91±0.11)和(1.25±0.04)mmol/L。4)老年重症患者中,低血镁组中男47例,女33例,年龄(78.95±7.64)岁;正常血镁组中男94例,女47例,年龄(79.95±7.72)岁,两组在性别构成比、年龄、血清电解质水平及慢性基础病(高血压、冠心病、糖尿病、脑梗死、慢性肾病等)比较均无统计学差异(P>0.05)。与正常血镁组相比较,低血镁组的死亡率(70%比 49.65%,χ2=8.628,P=0.003)、APACHE Ⅱ 评分(28.31 ±8.27 比 25.33±7.33,χ2=2.776,P=0.006)以及 SOFA 评分(15.89±6.31比11.65±5.32,χ2=5.311,P<0.001)更高、机械通气时间(d:8 比 7,Z=-2.476,P=0.013)更长。5)血清镁水平与主要临床指标进行Pearson相关分析显示:血清镁水平与SOFA评分、APACHE II 评分呈负相关,(分别为 r=-0.823,P<0.01;r=-0.904,P<0.01)。6)以所有研究对象的血镁水平、APACHE II评分、SOFA评分等因素为自变量,以是否死亡为因变量,根据多因素Logistic回归分析可知,SOFA评分(P<0.001)、血镁水平(P=0.018)、ICU住院时间(P=0.028)为影响老年重症患者死亡的独立危险因素。7)疾病组成中,肺部感染和严重脓毒症患者在低血镁组的比例显著高于正常血镁组(43.75%比 24.82%,x-=8.449,P=0.004;12.5%比 1.42%,x2=12.206,P<0.001),肺部感染和严重脓毒症患者低血镁的发生率明显高于其他疾病患者(分别为49.30%和71.43%);进一步分析显示:脓毒症患者中低血镁组SOFA评分(20.90±1.07 比 15.50±0.71,t=2.012,P=0.014)以及死亡率(90%比 0%,x2=3.309、P=0.009)更高,但两组APACHE II评分无明显差异(34.30±4.22比27.00±4.24,t=0.794,P=0.058)。扩大样本量进一步分析得到相似的结论,即脓毒症患者中低血镁组SOFA评分(20.65±3.99比16.90±4.73,t=2.512,P=0.016)以及死亡率(80.77%比 52.38%,x2=4.309、P=0.016)更高,但两组间的 APACHE Ⅱ 评分无明显差异(28.85±5.53 比 26.62±5.99,t=0.765,P=0.068)。结论:1)老年重症患者低镁血症发生率、死亡率高于中青年患者,且以脓毒症、肺部感染多见;中青年以胸腹部术后多见。2)与中青年患者相比,老年患者血清镁浓度偏低、低镁血症发生率、APACHE Ⅱ评分、死亡率以及SOFA评分更高、机械通气时间更长。3)老年重症患者中,血清镁水平与SOFA评分、APACHE Ⅱ评分呈显著负相关。4)疾病组成中,肺部感染和严重脓毒症患者在低血镁组的比例显著高于正常血镁组,肺部感染和严重脓毒症患者低镁血症的发生率明显高于其他疾病患者;进一步分析显示:严重脓毒症患者中低血镁组SOFA评分及死亡率更高。5)同样,血清镁水平是老年重症患者死亡的独立危险因素。临床需重视老年重症患者低镁血症的发生、发展及预后。更多还原

【Abstract】 Objective:This study aims to investigate the incidence of hypomagnesemia and the effect of serum magnesium levels on the prognosis of critically ill patients in intensive care unit(ICU).Methods:Clinical data of 322critically ill patients in the Second Affiliated Hospital of NanjingMedical University from January2013 to July2016 were retrospectively analyzed and they were expected to stay in hospital for no less than 48 hours.All patients were monitored for serum magnesium levels within 24 hours after ICU admission,and they were divided into three groups:normomagnesemic group(serum magnesium levels 0.75～1.2 mmol/L),hypomagnesemic group(serum magnesium levels<0.75 mmol/L)and hypermagnesemic group(serum magnesium levels>1.2 mmol/L).Three groups of related clinical indicators were analyzed and compared,for example duration of mechanical ventilation,ICU stay days,final outcome,the acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ)score,sequential organ failure assessment(SOFA)score,etc.The risk factors for the death in critically ill patients were postulated by logistic regression analysis.Results:1)A total of 322 critically ill patients were enrolled,87 patients(27.02%)in hypomagnesemic group,213 patients(61.15%)in normomagnesemic group,and 22 patients(6.80%)in hypermagnesemic group;serum magnesium levels were(0.62±0.06),(0.88±0.13)and(1.39±0.21)mmol/L,respectively.2)As to the disease composition,the proportion of patients with severe sepsis and thoracoabdominal surgery group were significantly higher in hypomagnesemia group than that in normomagnesemic group,while in hyperamgnesemic group patients with varying degrees of renal insufficiency,pulmonary infection was more common in normomagnesemic group(31.92%).3)Compared with the normomagnesemic group,the mortality rate(48.28%vs.32.86%,x2=6.271,P=0.012),APACHE Ⅱ scores(24.64±9.15 vs.18.63±9.70,x2=4.956,P<0.01),SOFA scores(15.53±6.52 vs.12.01±5.55,x2=4.715,P<0.01),ICU stay(8,80±7.30vs.7.15±3.58,x2=2.022,P=0.046)and mechanical ventilation time(x2=2.593,P=0.01)were higher in the hypomagnesemic group.4)Serum magnesium level was an risk factor for death in critically ill patients.Conclusion:1)In general,through this research,the morbidity and mortality of critically ill patients showed a rising tendency during the past three years.2)As to the disease composition,the proportion of patients with major abdominal,thoracic surgery and severe sepsis were significantly greater in hypomagnesemic group,and hypermagnesemic patients were complicated by renal dysfunction in different degrees,in normomagnesemic group was mainly consisted of patients with pneumonia.3)Compared with the normomagnesemic group,the mechanical ventilation time,mortality rate,ICU stay,SOFA scores and APACHE Ⅱ scores were higher in the hypomagnesemic group.4)Serum magnesium level was an independent risk factor for death in critically ill patients.Objective:This study aims to investigate the incidence of hypomagnesemia and the effect of serum magnesium levels on the prognosis of elderly critically ill patients in intensive care unit(ICU).Methods:Clinical data of 235 elderly critically ill patients in the Second Affiliated Hospital of Nanjing Medical University from January2013 to July2016 were retrospectively analyzed and they were expected to stay in hospital for no less than 48 hours.All patients were monitored for serum magnesium levels within 24 hours after ICU admission,and they were divided into three groups:normomagnesemic group(serum magnesium levels 0.75-1.2 mmol/L),hypomagnesemic group(serum magnesium levels<0.75 mmol/L)and hypermagnesemic group(serum magnesium levels>1.2 mmol/L).Three groups of related clinical indicators were analyzed and compared,for example duration of mechanical ventilation,ICU stay days,final outcome,the acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ)score,sequential organ failure assessment(SOFA)score,etc.The relationship between serum magnesium level and clinical datas is postulated by pearson correlation analysis,the risk factors for the death in critically ill patients were postulated by logistic regression analysis.Results:1)There were 87 patients(27.02%)in the middle-agedgroup,235patients(72.98%)in the elderly group;serum magnesium levels were(0.87±0.25),and(0.82±0.16)mmol/L,respectively.Compared with the middle-aged patients,the APACHE Ⅱ scores(26.91 ±7.60 vs.22.03±8.43,χ2=-4.963,P<0.001),SOFA scores(14.26±6.31 vs.11.95±5.69,χ2=-2.983,P=0.003),the incidence rate(32.86%vs.19.54%,χ2=5.326,P=0.021)and the mortality rate(55.74%vs.42.53%,χ2=-2.186,P=0.030)of low magnesium were higher and the mechanical ventilation time(d:8 vs.6,Z=-3.345,P=0.001)was longer in the elderly critically ill patients.2)In the composition of the disease,the incidence of pulmonary infection and sepsis in the elderly patients were significantly higher than that of the young and middle-aged patients(30.21%vs.6.90%,χ2=19.300,P<0.001;5.96%vs.0%,χ2=5.419,P=0.020).Patients with thoracic abdominal surgery was more common in young and middle-aged patients(19.54%vs.8.09%,χ2=8.390,P=0.004),and the number of elderly patients with severe chronic disease was more than that of young and middle-aged patients.There was no significant difference in the above indexes in all ages of elderly patients.3)A total of 235 elderly critically ill patients were enrolled,80 patients(34.04%)in hypomagnesemic group,141patients(60.00%)in normomagnesemic group,and 14 patients(5.96%)in hypermagnesemic group;serum magnesium levels were(0.66±0.06),(0.91±0.11)and(1.25±0.04)mmol/L,respectively.4)There were 47 males and 33 females,average age was 78.95±7.64 in the hypomagnesemic group.In the normal blood magnesium group,there were 94 males and 47 females,average age was 79.95±7.72.Two groups of proportion,age,serum electrolyte levels and chronic disease based on gender(hypertension,coronary heart disease and diabetes cerebral infarction,chronic kidney disease,etc.)were no statistically significant difference.Compared with the normomagnesemic group,the mortality rate(70%vs 49.65%,χ2=8.628,P=0.003),APACHE Ⅱ scores(28.31±8.27 vs.25.33 ±7.33,χ2=2.776,P=0.006),SOFA scores(15.89 ±6.31 vs.11.65 ±5.32,χ2=5.311,P<0.001)and mechanical ventilation time(d:8 vs.7,Z=-2.476,P=0.013)were higher in the hypomagnesemic group.5)The relationship between serum magnesium levels and the main clinical indicators use the Pearson correlation analysis,showed there was negative correlation between serum magnesium levels and SOFA scores,APACHE Ⅱ scores,(r=-0.823,P<0.01;r=-0.904,P<0.01).6)In this study,serum magnesium levels,SOFA scores,APACHE Ⅱ scores and other factors as independent variables,Whether death as the dependent variable,according to the multi-factor logistic regression analysis,SOFA scores(P<0.001),serum magnesium level(P=0.018),ICU hospitalization time(P=0.028)were independent risk factors for death in elderly critically ill patients.7)As to the disease composition,the proportion of patients with pulmonary infection or severe sepsis was significantly greater in the hypomagnesemic group compared with that of normomagnesemic group(43.75%vs.24.82%,χ2=8.449,P=0.004;12.5%vs.1.42%,χ2=12.206,P<0.001),and the incidence rate was significantly higher than that in patients with other diseases(49.30%and 71.43%,respectively);Further analysis showed that the mortality rate of severe sepsis in the hypomagnesemic group was significantly higher than that of other diseases(80.77%);Compared with the normomagnesemic group,the mortality rate(90%vs.0%,χ2=3.309,P=0.009),SOFA scores(20.90±1.07vs.15.50±0.71,t=2.012,P=0.014)were higher in the hypomagnesemic group.There was no significant difference between the two groups in terms of APACHE Ⅱ scores(34.30±4.22 vs.2700±4.24,1=0.794,P=0.058).After enlarged simples,we reach a similar conclusion.Conclusion:1)The incidence and mortality of the elderly patients were higher than that of the young and middle-aged patients,the proportion of sepsis and pneumonia were higher in this group.2)Compared with the young and middle-aged patients,the mechanical ventilation time,mortality rate,SOFA scores and APACHE Ⅱ scores were higher in the elderly group.3)The pearson correlation analysis,showed there was negative correlation between serum magnesium levels and SOFA scores,APACHE Ⅱ scores.4)As to the disease composition,the proportion of patients with pulmonary infection or severe sepsis was significantly greater in the hypomagnesemic group compared with that of normomagnesemic group.Further analysis,the mortality rate,APACHEⅡ scores and SOFA scores of sepsis patients were higher in the hypomagnesemic group.5)As shown by the result of the logistic regression analysis,serum magnesium level was an independent risk factor for death in elderly critically ill patients.更多还原