Analysis of risk factors of prolonged intensive care unit stay of critically ill obstetric patients: a 5-year retrospective review in 3 hospitals in Beijing

目的 评估危重孕产妇重症监护病房(ICU)住院时间延长的危险因素.方法 回顾性分析2006年1月1日至2010年12月31日北京市3家医院ICU危重孕产妇的临床资料,包括患者的基本特征、转入ICU的疾病种类、急性生理学与慢性健康状况评分系统I(APACHE I)评分、发病至转入ICU时间、各种检查结果、治疗措施、ICU住院时间以及孕产妇病死率.采用单因素比较和多因素Logistic回归分析危重孕产妇ICU住院时间延长的危险因素.结果 5年内共有207例危重孕产妇收入ICU,占所有孕产妇的0.42%;平均年龄(31.74±2.32)岁,平均孕龄(34.86+4.72)周.其中4例孕产妇死亡,病死率1.93%.207例危重孕产妇中,138例为产科重症,69例并发严重内科疾病.转入ICU最常见的产科病因为产后大出血(42例,20.29%)和妊娠相关性高血压(36例,17.39%),其次为妊娠急性脂肪肝(AFLP,27例,13.04%)和产科弥散性血管内凝血(DIC,23例,11.11%);最常见的内科病因为急性心功能衰竭(26例,12.56%)和急性呼吸衰竭(22例,10.63%),其次为重症急性胰腺炎(SAP,11例,5.31%).109例患者(占52.66%)ICU住院时间延长(ICU滞留时间＞3 d).单因素分析显示,未行规律产前检查、血肌酐、凝血酶原时间国际标准化比值(INR)、氧合指数(PaO2/FiO2)、AFLP、产科DIC、SAP、机械通气、血管活性药物、血液净化治疗和发病至转入ICU时间＞24 h与ICU住院时间延长有关.多因素Logistic回归分析显示,未行规律产前检查[优势比(OR)1.68,95%可信区间(95%CI)1.14～2.69,P=0.011]、PaO2/FiO2(OR 4.73,95%CI 1.46～11.37,P=0.013)、AFLP(OR 3.21,95%CI 1.13～4.76,P=0.026)、产科DIC(OR 2.73,95%CI 1.28～4.02,P=0.018)、SAP(OR 4.78,95%CI 1.83～7.42,P=0.021)、血管活性药物(OR 1.96,95%CI 1.24～3.15,P=0.001)、血液净化治疗(OR 11.02,95%CI 3.04～58.02,P=0.015)和发病至转入ICU时间＞24 h(OR 2.04,95%CI 1.21～4.25,P＜0.001)是ICU住院时间延长的独立危险因素.结论 危重孕产妇ICU住院时间延长的发生率较高.临床上可以根据危险因素预测危重孕产妇ICU住院时间延长,加强规律产前检查、避免产科及内科严重并发症;发病后尽快转入ICU并在ICU内加强各器官功能支持可能有助于缩短ICU住院时间.To identify the risk factors of prolonged intensive care unit (ICU) stay of critically ill obstetric patients.A retrospective analysis of cases of critically ill obstetric patients admitted to the ICUs of Peking University Third Hospital, Capital Medical University Affiliated Beijing Chaoyang Hospital, and PLA 306 Hospital from January 1st 2006 to December 31st 2010 was made. Data included demographics, causes of critical illness or complications that prompted ICU admission, the acute physiology and chronic health evaluation II (APACHEII) scores, the time intervals between onset of acute symptoms and ICU admission, laboratory test results, treatment measures, length of ICU stay and the final maternal mortality. Data were used to identify univariate and multivariate predictors for prolonged ICU stay.During the 5-year period there were 207 obstetric patients [mean age (31.74±2.32) years old, mean gestational age (34.86±4.72) weeks] were transferred to the ICU for critical care (42 ICU admissions per 10 000 deliveries), and among them 4 women died (mortality rate 1.93%). The pathogenesis of the cases could be divided into direct obstetric pathologies (n=138) and indirect or coincidental pathologies (n=69). The most common obstetric causes of admission were massive postpartum haemorrhage (n=42, 20.29%) and pregnancy associated hypertension (n=36, 17.39%), followed by acute fatty liver of pregnancy (AFLP, n=27, 13.04%), obstetric disseminated intravascular coagulation (DIC, n=23, 11.11%). The most common non obstetric causes of admission were acute heart failure (n=26, 12.56%) and acute respiratory failure (n=22, 10.63%), followed by severe acute pancreatitis (SAP, n=11, 5.31%). The incidence of prolonged ICU stay (ICU stay >3 days) was 52.66% (n=109). Univariate predictors of prolonged ICU stay included inadvertent antenatal care, high serum creatinine, abnormal international normalized ratio of prothrombin time (INR), abnormal oxygenation index (PaO(2)/FiO(2)), AFLP, obstetric DIC, SAP, use of mechanical ventilation, indications for inotropic support, and blood purification, and >24 hour interval between onset of acute symptoms and ICU admission. Multivariate modeling identified that inadvertent and irregular antenatal care [odds ratio (OR) 1.68, 95% confidence interval (95%CI) 1.14-2.69, P=0.011], PaO(2)/FiO(2) (OR 4.73, 95%CI 1.46-11.37, P=0.013), AFLP (OR3.21, 95%CI 1.13-4.76, P=0.026), DIC (OR 2.73, 95%CI 1.28-4.02, P=0.018), SAP (OR 4.78, 95%CI 1.83-7.42, P=0.021 ), indications for inotropic support (OR 1.96, 95%CI 1.24-3.15, P=0.001), blood purification (OR 11.02, 95%CI 3.04-58.02, P=0.015) and >24 hour interval between onset of acute symptoms and ICU admission (OR 2.04, 95%CI 1.21-4.25, P<0.001) were the independent predictors for prolonged ICU stay.The incidence of prolonged ICU stay is high for critically ill obstetric patients. Patients with identified multivariate predictors carry a high risk of prolonged ICU stay, they may benefit from enhanced regular antenatal care, prevention of critical obstetric and medical complications, shortening the interval between onset of acute symptoms and ICU admission and strengthening the support of organ function.北京市科技计划项目PubMed中文核心期刊要目总览(PKU)中国科技核心期刊(ISTIC)中国科学引文数据库(CSCD)08449-4532