战时军事烧伤中的急性呼吸窘迫综合征：柏林标准的应用。
Acute respiratory distress syndrome in wartime military burns: application of the Berlin criteria.
机构信息
From the San Antonio Military Medical Center (S.M.B., A.R.B., J.W.C., C.R.S., and J.L.H.); and US Army Institute of Surgical Research (S.M.B., J.K.A., J.B.L., E.M.R., A.I.B., L.C.C., K.K.C., and N.T.L.), Fort Sam Houston, San Antonio, Texas; and Uniformed Services University of the Health Sciences (J.W.C., E.M.R., and K.K.C.), Bethesda, Maryland.
出版信息
J Trauma Acute Care Surg. 2014 Mar;76(3):821-7. doi: 10.1097/TA.0b013e3182aa2d21.
BACKGROUND
Acute respiratory distress syndrome (ARDS) prevalence and related outcomes in burned military casualties from Iraq and Afghanistan have not been described previously. The objective of this article was to report ARDS prevalence and its associated in-hospital mortality in military burn patients.
METHODS
Demographic and physiologic data were collected retrospectively on mechanically ventilated military casualties admitted to our burn intensive care unit from January 2003 to December 2011. Patients with ARDS were identified in accordance with the new Berlin definition of ARDS. Subjects were categorized as having mild, moderate, or severe ARDS. Multivariate logistic regression identified independent risk factors for developing moderate-to-severe ARDS. The main outcome measure was the prevalence of ARDS in a cohort of patients burned as a result of recent combat operations.
RESULTS
A total of 876 burned military casualties presented during the study period, of whom 291 (33.2%) required mechanical ventilation. Prevalence of ARDS in this cohort was 32.6%, with a crude overall mortality of 16.5%. Mortality increased significantly with ARDS severity: mild (11.1%), moderate (36.1%), and severe (43.8%) compared with no ARDS (8.7%) (p < 0.001). Predictors for the development of moderate or severe ARDS were inhalation injury (odds ratio [OR], 1.90; 95% confidence interval [CI], 1.01-3.54; p = 0.046), Injury Severity Score (ISS) (OR, 1.04; 95% CI, 1.01-1.07; p = 0.0021), pneumonia (OR, 198; 95% CI, 1.07-3.66; p = 0.03), and transfusion of fresh frozen plasma (OR, 1.32; 95% CI, 1.01-1.72; p = 0.04). Size of burn was associated with moderate or severe ARDS by univariate analysis but was not an independent predictor of ARDS by multivariate logistic regression (p > 0.05). Age, size of burn, and moderate or severe ARDS were independent predictors of mortality.
CONCLUSION
In this cohort of military casualties with thermal injuries, nearly a third required mechanical ventilation; of those, nearly one third developed ARDS, and nearly one third of patients with ARDS did not survive. Moderate and severe ARDS increased the odds of death by more than fourfold and ninefold, respectively.
LEVEL OF EVIDENCE
Epidemiologic/prognostic study, level III.
背景
在伊拉克和阿富汗的烧伤军事伤员中，急性呼吸窘迫综合征（ARDS）的患病率和相关结局尚未有过描述。本文的目的是报告在我们烧伤重症监护病房（BICU）收治的烧伤军人患者中 ARDS 的患病率及其相关院内死亡率。
方法
我们回顾性收集了 2003 年 1 月至 2011 年 12 月期间入住我们烧伤 ICU 并接受机械通气的烧伤军人的人口统计学和生理学数据。ARDS 患者是按照新的柏林 ARDS 定义来确定的。患者分为轻度、中度和重度 ARDS。多变量逻辑回归确定了发生中重度 ARDS 的独立危险因素。主要结局指标是最近的作战行动中因烧伤而住院的患者队列中 ARDS 的患病率。
结果
在研究期间共有 876 例烧伤的军人患者就诊，其中 291 例（33.2%）需要机械通气。该队列中 ARDS 的患病率为 32.6%，总体死亡率为 16.5%。ARDS 严重程度与死亡率显著相关：轻度（11.1%）、中度（36.1%）和重度（43.8%）患者的死亡率均高于无 ARDS 患者（8.7%）（p < 0.001）。发生中重度 ARDS 的预测因素为吸入性损伤（比值比 [OR]，1.90；95%置信区间 [CI]，1.01-3.54；p = 0.046）、损伤严重度评分（ISS）（OR，1.04；95%CI，1.01-1.07；p = 0.0021）、肺炎（OR，198；95%CI，1.07-3.66；p = 0.03）和新鲜冰冻血浆输注（OR，1.32；95%CI，1.01-1.72；p = 0.04）。烧伤面积大小在单变量分析中与中重度 ARDS 相关，但在多变量逻辑回归分析中不是 ARDS 的独立预测因素（p > 0.05）。年龄、烧伤面积大小和中重度 ARDS 是死亡率的独立预测因素。
结论
在本队列中，有近三分之一的热损伤军人患者需要机械通气；其中，近三分之一的患者发生 ARDS，近三分之一的 ARDS 患者未能存活。中重度 ARDS 使死亡的可能性分别增加了四倍和九倍以上。
证据水平
流行病学/预后研究，III 级。
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