2014年墨西哥和加拿大甲型H1N1pdm09流感相关的危重病和死亡情况

Influenza A (H1N1pdm09)-Related Critical Illness and Mortality in Mexico and Canada, 2014.

作者信息

Dominguez-Cherit Guillermo, De la Torre Alethse, Rishu Asgar, Pinto Ruxandra, Ñamendys-Silva Silvio A, Camacho-Ortiz Adrián, Silva-Medina Marco Antonio, Hernández-Cárdenas Carmen, Martínez-Franco Michel, Quesada-Sánchez Alejandro, López-Gallegos Guadalupe Celia, Mosqueda-Gómez Juan L, Rivera-Martinez Norma E, Campos-Calderón Fernando, Rivero-Sigarroa Eduardo, Hernández-Gilsoul Thierry, Espinosa-Pérez Lourdes, Macías Alejandro E, Lue-Martínez Dolores M, Buelna-Cano Christian, Ramírez-García Luna Ana-Sofía, Cruz-Ruiz Nestor G, Poblano-Morales Manuel, Molinar-Ramos Fernando, Hernandez-Torre Martin, León-Gutiérrez Marco Antonio, Rosaldo-Abundis Oscar, Baltazar-Torres José Ángel, Stelfox Henry T, Light Bruce, Jouvet Philippe, Reynolds Steve, Hall Richard, Shindo Nikki, Daneman Nick, Fowler Robert A

机构信息

1Department of Critical Care Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.2Escuela de Medicina, Tecnologico de Monterrey, Monterrey, Mexico.3Department of Hospital Epidemiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.4Trauma, Emergency and Critical Care, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.5Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.6Department of Critical Care Medicine, Instituto Nacional de Cancerología, Mexico City, Mexico.7Department of Infectious Diseases, Hospital universitario Dr. José Eleuterio González, Monterrey, Nuevo León, Mexico.8Department of Critical Care Medicine and Emergency, Instituto de Salud del Estado de México, Toluca, Mexico.9Department of Critical Care Medicine, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico.10Department of Critical Care Medicine, Hospital General de Tijuana, Tijuana, Baja California, Mexico.11Department of Critical Care Medicine, Hospital Central Ignacio Morones Prieto, San Luis Potosi, Mexico.12Department of Critical Care Medicine, Hospital General de Uruapan, Uruapan, Michoacan, Mexico.13Department of Infectious Diseases, Hospital General Regional de León, León, Guanajuato, Mexico.14Department of Infectious Diseases, Hospital Regional de Alta Especialidad de Oaxaca, Oaxaca, Mexico.15Department of Critical Care Medicine, Hospital General "Dr. Manuel Gea González," Mexico City, Mexico.16Department of Disasters Response, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.17Department of Critical Care Medicine, Hospital San José Monterrey, Monterrey, Nuevo León, Mexico.18Faculty of Medicine, Universidad de Guanajuato, León, Guanajuato, Mexico.19Department of Critical Care Medicine, Hospital Regional de Alta Especialidad de Oaxaca,

出版信息

Crit Care Med. 2016 Oct;44(10):1861-70. doi: 10.1097/CCM.0000000000001830.

DOI:10.1097/CCM.0000000000001830

PMID:27359085

Abstract

OBJECTIVES

The 2009-2010 influenza A (H1N1pdm09) pandemic caused substantial morbidity and mortality among young patients; however, mortality estimates have been confounded by regional differences in eligibility criteria and inclusion of selected populations. In 2013-2014, H1N1pdm09 became North America's dominant seasonal influenza strain. Our objective was to compare the baseline characteristics, resources, and treatments with outcomes among critically ill patients with influenza A (H1N1pdm09) in Mexican and Canadian hospitals in 2014 using consistent eligibility criteria.

DESIGN

Observational study and a survey of available healthcare setting resources.

SETTING

Twenty-one hospitals, 13 in Mexico and eight in Canada.

PATIENTS

Critically ill patients with confirmed H1N1pdm09 during 2013-2014 influenza season.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The main outcome measures were 90-day mortality and independent predictors of mortality. Among 165 adult patients with H1N1pdm09-related critical illness between September 2013 and March 2014, mean age was 48.3 years, 64% were males, and nearly all influenza was community acquired. Patients were severely hypoxic (median PaO2-to-FIO2 ratio, 83 mm Hg), 97% received mechanical ventilation, with mean positive end-expiratory pressure of 14 cm H2O at the onset of critical illness and 26.7% received rescue oxygenation therapy with prone ventilation, extracorporeal life support, high-frequency oscillatory ventilation, or inhaled nitric oxide. At 90 days, mortality was 34.6% (13.9% in Canada vs 50.5% in Mexico, p < 0.0001). Independent predictors of mortality included lower presenting PaO2-to-FIO2 ratio (odds ratio, 0.89 per 10-point increase [95% CI, 0.80-0.99]), age (odds ratio, 1.49 per 10 yr increment [95% CI, 1.10-2.02]), and requiring critical care in Mexico (odds ratio, 7.76 [95% CI, 2.02-27.35]). ICUs in Canada generally had more beds, ventilators, healthcare personnel, and rescue oxygenation therapies.

CONCLUSIONS

Influenza A (H1N1pdm09)-related critical illness still predominantly affects relatively young to middle-aged patients and is associated with severe hypoxemic respiratory failure. The local critical care system and available resources may be influential determinants of patient outcome.

摘要

目的

2009 - 2010年甲型H1N1流感大流行（2009年甲型H1N1流感）在年轻患者中造成了大量发病和死亡；然而，死亡率估计因资格标准的地区差异和选定人群的纳入而受到混淆。在2013 - 2014年，2009年甲型H1N1流感成为北美主要的季节性流感毒株。我们的目的是在2014年使用一致的资格标准，比较墨西哥和加拿大医院中甲型H1N1流感（2009年甲型H1N1流感）重症患者的基线特征、资源和治疗与结局。

设计

观察性研究以及对可用医疗资源的调查。

地点

21家医院，墨西哥13家，加拿大8家。

患者

2013 - 2014年流感季节确诊为2009年甲型H1N1流感的重症患者。

干预措施

无。

测量指标及主要结果

主要结局指标为90天死亡率及死亡率的独立预测因素。在2013年9月至2014年3月期间的165例与2009年甲型H1N1流感相关的重症成年患者中，平均年龄为48.3岁，64%为男性，几乎所有流感均为社区获得性。患者严重缺氧（动脉血氧分压与吸入氧浓度比值中位数为83 mmHg），97%接受机械通气，在危重病发作时平均呼气末正压为14 cmH₂O，26.7%接受了俯卧通气、体外生命支持、高频振荡通气或吸入一氧化氮等挽救性氧合治疗。90天时，死亡率为34.6%（加拿大为13.9%，墨西哥为50.5%，p < 0.0001）。死亡率的独立预测因素包括较低的初始动脉血氧分压与吸入氧浓度比值（比值比，每增加10个单位为0.89 [95%可信区间，0.80 - 0.99]）、年龄（比值比，每增加10岁为1.49 [95%可信区间，1.10 - 2.02]）以及在墨西哥接受重症监护（比值比，7.76 [95%可信区间，2.02 - 27.35]）。加拿大的重症监护病房通常有更多床位、呼吸机、医护人员和挽救性氧合治疗。