Thomas C E, Mayer S A, Gungor Y, Swarup R, Webster E A, Chang I, Brannagan T H, Fink M E, Rowland L P
Division of Critical Care Neurology, Neurological Institute, New York, NY 10032, USA.
Neurology. 1997 May;48(5):1253-60. doi: 10.1212/wnl.48.5.1253.
We retrospectively reviewed the hospital records of 53 patients admitted for 73 episodes of myasthenic crisis at Columbia-Presbyterian Medical Center over a period of 12 years, from 1983 to 1994. Median age at the onset of first crisis was 55 (range, 20 to 82), the ratio of women to men was 2:1, and the median interval from onset of symptoms to first crisis was 8 months. Infection (usually pneumonia or upper respiratory infection) was the most common precipitating factor (38%), followed by no obvious cause (30%) and aspiration (10%). Twenty-five percent of patients were extubated at 7 days, 50% at 13 days, and 75% at 31 days; the longest crisis exceeded 5 months. Using survival analysis and backward stepwise Cox regression, we identified three independent predictors of prolonged intubation: (1) pre-intubation serum bicarbonate > or = 30 mg/dl (p = 0.0004, relative hazard 4.5), (2) peak vital capacity day 1 to 6 post-intubation < 25 ml/kg (p = 0.001, relative hazard 2.9), and (3) age > 50 (p = 0.01, relative hazard 2.4). The proportion of patients intubated longer than 2 weeks was 0% among those with no risk factors, 21% with one risk factor, 46% with two risk factors, and 88% with three risk factors (p = 0.0004). Complications independently associated with prolonged intubation included atelectasis (p = 0.002), anemia treated with transfusion (p = 0.03), Clostridium difficile infection (p = 0.01), and congestive heart failure (p = 0.03). Three episodes of crisis were fatal, for a mortality rate of 4% (3/73); four additional patients died after extubation. All seven deaths were due to overwhelming medical comorbidity. Over half of those who survived were functionally dependent (home or institutionalized) at discharge. In addition to prospective controlled studies of immunotherapies, the prevention and treatment of medical complications offers the best opportunity for further improving the outcome of myasthenic crisis.
我们回顾性分析了1983年至1994年这12年间在哥伦比亚长老会医学中心因73次重症肌无力危象入院的53例患者的医院记录。首次危象发作时的中位年龄为55岁（范围20至82岁），女性与男性比例为2:1，从症状出现到首次危象的中位间隔时间为8个月。感染（通常为肺炎或上呼吸道感染）是最常见的诱发因素（38%），其次是无明显病因（30%）和误吸（10%）。25%的患者在7天拔管，50%在13天拔管，75%在31天拔管；最长的危象超过5个月。通过生存分析和向后逐步Cox回归，我们确定了延长插管时间的三个独立预测因素：（1）插管前血清碳酸氢盐≥30mg/dl（p = 0.0004，相对风险4.5），（2）插管后第1至6天的肺活量峰值<25ml/kg（p = 0.001，相对风险2.9），以及（3）年龄>50岁（p = 0.01，相对风险2.4）。无危险因素的患者中插管超过2周的比例为0%，有一个危险因素的为21%，有两个危险因素的为46%，有三个危险因素的为88%（p = 0.0004）。与延长插管时间独立相关的并发症包括肺不张（p = 0.0
