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Article(id=1198202432342815282, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1198202427301265552, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.0128.2024.0517, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1689609600000, receivedDateStr=2023-07-18, revisedDate=null, revisedDateStr=null, acceptedDate=1705248000000, acceptedDateStr=2024-01-15, onlineDate=1763603321395, onlineDateStr=2025-11-20, pubDate=1730044800000, pubDateStr=2024-10-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1763603321395, onlineIssueDateStr=2025-11-20, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1763603321395, creator=13701087609, updateTime=1763603321395, updator=13701087609, issue=Issue{id=1198202427301265552, tenantId=1146029695717560320, journalId=1189873630562394117, year='2024', volume='49', issue='10', pageStart='1099', pageEnd='1220', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1763603320193, creator=13701087609, updateTime=1763603941762, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1198205034396746241, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1198202427301265552, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1198205034396746242, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1198202427301265552, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=1150, endPage=1155, ext={EN=ArticleExt(id=1198202432598667832, articleId=1198202432342815282, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Analysis of risk factors for postoperative delayed weaning in patients with intracerebral hemorrhage and establishment of a predictive model, columnId=1190310109000602400, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Clinical Research, runingTitle=null, highlight=null, articleAbstract=

Objective To identify the risk factors for postoperative delayed weaning in patients with intracerebral hemorrhage and to establish a predictive model. Methods A retrospective study was conducted on 207 patients who underwent surgery for intracerebral hemorrhage at the intensive care unit (ICU) of Peking University People's Hospital from October 2014 to October 2021. Utilizing the 2007 European Respiratory Society consensus criteria, patients were divided into delayed weaning group (n=66) and non-delayed weaning group (n=141). The demographic and operation-related conditions of the two groups were compared. Multiple logistic regression analysis was employed to identify the risk factors for delayed weaning, and a risk assessment nomogram was constructed and validated. Results Compared with the non-delayed weaning group, the delayed weaning group exhibited a significantly higher proportion of comorbid cardiovascular and cerebrovascular diseases, a lower Glasgow coma scale (GCS) score on admission, a greater incidence of preoperative brain herniation, a higher proportion of patients undergoing emergency surgeries and decompression craniotomies, and higher postoperative APACHE Ⅱ score, GCS score, incidence of atelectasis, weaning failure rate and mortality rate, and longer ICU stay and hospital stay (P<0.05). Multiple logistic regression analysis indicated that emergency surgery, low postoperative oxygenation index, low postoperative score of highest GCS before weaning, and incidence of atelectasis were independent risk factors for postoperative delayed weaning (P<0.05). A nomogram predictive model was established using these four predictors, with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.855(95%CI 0.804-0.907), and the Hosmer-Lemeshow test showed good model fit (P=0.659). Conclusions Postoperative delayed weaning is associated with extended durations of mechanical ventilation, ICU stay, and hospital stay, as well as an increased risk of weaning failure and in-hospital mortality rate. The nomogram model provides valuable insights for the early recognition of patients at high risk for postoperative delayed weaning, thereby facilitating timely adjustment in ventilation management strategies.

, correspAuthors=Hui-Ying Zhao, authorNote=null, correspAuthorsNote=
E-mail:
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目的 分析脑出血患者术后延迟脱机的危险因素并建立预测模型。方法 选择2014年10月－2021年10月北京大学人民医院重症医学科(ICU)收治的因脑出血行外科手术的207例患者的临床资料进行回顾性分析。根据2007年欧洲呼吸学会共识，将207例患者分为延迟脱机组(n=66)与非延迟脱机组(n=141)。比较两组患者基本情况及手术相关状况；采用多因素logistic回归分析患者延迟脱机的危险因素，并构建延迟脱机风险评估列线图并验证。结果 与非延迟脱机组比较，延迟脱机组患者合并心脑血管疾病比例较高、入院格拉斯哥昏迷评分法(GCS)评分较低、术前合并脑疝比例较高，急诊手术、接受骨瓣减压比例较高，且术后急性生理与慢性健康(APACH) Ⅱ评分、GCS评分、发生肺不张比例、脱机失败率、死亡发生率均较高，住ICU时间及住院时间均较长(P<0.05)。多因素logistic回归分析提示，急诊手术、术后氧合指数低、术后至脱机前最高GCS评分低及发生肺不张是导致术后脱机延迟的独立危险因素(P<0.05)，联合此4项指标构建Nomogram风险预测模型，其受试者工作特征(ROC)曲线下面积(AUC)为0.855(95%CI 0.804~0.907)，Hosmer-Lemeshow检验表明模型拟合度较好(P=0.659)。结论 延迟脱机可导致患者机械通气时间、住ICU时间及住院时间延长，脱机失败率及院内死亡风险增加。Nomogram模型对预测延迟脱机具有一定价值，可帮助临床医师早期发现高风险患者，并及时调整通气策略。

, correspAuthors=赵慧颖, authorNote=null, correspAuthorsNote=
赵慧颖，E-mail：
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杜安琪，主管技师，主要从事呼吸治疗方面的研究

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杜安琪，主管技师，主要从事呼吸治疗方面的研究

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杜安琪，主管技师，主要从事呼吸治疗方面的研究

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Predictors of extubation failure and prolonged mechanical ventilation among patients with intracerebral hemorrhage after surgery[J]. Respir Res, 2024, 25(1): 19., articleTitle=Predictors of extubation failure and prolonged mechanical ventilation among patients with intracerebral hemorrhage after surgery, refAbstract=null), Reference(id=1198319032983187858, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432342815282, doi=null, pmid=null, pmcid=null, year=2021, volume=120, issue=8, pageStart=1657, pageEnd=null, url=null, language=null, rfNumber=[23], rfOrder=22, authorNames=Fu Q, journalName=J Formos Med Assoc, refType=null, unstructuredReference=Fu Q. Clinical outcomes and prognostic factors for prolonged mechanical ventilation in patients with acute stroke and brain trauma[J]. 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N Engl J Med, 2022, 387(20): 1843-1854., articleTitle=Spontaneous-breathing trials with pressure-support ventilation or a T-piece, refAbstract=null)], funds=[Fund(id=1198319029267034389, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432342815282, awardId=XZ2022ZR-ZY04(Z), language=EN, fundingSource=Tibet Autonomous Region Natural Science Foundation Group Medical Aid Project(XZ2022ZR-ZY04(Z)), fundOrder=null, country=null), Fund(id=1198319029350920476, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432342815282, awardId=XZ2022ZR-ZY04(Z), language=CN, fundingSource=西藏自治区自然科学基金组援医学项目(XZ2022ZR-ZY04(Z)), fundOrder=null, country=null)], companyList=[AuthorCompany(id=1198319024753963132, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432342815282, xref=null, ext=[AuthorCompanyExt(id=1198319024762351741, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432342815282, companyId=1198319024753963132, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=Department of Critical Care Medicine, Peking University People's Hospital, Beijing 100044, China), AuthorCompanyExt(id=1198319024770740350, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432342815282, companyId=1198319024753963132, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=北京大学人民医院重症医学科，北京 100044)])], figs=[ArticleFig(id=1198319026561708220, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432342815282, language=EN, label=Fig.1, caption=A nomogram predicting prolong ventilation for intracerebral hemorrhage patients, figureFileSmall=srCsmicrF1YZD/FoQMmJUA==, figureFileBig=+ZBON0WzauvX0c66iVJZXw==, tableContent=null), ArticleFig(id=1198319026662371521, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432342815282, language=CN, label=图1, caption=脑出血患者术后延迟脱机风险的Nomogram预测模型

GCS. 格拉斯哥昏迷评分法

, figureFileSmall=srCsmicrF1YZD/FoQMmJUA==, figureFileBig=+ZBON0WzauvX0c66iVJZXw==, tableContent=null), ArticleFig(id=1198319026779812042, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432342815282, language=EN, label=Fig.2, caption=ROC curves of the nomogram predicting prolong ventilation for intracerebral hemorrhage patients, figureFileSmall=6QyU0zoB3NcaJEBgxPUqZA==, figureFileBig=hsmoe9+ZjuMA/JXW41j93w==, tableContent=null), ArticleFig(id=1198319026926612684, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432342815282, language=CN, label=图2, caption=脑出血患者术后延迟脱机风险的Nomogram预测模型的ROC曲线

ROC. 受试者工作特征

, figureFileSmall=6QyU0zoB3NcaJEBgxPUqZA==, figureFileBig=hsmoe9+ZjuMA/JXW41j93w==, tableContent=null), ArticleFig(id=1198319028004548818, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432342815282, language=EN, label=Tab.1, caption=

Comparison of basic conditions of intracerebral hemorrhage patients between two groups

, figureFileSmall=null, figureFileBig=null, tableContent=
指标非延迟脱机组(n=141)延迟脱机组(n=66)Z/χ2P
男性[例(%)]78(55.3)39(59.1)0.2600.610
年龄[岁, M(Q1, Q3)]31(49, 70)63(53, 69)-1.1300.259
体重指数[kg/m2, M(Q1, Q3)]23.5(21.2, 25.7)24.0(22.2, 26.6)-1.3730.170
合并基础疾病[例(%)]
高血压67(47.5)41(62.1)3.8420.050
糖尿病24(17.0)16(24.2)1.5040.220
心脑血管疾病24(17.0)22(33.3)6.9210.009
呼吸系统疾病9(6.4)6(9.1)0.1700.680
脑出血原因[例(%)]12.6470.017
外伤性14(9.9)3(4.5)
高血压24(17.0)13(19.7)
脑血管畸形74(52.5)46(69.7)
肿瘤23(16.3)2(3.0)
其他6(4.3)2(3.0)
入院GCS评分[分, M(Q1, Q3)]14(8, 15)7(5, 13)5.676<0.001
术前误吸[例(%)]33(23.4)19(28.8)0.6930.405
术前脑疝[例(%)]31(22.0)30(45.5)11.9130.001
), ArticleFig(id=1198319028109406423, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432342815282, language=CN, label=表1, caption=

两组脑出血患者基础情况比较

, figureFileSmall=null, figureFileBig=null, tableContent=
指标非延迟脱机组(n=141)延迟脱机组(n=66)Z/χ2P
男性[例(%)]78(55.3)39(59.1)0.2600.610
年龄[岁, M(Q1, Q3)]31(49, 70)63(53, 69)-1.1300.259
体重指数[kg/m2, M(Q1, Q3)]23.5(21.2, 25.7)24.0(22.2, 26.6)-1.3730.170
合并基础疾病[例(%)]
高血压67(47.5)41(62.1)3.8420.050
糖尿病24(17.0)16(24.2)1.5040.220
心脑血管疾病24(17.0)22(33.3)6.9210.009
呼吸系统疾病9(6.4)6(9.1)0.1700.680
脑出血原因[例(%)]12.6470.017
外伤性14(9.9)3(4.5)
高血压24(17.0)13(19.7)
脑血管畸形74(52.5)46(69.7)
肿瘤23(16.3)2(3.0)
其他6(4.3)2(3.0)
入院GCS评分[分, M(Q1, Q3)]14(8, 15)7(5, 13)5.676<0.001
术前误吸[例(%)]33(23.4)19(28.8)0.6930.405
术前脑疝[例(%)]31(22.0)30(45.5)11.9130.001
), ArticleFig(id=1198319028218458332, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432342815282, language=EN, label=Tab.2, caption=

Comparison of surgical related indicators of intracerebral hemorrhage patients between two groups [n(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
指标

非延迟脱机组

(n=141)

延迟脱机组

(n=66)

χ2P
基底节出血55(39.0)30(45.5)0.7720.449
丘脑出血11(7.8)2(3.0)1.0230.312
脑叶出血70(49.6)32(48.5)0.0240.883
脑干出血5(3.5)3(4.5)-0.712
小脑出血16(11.3)5(7.6)0.7020.468
脑室出血42(29.8)27(40.9)2.5020.154
非单一部位出血74(52.1)39(59.1)0.7920.373
急诊手术91(64.5)60(90.9)15.841<0.001
术中输血41(29.1)21(31.8)0.1610.688
去骨瓣减压22(15.6)24(36.4)11.2110.001
二次手术25(17.7)12(18.2)0.0060.937
), ArticleFig(id=1198319028390424802, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432342815282, language=CN, label=表2, caption=

两组脑出血患者手术相关指标比较[例(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
指标

非延迟脱机组

(n=141)

延迟脱机组

(n=66)

χ2P
基底节出血55(39.0)30(45.5)0.7720.449
丘脑出血11(7.8)2(3.0)1.0230.312
脑叶出血70(49.6)32(48.5)0.0240.883
脑干出血5(3.5)3(4.5)-0.712
小脑出血16(11.3)5(7.6)0.7020.468
脑室出血42(29.8)27(40.9)2.5020.154
非单一部位出血74(52.1)39(59.1)0.7920.373
急诊手术91(64.5)60(90.9)15.841<0.001
术中输血41(29.1)21(31.8)0.1610.688
去骨瓣减压22(15.6)24(36.4)11.2110.001
二次手术25(17.7)12(18.2)0.0060.937
), ArticleFig(id=1198319028495282405, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432342815282, language=EN, label=Tab.3, caption=

Comparison of clinical parameters of intracerebral hemorrhage patients in ICU before weaning between two groups

, figureFileSmall=null, figureFileBig=null, tableContent=
指标非延迟脱机组(n=141)延迟脱机组(n=66)Z/χ2P
APACHE Ⅱ评分[分, M(Q1, Q3)]16(14, 19)20(17, 23)-4.998<0.001
术后至脱机前最高GCS评分[分, M(Q1, Q3)]10(6, 11)5(3, 7)6.923<0.001
肌钙蛋白升高[例(%)]33(23.4)32(48.5)13.128<0.001
心率[次/min, M(Q1, Q3)]80(68, 95)88(75, 102)-2.4920.013
平均动脉压[mmHg, M(Q1, Q3)]96(84, 106)94(84, 106)0.4610.645
pH值[M(Q1, Q3)]7.421(7.382, 7.460)7.412(7.376, 7.448)-0.9500.342
二氧化碳分压[mmHg, M(Q1, Q3)]34.1(30.4, 38.9)22.8(29.4, 37.1)0.9900.322
氧合指数[M(Q1, Q3)]390(283, 478)266(206, 387)3.679<0.001
乳酸[mmol/L, M(Q1, Q3)]1.4(0.9, 2.2)2.1(1.3, 3.0)-3.4500.003
钾离子[mmol/L, M(Q1, Q3)]3.9(3.6, 4.2)3.9(3.6, 4.3)-0.5270.598
血红蛋白[g/L, M(Q1, Q3)]110(95, 125)109(96, 123)1.1700.245
使用镇静镇痛药物[例(%)]90(63.8)45(68.2)0.3750.540
术后至脱机肺不张[例(%)]33(23.4)35(53.0)17.889<0.001
), ArticleFig(id=1198319028633694446, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198202432342815282, language=CN, label=表3, caption=

两组脑出血患者转入ICU后直至脱机前情况比较

, figureFileSmall=null, figureFileBig=null, tableContent=
指标非延迟脱机组(n=141)延迟脱机组(n=66)Z/χ2P
APACHE Ⅱ评分[分, M(Q1, Q3)]16(14, 19)20(17, 23)-4.998<0.001
术后至脱机前最高GCS评分[分, M(Q1, Q3)]10(6, 11)5(3, 7)6.923<0.001
肌钙蛋白升高[例(%)]33(23.4)32(48.5)13.128<0.001
心率[次/min, M(Q1, Q3)]80(68, 95)88(75, 102)-2.4920.013
平均动脉压[mmHg, M(Q1, Q3)]96(84, 106)94(84, 106)0.4610.645
pH值[M(Q1, Q3)]7.421(7.382, 7.460)7.412(7.376, 7.448)-0.9500.342
二氧化碳分压[mmHg, M(Q1, Q3)]34.1(30.4, 38.9)22.8(29.4, 37.1)0.9900.322
氧合指数[M(Q1, Q3)]390(283, 478)266(206, 387)3.679<0.001
乳酸[mmol/L, M(Q1, Q3)]1.4(0.9, 2.2)2.1(1.3, 3.0)-3.4500.003
钾离子[mmol/L, M(Q1, Q3)]3.9(3.6, 4.2)3.9(3.6, 4.3)-0.5270.598
血红蛋白[g/L, M(Q1, Q3)]110(95, 125)109(96, 123)1.1700.245
使用镇静镇痛药物[例(%)]90(63.8)45(68.2)0.3750.540
术后至脱机肺不张[例(%)]33(23.4)35(53.0)17.889<0.001
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Multivariate logistic analysis of risk factors associated with prolong ventilation in intracerebral hemorrhage patients

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变量βSEWald χ2POR(95%CI)
急诊手术1.5660.5528.0590.0054.79(1.73~15.42)
术后至脱机肺不张1.1080.3768.6730.0033.03(1.46~6.42)
术后至脱机前最高GCS评分-0.3440.06428.601<0.0010.71(0.62~0.80)
术后氧合指数-0.0040.0028.0890.0041.00(0.99~1.00)
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脑出血患者术后脱机延迟的多因素logistic回归分析

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变量βSEWald χ2POR(95%CI)
急诊手术1.5660.5528.0590.0054.79(1.73~15.42)
术后至脱机肺不张1.1080.3768.6730.0033.03(1.46~6.42)
术后至脱机前最高GCS评分-0.3440.06428.601<0.0010.71(0.62~0.80)
术后氧合指数-0.0040.0028.0890.0041.00(0.99~1.00)
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Comparison of clinical outcome of intracerebral hemorrhage patients between two groups

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指标非延迟脱机组(n=141)延迟脱机组(n=66)Z/χ2P
脱机失败[例(%)]17(12.1)25(37.9)18.535<0.001
死亡[例(%)]19(13.5)36(54.5)38.867<0.001
机械通时间[h, M(Q1, Q3)]29(10, 75)273(226, 379)11.587<0.001
住ICU时间[d, M(Q1, Q3)]4(3, 6)17(12, 25)10.236<0.001
住院时间[d, M(Q1, Q3)]14(10, 23)16(12, 22)4.556<0.001
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两组脑出血患者术后临床结局比较

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指标非延迟脱机组(n=141)延迟脱机组(n=66)Z/χ2P
脱机失败[例(%)]17(12.1)25(37.9)18.535<0.001
死亡[例(%)]19(13.5)36(54.5)38.867<0.001
机械通时间[h, M(Q1, Q3)]29(10, 75)273(226, 379)11.587<0.001
住ICU时间[d, M(Q1, Q3)]4(3, 6)17(12, 25)10.236<0.001
住院时间[d, M(Q1, Q3)]14(10, 23)16(12, 22)4.556<0.001
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脑出血患者术后延迟脱机的危险因素分析及预测模型建立
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杜安琪 , 安友仲 , 赵慧颖 *
解放军医学杂志 | 临床研究 2024,49(10): 1150-1155
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解放军医学杂志 | 临床研究 2024, 49(10): 1150-1155
脑出血患者术后延迟脱机的危险因素分析及预测模型建立
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杜安琪, 安友仲, 赵慧颖*
作者信息
  • 北京大学人民医院重症医学科，北京 100044

    • 杜安琪，主管技师，主要从事呼吸治疗方面的研究

通讯作者:

赵慧颖，E-mail：
Analysis of risk factors for postoperative delayed weaning in patients with intracerebral hemorrhage and establishment of a predictive model
An-Qi Du, You-Zhong An, Hui-Ying Zhao*
Affiliations
  • Department of Critical Care Medicine, Peking University People's Hospital, Beijing 100044, China
出版时间: 2024-10-28 doi: 10.11855/j.issn.0577-7402.0128.2024.0517
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摘要
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目的 分析脑出血患者术后延迟脱机的危险因素并建立预测模型。方法 选择2014年10月－2021年10月北京大学人民医院重症医学科(ICU)收治的因脑出血行外科手术的207例患者的临床资料进行回顾性分析。根据2007年欧洲呼吸学会共识，将207例患者分为延迟脱机组(n=66)与非延迟脱机组(n=141)。比较两组患者基本情况及手术相关状况；采用多因素logistic回归分析患者延迟脱机的危险因素，并构建延迟脱机风险评估列线图并验证。结果 与非延迟脱机组比较，延迟脱机组患者合并心脑血管疾病比例较高、入院格拉斯哥昏迷评分法(GCS)评分较低、术前合并脑疝比例较高，急诊手术、接受骨瓣减压比例较高，且术后急性生理与慢性健康(APACH) Ⅱ评分、GCS评分、发生肺不张比例、脱机失败率、死亡发生率均较高，住ICU时间及住院时间均较长(P<0.05)。多因素logistic回归分析提示，急诊手术、术后氧合指数低、术后至脱机前最高GCS评分低及发生肺不张是导致术后脱机延迟的独立危险因素(P<0.05)，联合此4项指标构建Nomogram风险预测模型，其受试者工作特征(ROC)曲线下面积(AUC)为0.855(95%CI 0.804~0.907)，Hosmer-Lemeshow检验表明模型拟合度较好(P=0.659)。结论 延迟脱机可导致患者机械通气时间、住ICU时间及住院时间延长，脱机失败率及院内死亡风险增加。Nomogram模型对预测延迟脱机具有一定价值，可帮助临床医师早期发现高风险患者，并及时调整通气策略。

脑出血  /  延迟脱机  /  危险因素  /  预测模型

Objective To identify the risk factors for postoperative delayed weaning in patients with intracerebral hemorrhage and to establish a predictive model. Methods A retrospective study was conducted on 207 patients who underwent surgery for intracerebral hemorrhage at the intensive care unit (ICU) of Peking University People's Hospital from October 2014 to October 2021. Utilizing the 2007 European Respiratory Society consensus criteria, patients were divided into delayed weaning group (n=66) and non-delayed weaning group (n=141). The demographic and operation-related conditions of the two groups were compared. Multiple logistic regression analysis was employed to identify the risk factors for delayed weaning, and a risk assessment nomogram was constructed and validated. Results Compared with the non-delayed weaning group, the delayed weaning group exhibited a significantly higher proportion of comorbid cardiovascular and cerebrovascular diseases, a lower Glasgow coma scale (GCS) score on admission, a greater incidence of preoperative brain herniation, a higher proportion of patients undergoing emergency surgeries and decompression craniotomies, and higher postoperative APACHE Ⅱ score, GCS score, incidence of atelectasis, weaning failure rate and mortality rate, and longer ICU stay and hospital stay (P<0.05). Multiple logistic regression analysis indicated that emergency surgery, low postoperative oxygenation index, low postoperative score of highest GCS before weaning, and incidence of atelectasis were independent risk factors for postoperative delayed weaning (P<0.05). A nomogram predictive model was established using these four predictors, with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.855(95%CI 0.804-0.907), and the Hosmer-Lemeshow test showed good model fit (P=0.659). Conclusions Postoperative delayed weaning is associated with extended durations of mechanical ventilation, ICU stay, and hospital stay, as well as an increased risk of weaning failure and in-hospital mortality rate. The nomogram model provides valuable insights for the early recognition of patients at high risk for postoperative delayed weaning, thereby facilitating timely adjustment in ventilation management strategies.

intracerebral hemorrhage  /  prolong ventilation  /  risk factors  /  predictive model
杜安琪, 安友仲, 赵慧颖. 脑出血患者术后延迟脱机的危险因素分析及预测模型建立. 解放军医学杂志, 2024 , 49 (10) : 1150 -1155 . DOI: 10.11855/j.issn.0577-7402.0128.2024.0517
An-Qi Du, You-Zhong An, Hui-Ying Zhao. Analysis of risk factors for postoperative delayed weaning in patients with intracerebral hemorrhage and establishment of a predictive model[J]. Medical Journal of Chinese People’s Liberation Army, 2024 , 49 (10) : 1150 -1155 . DOI: 10.11855/j.issn.0577-7402.0128.2024.0517
正文
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脑出血是神经外科及重症医学科常见的急危重症，具有起病急、病情重、病死率高等特点[1]。目前认为，脑出血患者出血部位、深度、出血量对神智、言语、运动的影响差异较大；另外，初次就诊时间、手术时机、手术方式的选择，也对脑出血患者术后颅内血肿清除效率、脑组织水肿程度及颅内压改变有不同影响[1-2]。术后大部分患者在麻醉恢复后可以立即停止机械通气并脱离呼吸机(简称“脱机”)，但仍有3%~6%的患者需要接受更长时间的机械通气治疗[3-4]，其中神经重症患者脱机困难比例高达26%，脱机失败率高达30%[5-7]。总之，神经重症患者脱机存在一定的特殊性及复杂性，原发病对这类患者的影响不可忽视。常规脱机时采用的自主呼吸试验主要关注患者的心肺功能是否可以耐受，这对于神经外科患者尤其是脑出血患者的脱机评估远远不够。本研究对脑出血患者术前、术中、术后情况进行分析，探讨导致延迟脱机的影响因素，以期为临床优化治疗措施提供参考。
1 资料与方法
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1.1 研究对象
本研究为回顾性队列研究。收集2014年10月－2021年10月北京大学人民医院重症医学科收治的因脑出血行外科手术患者的资料进行分析。纳入标准：(1)年龄≥18岁；(2)经CT或MRI确诊为脑出血并行手术治疗；(3)术后仍需机械通气，且住重症监护病房(ICU)时间>24 h；(4)病历资料完整。排除标准：(1)行有创机械通气的主要原因非原发性颅脑疾病；(2)入院时存在严重的多器官衰竭；(3)术前双瞳孔散大固定，无任何对光反射；(4)放弃治疗。共纳入207例脑出血术后患者，其中男117例，女90例，年龄18~94岁，中位年龄61岁。出血原因：外伤17例(8.2%)，高血压脑出血37例(17.9%)，脑血管畸形120例(58.0%)，肿瘤25例(12.1%)，其他8例(3.9%)。根据2007年欧洲呼吸学会共识[3]，将207例患者分为非延迟脱机组(n=141)与延迟脱机组(n=66)。延迟脱机定义为3次自主脱机试验(SBT)失败或首次尝试SBT时带机超过7 d，脱机失败为脱机后24 h内需要再插管、有创通气或死亡[3]。
1.2 研究方法
收集两组患者的基础信息[性别、年龄、身高、体重、基础疾病(高血压、糖尿病、心脑血管疾病、呼吸系统疾病)]、术前状况[格拉斯哥昏迷评分法(Glasgow coma scale，GCS)评分、是否脑疝、误吸、实验室检查结果]、手术情况(急诊或择期手术、出血原因、部位、数量、是否输血、去骨瓣、二次手术等)、入ICU后情况[急性生理与慢性健康(acute physiology and chronic health evaluation，APACHE)Ⅱ评分、生命体征、血气分析结果、实验室检查结果，入室至脱机前最高GCS评分、是否发生肺不张及用药]。比较两组患者的基础信息、术前状况、手术情况及入ICU后情况，筛选出影响脑出血者术后延迟脱机的危险因素并构建风险预测模型，并评价其预测效能。
1.3 统计学处理
采用R4.1.0软件进行统计分析。年龄、身高、体重、术前GCS评分、实验室检查结果、入ICU后情况等连续性变量均不符合正态分布，以M(Q1，Q3)表示，两组间比较采用非参数秩和检验。性别、基础疾病、术前是否脑疝、误吸、手术情况及术后是否肺不张等计数资料以例(%)表示，两组间比较采用χ2检验或Fisher确切概率法。对单因素分析中可能导致延迟脱机的因素，采用Backward逐步回归法进行分析，确定独立的危险因素并构建回归方程。采用Bootstrap自抽样法抽样300次进行内部验证，通过Hosmer-Lemeshow检验预测模型的拟合优度。采用受试者工作特征(ROC)曲线下面积(AUC)评价模型的区分度。P<0.05为差异有统计学意义。
2 结果
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2.1 两组基础情况比较
两组患者术前均未发现明显肺部感染。与非延迟脱机组比较，延迟脱机组合并心脑血管疾病比例较高、入院GCS评分较低、术前合并脑疝比例较高，差异均有统计学意义(P<0.05)，且两组发生脑出血的原因分布差异有统计学意义(P<0.05，表1)。
2.2 两组手术相关指标比较
两组患者具体出血部位无明显差异，且均有超过半数者为非单一部位出血，部分患者需进行输血、二次手术，但两组间差异无统计学意义(P>0.05)。与非延迟脱机组相比，延迟脱机组患者急诊手术比例及接受去骨瓣减压比例高，差异有统计学意义(P<0.05)(表2)。
2.3 两组转入ICU直至脱机前情况比较
术后82.6%(171/207)患者的GCS评分较术前有所改善，与非延迟脱机组比较，延迟脱机组患者APACHE Ⅱ评分高，术后至脱机前最高GCS评分低，且合并肌钙蛋白升高比例高，差异有统计学意义(P<0.001)。入ICU后，延迟脱机组患者病情相对更重，表现为心率快、氧合指数低、乳酸水平高、术后至脱机肺不张比例高(P<0.05)。但两组平均动脉压、pH值、二氧化碳分压、钾离子浓度、血红蛋白水平及使用镇静镇痛药物比例差异均无统计学意义(P>0.05)(表3)。
2.4 多因素logistic回归分析脑出血患者术后脱机延迟的影响因素
以脑出血患者术后脱机延迟为因变量，以除病因、出血部位外的所有变量为自变量，进行logistic回归分析，采用Backward方法。结果显示，急诊手术、术后至脱机肺不张、术后至脱机前最高GCS评分低、术后氧合指数低是脑出血患者术后脱机延迟的独立危险因素(P<0.05，表4)。
2.5 两组术后临床结局比较
207例患者中共有42例(20.3%)脱机失败，延迟脱机组脱机失败率、死亡发生率，机械通气时间、住ICU时间及住院时间均明显高于或长于非延迟脱机组，差异有统计学意义(P<0.001，表5)。
2.6 预测模型的建立及验证
基于多因素logistic回归分析结果及临床经验，利用R语言建立了脑出血术后延迟脱机预测模型(图1)。采用Bootstrap自抽样法重复抽样300次进行内部验证，该预测模型校正后的C-index为0.855，具有较好的区分度和预测能力。此外，校准曲线显示实际概率与预测概率有良好的一致性。通过Hosmer-Lemeshow检验判断模型的拟合优度提示模型拟合度较好(P=0.659)。以脑出血术后患者是否发生延迟脱机为因变量，列线图风险总分为自变量进行ROC曲线分析，结果显示AUC为0.855(95%CI 0.804~0.907)(图2)。
3 讨论
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神经重症患者由于病情的复杂性及其特殊性[8]，脱机较一般患者更困难[9]。本研究中患者的脱机流程相对统一，且绝大部分患者采用低水平压力支持方式进行SBT，仅少数气管切开患者选择人工鼻方式进行脱机。本研究纳入患者中延迟脱机者占31.9%(66/207)，且这部分患者住ICU及住院时间明显延长，脱机失败率及院内死亡风险明显增高，与Jeong等[5]报道基本一致。因此，早期识别脑出血术后延迟脱机的高危患者，并进行积极干预，对缩短机械通气时间、改善患者预后具有重要意义。
目前认为，GCS是用来评估昏迷患者颅脑损伤程度及意识障碍程度的综合评分系统，包括睁眼、语言及肢体反应3个方面[10]。既往研究显示，GCS评分可预测急性脑出血患者的死亡及不良预后[11-13]。脑出血患者往往病情急且重，早发现、早干预有助于改善预后[1]，尤其当存在颅内高压、脑疝时，手术必须争分夺秒。延迟脱机患者术前GCS评分明显低于非延迟脱机组(7 vs. 14，P<0.001)。术后82.6%(171/207)的患者GCS评分较术前有所改善，但程度不尽相同，但与非延迟脱机组的患者相比，延迟脱机组患者术后至脱机前最高GCS评分依旧明显更低(5 vs. 10，P<0.001)。进一步分析发现，患者术后至脱机前最高GCS评分较低是脑出血术后延迟脱机的独立危险因素。
《高血压性脑出血中国多学科诊治指南》[13]也提出高血压脑出血具体手术时机仍存在争议。目前有研究发现，与非超早期手术相比，发病后4 h内接受超早期手术患者的术后再出血风险增加，病死率增高，可能与血肿形成尚不稳定相关。此外，既往较多研究发现，术前无法对急诊手术患者的基础呼吸功能进行评估及改善，且无法掌握肺部影像学资料，以了解是否存在感染并积极合理应用抗生素，这些因素均会导致术后发生肺部感染的比例增高[10,14]。本研究也发现，接受急诊手术患者术后发生延迟脱机的比例更高，延迟脱机组脱机前肺不张及呼吸机相关肺炎发生率增高，提示临床医师在缺乏患者术前肺部相关临床资料时，应提高警惕。本研究还发现，两组患者术前肺部均无明确感染，但分别有近25%的误吸比例，与Weinhardt等[11]的观察结果相似，提示脑出血患者术前存在呕吐史者误吸风险较高。多因素分析结果显示，肺不张是导致脱机延迟的影响因素，结合既往相关研究认为，肺不张导致患者的通气功能降低[8,15]，以及长期带机或不充分肺复张时，肺部更容易发生实变，不仅影响氧合指数，还可导致肺部感染风险增加，进而影响脱机[16]。
本研究纳入患者的脑出血病因主要为脑血管畸形(58.0%，120/207)、肿瘤(12.1%，25/207)、高血压(17.9%，37/207)、外伤性(8.2%，17/207)，虽两组患者间差异有统计学意义(P=0.017)，但由于总样本量有限，不排除存在纳入偏倚的情况。既往研究显示，对于不同原因导致的脑出血，出血部位对患者的影响可能不同[13]。高血压脑出血患者则可能因脑出血损伤舌咽神经、迷走神经，从而影响吞咽、呛咳反射[17]。而外伤所致颅脑出血患者大多存在不同程度的脑水肿、意识障碍，若合并其他部位的损伤，尤其是胸部，创伤引起的疼痛可导致患者气道自洁能力受限[18]。当合并脑干损伤时，患者呼吸频率及节律可能受到影响，本研究仅8例患者存在脑干出血，且两组患者出血部位差异无统计学意义。但既往研究及临床经验认为，神经外科患者多合并呛咳反射障碍，导致气道自洁能力明显降低[17]。因此，临床医师应根据患者的出血情况具体评估，着重观察患者呼吸节律及呛咳能力，一旦发现患者出现肺不张，应积极清理气道的分泌物，适当肺复张，以减少肺部感染的发生。
动态血气分析是评估长期机械通气治疗有效性的重要指标[19]，其中氧合指数是反映患者换气功能的重要指标，与通气血流比密切相关，且目前认为氧合指数的高低与肺部病变的严重程度高度相关[20-21]。大量研究证实，自主脱机试验时氧合指数的高低与脱机结果密切相关[22-24]。本研究中，延迟脱机组患者术后氧合指数明显低于非延迟脱机组，且多因素分析显示术后氧合指数低是影响脑出血患者术后延迟脱机的独立危险因素。以上结果提示，术后氧合指数可帮助临床医师判断患者的肺部情况，动态监测患者的治疗反应，以便尽早进行干预。
本研究还联合手术类型、术后氧合指数、术后是否发生肺不张及术后至脱机前最高GCS评分这4项指标，建立了一个简单且便于临床应用的脑出血术后延迟脱机的Nomogram预测模型，验证结果显示该模型具有良好的区分度及校准度。期望通过采用临床上容易获得的指标，早期识别脱机困难患者，以尽早调整通气策略，并进行干预，包括减少镇静镇痛药物，避免肌松药物的使用，早期降低呼吸机支持条件以减少膈肌萎缩，并在条件允许的情况下积极进行康复锻炼[16]，以期尽早脱机，改善患者的预后。
综上所述，急诊手术、术后氧合指数低、术后至脱机前最高GCS评分低及发生肺不张是导致术后脱机延迟的独立危险因素，以此构建的列线图模型具有较高的区分度及预测能力。但本研究仍存在一定局限性：为单中心回顾性研究，且在收集数据时未能完全收集到所有患者的脑出血量。未来希望可通过多中心、大样本量、严格统一脱机流程的前瞻性研究对本模型进行验证，并进一步分析不同病因、不同出血特点对患者脱机的影响。
基金
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  • 西藏自治区自然科学基金组援医学项目(XZ2022ZR-ZY04(Z))
文献
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2024年第49卷第10期
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doi: 10.11855/j.issn.0577-7402.0128.2024.0517
  • 接收时间：2023-07-18
  • 首发时间：2025-11-20
  • 出版时间：2024-10-28
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  • 收稿日期：2023-07-18
  • 录用日期：2024-01-15
基金
Tibet Autonomous Region Natural Science Foundation Group Medical Aid Project(XZ2022ZR-ZY04(Z))
西藏自治区自然科学基金组援医学项目(XZ2022ZR-ZY04(Z))
作者信息
    北京大学人民医院重症医学科，北京 100044

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赵慧颖，E-mail：
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