A propensity score-matched study of correlation between early hyperoxia and acute gastrointestinal injury in patients with severe non-abdominal trauma
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摘要: 目的 探讨严重非腹部创伤患者入ICU后24 h内高氧血症与急性胃肠损伤(AGI)的相关性。方法 回顾性分析2013年1月—2020年3月期间就诊于南京医科大学附属江宁医院ICU的损伤严重程度评分(ISS)≥16分的严重非腹部创伤患者。根据入ICU 24 h内血气分析获得的动脉血氧分压(PaO2)平均值分为两个队列：高氧组[PaO2＞120 mmHg(1 mmHg=0.133 kPa)]和常氧组(PaO2=60~120 mmHg)。最终共有404例患者纳入本研究，其中高氧组195例，常氧组209例。收集患者临床资料，通过倾向性评分匹配(PSM)校正患者年龄、性别、APACHE Ⅱ评分等因素，比较PSM前后高氧组和常氧组之间的临床资料，使用匹配后数据集比较两组患者发生AGI等临床结局的差异。随后采用logistic回归分析404例严重非腹部患者AGI的独立危险因素。结果 高氧组和常氧组PSM前ISS评分、APACHE Ⅱ评分、机械通气、心率、头/颈部创伤患病率分布不均衡，差异有统计学意义(P＜0.05)。经倾向性评分最邻近匹配法(按1∶1匹配)，共139对匹配。匹配后高氧组和常氧组在各协变量的差异全部均衡可比，差异无统计学意义(P＞0.05)。与常氧组(41.0%)相比，高氧组患者AGI发生率(70.5%)更高(P＜0.01)，ICU住院时间延长(6 d vs. 5 d，P=0.04)，均差异有统计学意义。而两组患者住院病死率(29.5% vs. 20.9%，P=0.13)及ICU机械通气时间[7.1(4.1~10.3) vs. 6.1(4.1~9.2)，P=0.22]比较，均差异无统计学意义(P＞0.05)。Logistic分析显示年龄较大的患者AGI发生率降低(OR=0.98，95%CI：0.97~0.99，P＜0.01)，机械通气患者AGI发生率增高(OR=2.34，95%CI：1.34~4.09，P＜0.01)。结论 严重非腹部创伤患者早期高氧血症可导致AGI的发生，并延长ICU住院时间。机械通气及年龄较低是AGI发生的独立危险因素。Abstract: Objective To investigate the correlation between early hyperoxia and acute gastrointestinal injury(AGI) in ICU patients with severe non-abdominal trauma.Methods This was a retrospective analysis conducted in the Affiliated Jiangning Hospital of Nanjing Medical University. Non-abdominal trauma patients was enrolled with Injury Severity Score(ISS) ≥16 who admitted to hospital from January 2013 to March 2020. The cohorts were categorized into two groups based on the mean arterial partial pressure of oxygen(PaO2) within 24 hours of admission to ICU: hyperoxia and normoxia group[defined as PaO2 > 120 mmHg(1 mmHg=0.133 kPa) and PaO2=60-120 mmHg, respectively]. A total of 404 patients were finally enrolled, including 195 in the hyperoxia group and 209 in the normoxia group. Propensity score-matching(PSM) was used to assemble a cohort of patients with similar baseline characteristics, including age, gender, APACHE Ⅱ score, etc. The clinical data of the two groups before and after PSM were compared. The data set after PSM was used for further analysis including incidence of AGI, duration of mechanical ventilation, length of ICU stay and in-hospital mortality. Logistic regression was used to analyse the independent risk factors of AGI in 404 severe non-abdominal patients.Results Before PSM, ISS score, APACHE Ⅱ score, incidence of mechanical ventilation, heart rate, and the incidence of head/neck trauma were significantly different between the two groups(P < 0.05). A total of 141 pairs were matched in a 1: 1 greedy nearest neighbor algorithm. After PSM, the included covariates had a good balance between the hyperoxia group and the normoxia group, and the differences were not statistically significant. Patients in the hyperoxia group had a higher AGI incidence(70.5% vs. 41.0%, P < 0.01) and length of stay in ICU(6 days vs. 5 days, P=0.01). There was no significant difference between the groups with respect to in-hospital mortality[7.1(4.1-10.3) vs 6.1(4.1-9.2), P=0.22]and the duration of mechanical ventilation(29.5% vs. 20.9%, P=0.13). Logistic analysis showed that the incidence of AGI was lower in the older age group(OR=0.98, 95%CI: 0.97-0.99, P < 0.01), and was higher in mechanical ventilation group(OR=2.34, 95%CI: 1.34-4.09, P < 0.01).Conclusion The results of this study suggest a significant association between early hyperoxia and high AGI incidence and prolonged ICU length of stay in patients with severe non-abdominal trauma. Mechanical ventilation and younger age are independent risk factors for AGI.
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表 1 高氧组与常氧组严重非腹部创伤患者PSM前的基线资料比较
例(%)，X±S 变量 高氧(195例) 常氧(209例) χ2/Z/t P 年龄/岁 48.72±17 50.68±14.9 -1.24 0.22 男性 145(74.4) 154(73.7) 0.02 0.88 ISS评分 28(20~36) 25(18~33) 2.41 0.02 胸部AIS评分 3(0~4) 3(0~4) -1.42 0.16 入院GCS 14(6~15) 14(7~15) -0.93 0.35 APACHE Ⅱ评分 20(14.4~26.4) 17.6(12.6~25.0) 2.48 0.01 创伤至入住ICU时间/min 86(60~120) 100(60~120) -1.16 0.25 入院机械通气 48(24.6) 24(11.5) 11.88 ＜0.01 入院血管活性药使用 13(6.7) 8(3.8) 1.65 0.2 基线生命体征 心率/(次·min-1) 93.69±20.80 88.42±21.79 2.48 0.01 收缩压/mmHg 126.49±26.62 131.52±27.53 -1.86 0.06 创伤部位 头/颈部 137(70.3) 124(59.3) 5.27 0.02 面部 37(19) 29(13.9) 1.92 0.17 胸部 147(75.4) 148(70.8) 1.07 0.3 四肢 101(51.8) 106(50.7) 0.05 0.83 脊髓 2(1) 3(1.4) 0.14 0.71 骨盆 13(6.7) 14(6.7) 0 0.99 既往疾病史 高血压 35(17.9) 35(16.7) 0.1 0.75 慢性阻塞性肺疾病 15(7.7) 13(6.3) 0.32 0.57 2型糖尿病 27(13.8) 31(14.8) 0.08 0.78 冠心病 8(4.1) 11(5.3) 0.3 0.58 脑血管疾病 8(4.1) 14(6.7) 1.32 0.25 慢性肾功能不全 6(3.2) 9(4.4) 0.43 1.51 
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表 2 高氧组与常氧组严重非腹部创伤患者PSM后的基线资料比较
例(%) 变量 高氧(139例) 常氧(139例) χ2/Z/t P 年龄/岁 48.37±17.13 48.73±15.35 -0.19 0.85 男性 104(74.8) 103(74.1) 0.02 0.89 ISS评分 26(19，32) 27(21，35) -1.2 0.23 胸部AIS评分 3(0，4) 3(0，4) -0.58 0.57 入院GCS 15(7，15) 13(6，15) 1.28 0.2 APACHE Ⅱ评分 18(13.8，23.8) 20(14，27) -1.39 0.16 创伤至入住ICU时间/min 75(60，120) 68(60，120) 1.07 0.28 入院机械通气 24(17.3) 20(14.4) 0.43 0.51 入院血管活性药使用 8(5.8) 8(5.8) 0 1.00 基线生命体征 心率/(次·min-1) 90.54±20.70 91.41±22.17 -0.34 0.74 收缩压/mmHg 128.44±26.31 125.51±26.47 0.93 0.36 创伤部位 头/颈部 94(67.6) 95(68.3) 0.02 0.90 面部 22(15.8) 21(15.1) 0.03 0.87 胸部 102(73.4) 103(74.1) 0.02 0.89 四肢 66(47.5) 71(51.1) 0.36 0.55 脊髓 2(1.4) 0(0) 2.01 0.16 骨盆 11(7.9) 9(6.5) 0.22 0.64 既往疾病史 高血压 27(19.4) 20(14.4) 1.26 0.26 慢性阻塞性肺疾病 4(2.9) 10(7.2) 2.71 0.10 2型糖尿病 16(11.5) 17(12.2) 0.03 0.85 冠心病 6(4.3) 5(3.6) 0.1 0.76 脑血管疾病 6(4.3) 7(5.0) 0.08 0.78 慢性肾功能不全 5(3.6) 6(4.3) 0.1 0.76
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表 3 高氧组与非高氧组严重非腹部创伤患者PSM后的动脉血气指标比较
变量 高氧(139例) 常氧(139例) χ2/Z/t P FiO2 0.7(0.6~1.0) 0.5(0.4~1.0) 5.27 0.02 PaO2/mmHg 161(139~187) 85(73~95) 10.31 ＜0.01 PaO2/FiO2/mmHg 247(186~375) 144(87~198) 9.16 ＜0.01
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表 4 高氧组与非高氧组严重非腹部创伤患者PSM后的临床结局比较
例(%) 变量 高氧(139例) 常氧(139例) χ2/Z/t P AGI分级 98(70.5) 57(41.0) 14.51 ＜0.01 Ⅰ级 29(20.9) 31(22.3) Ⅱ级 50(36.0) 22(15.8) Ⅲ级 16(11.5) 7(5.0) Ⅳ级 3(2.2) 2(1.4) 机械通气时间/d 7.1(4.1~10.3) 6.1(4.1~9.2) 1.22 0.22 ICU住院时间/d 6(3~11) 5(3~8) 1.97 0.04 住院预后情况 2.76 0.13 存活 98(70.5) 110(79.1) 死亡 41(29.5) 29(20.9)
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表 5 严重非腹部创伤患者发生AGI的单因素分析
例(%) 变量 AGI(214例) 非AGI(190例) χ2/Z/t P 年龄/岁 47.57±16.61 52.17±14.93 -2.91 ＜0.01 男性 158(73.8) 141(74，2) 0.01 0.93 ISS评分 24.5(19~33) 27(21~34) -1.49 0.14 胸部AIS评分 3(0~4) 3(0~4) -1.69 0.09 入院GCS 15(8~15) 13(6~15) -1.36 0.18 APACHE Ⅱ评分 17.6(13~24) 19(13.73~26.45) -1.23 0.22 创伤至入住ICU时间/min 120(60~120) 81(60~120) 0.675 0.50 入院机械通气 50(23.4) 22(11.6) 9.55 ＜0.01 入院血管活性药使用 13(6.1) 8(4.2) 0.71 0.40 基线生命体征 心率/(次·min-1) 92.06±21.26 89.72±21.65 1.09 0.27 收缩压/mmHg 130.11±25.89 127.94±28.58 0.8 0.42 创伤部位 头/颈部 137(64) 124(65.3) 0.07 0.79 面部 39(18.2) 27(14.2) 1.12 0.28 胸部 151(70.6) 144(75.8) 1.39 0.24 四肢 108(50.5) 99(52.1) 0.11 0.74 脊髓 3(1.4) 2(1.1) 0.1 0.75 骨盆 11(5.1) 16(8.4) 1.74 0.19 既往疾病史 高血压 37(17.3) 33(17.4) 0 0.98 慢性肺病 15(7) 13(6.9) 0 0.96 2型糖尿病 31(14.5) 27(14.2) 0.01 0.93 冠心病 10(4.7) 9(4.7) 0.01 0.97 脑血管疾病 8(3.7) 14(7.4) 2.58 0.11 慢性肾病 6(2.8) 9(4.7) 1.05 0.31
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表 6 严重非腹部创伤患者发生AGI的多因素logistic回归分析
变量 β 标准误 Wald P OR 95%CI 年龄 -0.02 0.01 8.23 ＜0.01 0.98 0.97~0.99 ISS评分 0.03 0.03 1.72 0.19 1.03 0.98~1.09 GCS -0.01 0.01 0.36 0.55 0.99 0.97~1.01 入院机械通气 0.85 0.29 8.86 ＜0.01 2.34 1.34~4.09 骨盆 0.58 0.42 1.87 0.17 0.56 0.25~1.28 脑血管疾病 0.61 0.46 1.72 0.19 0.55 0.22~1.35 常数 0.79 0.61 1.68 0.2 2.19
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[1] Singer M, Young PJ, Laffey JG, et al. Dangers of hyperoxia[J]. Crit Care, 2021, 25(1): 440. doi: 10.1186/s13054-021-03815-y
[2] Demiselle J, Calzia E, Hartmann C, et al. Target arterial PO2 according to the underlying pathology: a mini-review of the available data in mechanically ventilated patients[J]. Ann Intensive Care, 2021, 11(1): 88. doi: 10.1186/s13613-021-00872-y
[3] Christensen MA, Steinmetz J, Velmahos G, et al. Supplemental oxygen therapy in trauma patients: An exploratory registry-based study[J]. Acta Anaesthesiol Scand, 2021, 65(7): 967-978. doi: 10.1111/aas.13829
[4] Douin DJ, Anderson EL, Dylla L, et al. Association Between Hyperoxia, Supplemental Oxygen, and Mortality in Critically Injured Patients[J]. Crit Care Explor, 2021, 3(5): e0418. doi: 10.1097/CCE.0000000000000418
[5] Khan R, Alromaih S, Alshabanat H, et al. The Impact of Hyperoxia Treatment on Neurological Outcomes and Mortality in Moderate to Severe Traumatic Brain Injured Patients[J]. J Crit Care Med(Targu Mures), 2021, 7(3): 227-236. doi: 10.2478/jccm-2021-0014
[6] Li Y, Tao Y, Xu J, et al. Hyperoxia Provokes Time-and Dose-Dependent Gut Injury and Endotoxemia and Alters Gut Microbiome and Transcriptome in Mice[J]. Front Med(Lausanne), 2021, 8: 732039.
[7] 庄苗, 李玉兰, 张小晓, 等. 基于SIRT1/Nrf2/HO-1通路探讨富氢水对小鼠高氧肠损伤的保护机制[J]. 中国急救医学, 2021, 41(12): 1075-1080. doi: 10.3969/j.issn.1002-1949.2021.12.013
[8] 朱承睿, 栾正刚, 尹晓晗, 等. 急性胃肠损伤分级对疾病严重程度及预后评估价值研究(附296例报告)[J]. 中国实用外科杂志, 2015, 35(5): 531-533. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGWK201505025.htm
[9] Page D, Ablordeppey E, Wessman BT, et al. Emergency department hyperoxia is associated with increased mortality in mechanically ventilated patients: a cohort study[J]. Crit Care, 2018, 22(1): 9. doi: 10.1186/s13054-017-1926-4
[10] Reintam Blaser A, Preiser JC, Fruhwald S, et al. Gastrointestinal dysfunction in the critically ill: a systematic scoping review and research agenda proposed by the Section of Metabolism, Endocrinology and Nutrition of the European Society of Intensive Care Medicine[J]. Crit Care, 2020, 24(1): 224. doi: 10.1186/s13054-020-02889-4
[11] Harijith A, Basa P, Ha A, et al. NOX4 Mediates Epithelial Cell Death in Hyperoxic Acute Lung Injury Through Mitochondrial Reactive Oxygen Species[J]. Front Pharmacol, 2022, 13: 880878. doi: 10.3389/fphar.2022.880878
[12] Pérez S, Taléns-Visconti R, Rius-Pérez S, et al. Redox signaling in the gastrointestinal tract[J]. Free Radic Biol Med, 2017, 104: 75-103. doi: 10.1016/j.freeradbiomed.2016.12.048
[13] Payen D. The gut as a hidden source of sepsis[J]. Minerva Anestesiol, 2020, 86(6): 662-669.
[14] Hedley-Whyte J. Pulmonary oxygen toxicity: investigation and mentoring[J]. Ulster Med J, 2008, 77(1): 39-42.
[15] Yamamoto R, Fujishima S, Sasaki J, et al. Hyperoxemia during resuscitation of trauma patients and increased intensive care unit length of stay: inverse probability of treatment weighting analysis[J]. World J Emerg Surg, 2021, 16(1): 19. doi: 10.1186/s13017-021-00363-2
[16] Douin DJ, Anderson EL, Dylla L, et al. Association Between Hyperoxia, Supplemental Oxygen, and Mortality in Critically Injured Patients[J]. Crit Care Explor, 2021, 3(5): e0418. doi: 10.1097/CCE.0000000000000418
[17] Zhu Z, Zhou M, Wei Y, et al. Time-varying intensity of oxygen exposure is associated with mortality in critically ill patients with mechanical ventilation[J]. Crit Care, 2022, 26(1): 239. doi: 10.1186/s13054-022-04114-w
[18] de Graaff AE, Dongelmans DA, Binnekade JM, et al. Clinicians' response to hyperoxia in ventilated patients in a Dutch ICU depends on the level of FiO2[J]. Intensive Care Med, 2011, 37(1): 46-51. doi: 10.1007/s00134-010-2025-z
[19] Boerman EM, Segal SS. Depressed perivascular sensory innervation of mouse mesenteric arteries with advanced age[J]. J Physiol, 2016, 594(8): 2323-2338. doi: 10.1113/JP270710
[20] O'Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings[J]. Thorax, 2017, 72(Suppl 1): ii1-ii90. doi: 10.1136/thoraxjnl-2016-209729
[21] Madotto F, Rezoagli E, Pham T, et al. Hyperoxemia and excess oxygen use in early acute respiratory distress syndrome: insights from the LUNG SAFE study[J]. Crit Care, 2020, 24(1): 125. doi: 10.1186/s13054-020-2826-6
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