重症脑卒中机械通气患者非计划性拔管预测因素-现代医学

重症脑卒中机械通气患者非计划性拔管预测因素

单位：1. 首都医科大学附属北京友谊医院急诊科, 北京 100050;
2. 中国中医科学院望京医院重症医学科, 北京 100102;
3. 首都医科大学附属北京友谊医院神经内科, 北京 100050

分类号：R743.3

出版年·卷·期（页码）：2025·53·第八期（1272-1277）

摘要：

目的：探讨重症脑卒中机械通气(MV)患者非计划性拔管(UEX)的影响因素。方法: 回顾性选择2022年3月至2024年12月并发UEX的重症脑卒中MV患者70例为UEX组，同期选取未并发UEX的重症脑卒中MV患者140例为无UEX组。收集患者临床资料，Logistic回归分析重症脑卒中MV患者并发UEX的影响因素，构建UEX预测模型，受试者操作特征(ROC)曲线、校准曲线、H-L检验评价UEX预测模型的区分度、一致性。结果：Logistic回归分析显示MV插管方式(OR=3.954)、口渴缓解方式(OR=0.265)、昼夜时间段(OR=4.527)、中重度疼痛出现情况(OR=3.837)、谵妄发生情况(OR=4.868)、MV时间(OR=1.690)是重症脑卒中MV患者并发UEX的影响因素(P＜0.05)。构建预测模型Logit(P)=-4.986＋1.375×MV插管方式(经鼻气管插管=0，经口气管插管=1)-1.329×口渴缓解方式(温水注射法=0，冰水喷雾法=1)+1.510×昼夜时间段(白昼6:00～22:00=0，夜间22:00～6:00=1)+1.345×中重度疼痛出现情况(否=0，是=1)+1.583×谵妄发生情况(否=0，是=1)+0.525×MV时间/d。ROC曲线显示，该预测模型对重症脑卒中MV患者并发UEX的曲线下面积(AUC)为0.918，绘制校准曲线显示，模型平均绝对误差为0.027，校准度良好，H-L检验显示，该模型预测值与实际观测值差异无统计学意义(χ²=3.652，P=0.072)。结论：重症脑卒中MV患者并发UEX可受MV插管方式、口渴缓解方式、昼夜时间段、中重度疼痛出现情况、谵妄发生情况、MV时间多种因素影响，据此构建的UEX预测模型具有良好的区分度与一致性。

Objective: To investigate factors influencing unplanned extubation(UEX) in mechanically ventilated(MV) patients with severe stroke. Methods: 70 severe stroke patients with UEX during MV were set as UEX group and 140 severe stroke patients without UEX during MV were selected as non-UEX group from March 2022 to December 2024. Their clinical data were collected and retrospectively studied. Logistic regression analysis was used to identify factors influencing UEX in MV patients with severe stroke and a prediction model for UEX was constructed based on the influencing factors. The discrimination and consistency of the model were evaluated using receiver operating characteristic(ROC) curve, calibration curve and Hosmer-Lemeshow test. Results: Logistic regression analysis showed that MV intubation method(OR=3.954), thirst relief method(OR=0.265), day-night time period(OR=4.527), moderate to severe pain occurrence(OR=3.837), delirium occurrence(OR=4.868), and MV duration(OR=1.690) were factors influencing UEX in MV patients with severe stroke(P<0.05).The prediction model was constructed as: Logit(P)=-4.986+1.375×MV intubation method(nasotracheal=0, orotracheal=1)-1.329×thirst relief method(warm water injection=0, ice water spray=1)+1.510×day-night period(daytime 6:00-22:00=0, nighttime 22:00-6:00=1)+1.345×moderate to severe pain(no=0, yes=1)+1.583×delirium(no=0, yes=1)+0.525×MV duration(days). The ROC curve showed an area under the curve(AUC) of 0.918 for predicting UEX. The calibration curve showed good calibration with a mean absolute error of 0.027. The Hosmer-Lemeshow test showed no statistically significant differences between the predicted and the observed values(χ²=3.652,P=0.072). Conclusion: MV patients with severe stroke complicated with UEX can be affected by the means of MV intubation and thirst relief, time period of day and night, occurrence of moderate and severe pain, occurrence of delirium and the time of MV. The UEX prediction model constructed based on the factors has good differentiation and consistency.

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