入院早期血乳酸值对中重型创伤性脑损伤患儿死亡的预测价值

发布时间：2018-07-24 20:13

【摘要】：背景创伤性脑损伤是临床上较常见的急危重症,是导致儿童死亡和致残的重要原因。脑创伤后由于颅内血肿、脑水肿等,导致颅内压升高,脑血流的自动调节功能受损,脑灌注压下降,造成继发性脑缺血缺氧。利用脑组织氧代谢能早期发现和治疗脑缺血和缺氧,维持脑氧供需的平衡,减轻颅脑创伤后的继发性损害,从而改善病人的预后。乳酸酸中毒在危重症患者中常见,血液乳酸水平可反映细胞缺氧和组织低灌注的程度,是评价氧代谢的重要指标,高乳酸血症与危重患者的死亡密切相关。目的探讨入院早期血乳酸值对中重型创伤性脑损伤(TBI)患儿死亡的影响及乳酸与危重症评分、GCS评分、凝血功能之间的相关关系。方法1.回顾性纳入2011年05月至2014年10月在重庆医科大学附属儿童医院重症医学科治疗的中重型TBI[入院GCS昏迷评分(GCS)≤13分]患儿;2.根据预后分为死亡组和存活组;截取年龄、性别、体重、住院时间、入院早期实验室指标(血乳酸、血钾、血钠、PLT计数、PT、APTT、TT、FIB、D-二聚体)和血压、危重症评分等;3.用SPSS 21.0统计软件进行数据统计,行两组间单因素和多因素分析;入院早期血乳酸水平行受试者工作曲线分析,考察血乳酸预测死亡的最佳界值及其敏感度和特异度;行乳酸与危重症评分、GCS评分、凝血功能的相关性分析。结果1.共109例患儿纳入分析。其中存活92例,死亡17例。2.死亡组患儿入院中位血乳酸值、入院中位24小时内血乳酸峰值、合并其它脏器损伤率、入院GCS评分≤8和低血压发生率明显高于存活组(4.90 vs.0.80mmo/L,5.00 vs.0.90mmol/L,76.47%vs.42.49%,94.12%vs.45.65%,76.47%vs.7.61%;P值均0.05),凝血功能指标PT值、中位APTT值、TT值高于存活组(18.20±5.00s vs.13.76±1.89s,36.90 vs.28.60s,26.41±8.18s vs.19.05±2.60s;P值0.05);而死亡组中位总住院天数、中位FIB值、入院血钾低于存活组(2.00 vs.20.00 d,0.54 vs.1.40mg/L,3.38±0.52 vs.3.68±0.57mmol/L;P值均0.05)。3.采用ROC曲线分析发现入院血乳酸水平是中重型创伤性脑损伤患儿死亡的预测因子(AUC:0.949,95%CI 0.889 to 0.982,P0.001),乳酸界值为2.5mmo/L,敏感度为88.24%,特异度为90.22%。4.多因素Logistic回归分析发现入院乳酸值(OR=1.597;95%CI:1.064-2.399;P=0.024)是中重度创伤性脑损伤患儿死亡的独立危险因素;而入院GCS≤8、合并其它脏器损伤、血钾水平和危重症评分并不是此类患儿死亡的独立危险因素。5.中重型TBI患儿入院血乳酸水平与危重症评分、CGS评分呈负相关。乳酸水平越高,危重症评分越低、GCS评分亦越低,提示病情越危重。结论1.入院早期血乳酸水平可以预测中重型创伤性脑损伤患儿预后;2.入院早期高乳酸是中重型创伤性脑损伤患儿死亡的独立危险因素;3.中重型创伤性脑损伤患儿的早期血乳酸水平与危重症评分、GCS评分、凝血功能呈显著相关性。
[Abstract]:Background traumatic brain injury (TBI) is an important cause of death and disability in children. After brain trauma, intracranial hematoma, brain edema and so on lead to the increase of intracranial pressure, the impairment of automatic regulation of cerebral blood flow, and the decrease of cerebral perfusion pressure, resulting in secondary cerebral ischemia and hypoxia. The early detection and treatment of cerebral ischemia and hypoxia by oxygen metabolism in brain tissue can maintain the balance of cerebral oxygen supply and demand, alleviate the secondary damage after traumatic brain injury, and improve the prognosis of patients. Lactate acidosis is common in critically ill patients. The level of blood lactic acid can reflect the degree of cell hypoxia and tissue hypoperfusion. It is an important index to evaluate oxygen metabolism. Hyperlactic acidemia is closely related to the death of critically ill patients. Objective to investigate the effect of early blood lactic acid on the death of children with moderate and severe traumatic brain injury (TBI) and the correlation between lactic acid and critical grade score (GCS) and coagulation function. Method 1. From May 2011 to October 2014, the patients with moderate and severe TBI [admission GCS coma score (GCS) 鈮，

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