多层螺旋CT对严重创伤患者血流动力学评估的研究

发布时间：2018-06-28 14:32

本文选题：创伤 + 血流动力学　；参考：《第三军医大学》2013年博士论文

【摘要】：背景与目的：创伤在全球范围内正日益成为现代社会的第一大公害。据有关统计数据显示,全球每年死于创伤的人数高达500万,占全球总死亡人数的9%,平均每分钟就有9.5人因意外创伤死亡。在我国,每年的创伤死亡人数高达70万,是第五位死亡原因。创伤尤其是严重创伤的救治一直是当今医学界所面临的一个重要难题。严重创伤患者病情复杂、危重,快速对患者做出准确的伤情评估是严重创伤救治的关键。CT在全身各部位损伤检查中具有不可比拟的优势,在严重创伤患者的伤情评估中具有重大的作用。然而,CT检查必须将危重症患者转移至放射科而有潜在风险,常常出现患者在检查过程中或检查完后不久血流动力学状态突然恶化的情况。组织器官灌注不足是休克发生的核心环节。当创伤患者因失血而导致循环血量不足时,早期机体会激活交感神经系统和肾素-血管紧张素系统来减少诸如胃肠道、肾脏、皮肤等器官的血供以保证心、脑的血供。腹部脏器在休克早期是最先被牺牲血供的部位之一,而腹部脏器血供的减少在增强CT上将表现为乏血供状态。当血容量进一步减少以至不足以支撑大循环后,将会出现主动脉、下腔静脉等大血管的塌陷征象。基于以上对休克病理生理学的改变及低血容量休克患者中的一些CT征象认识,将多层螺旋CT对创伤患者血流动力学的评估应用于严重创伤患者的早期救治中将会是一条全新的思路。在严重创伤患者早期救治中广泛应用多层螺旋CT检查,不仅可以有效地缩短从入院到给予确定性治疗的时间,同时可以为更为全面的了解各脏器的血液灌流情况及对复苏终点时机的把握提供依据。据此,本研究希望通过分析严重创伤患者伤后的CT影像学资料,量化个腹部血管及实质脏器CT数据,以创伤患者是否发生休克事件为分组依据,将入院研究创伤患者分为稳定组和休克组。比较两组患者CT数据的差异,探讨可用于评估创伤患者血流动力学状态的CT影像学征象,为多层螺旋CT应用于严重创伤患者血流动力学的评估提供具体数据支持。研究对象与方法：选取第三军医大学大坪医院野战外科研究所全军战创伤中心2008年1月—2011年12月收治的严重创伤患者的病历及影像学资料。根据患者的入院及病程记录资料,将63例患者按CT检查后24h内是否发生休克事件分为稳定组与休克组。通过影像诊断工作站调阅患者CT影像学资料,利用CT影像诊断工具中的长度测量尺测量血管直径、长度等,利用CT值测量工具测定血管及组织器官各期扫描的CT值。利用统计学方法比较两组患者间存在差异性的指标。然后以休克分组作为状态标量,对组间具有统计学差异的指标进行ROC曲线分析,得出最佳诊断切点,计算诊断指标的SEN、SPE、PPV、NPV及AUC,以评价各诊断指标的诊断价值。最后将通过Logistic回归将各CT诊断指标整合,建立联合CT诊断模型,得出模型方程,并采用归一变换法得到CT联合诊断新指标——CTSI (CT Shock Index, CT休克指数),代入创伤患者数据计算出CTSI后,以其结果作为新的预测指标绘制ROC曲线,以评估最终预测模型的诊断效能。结果：1.休克组(34人)与稳定组(29人)在性别组成、年龄、受伤至入院时间、受伤至行CT检查时间、平均住院天数和平均ICU天数等方面差异均无统计学意义(P0.05)。休克组死亡率显著高于稳定组(P0.001),并且休克组创伤患者平均输血量也显著大于稳定组(5986±6510ml vs 1083±2068ml, P0.001).休克组入院时HR、SBP, Hgb及Hct与稳定组比较差异无统计学意义(P0.05),但ISS及SI显著大于稳定组(30±8 vs 22±6, P0.001;1.17±0.37 vs 0.96±0.33, P=0.019)。血气分析指标方面,休克组血pH与稳定组之间无统计学差异(7.37±0.05 vs 7.35±0.05,P=0.019),而Lac显著高于稳定组(3.27±0.69 mmol/L vs 2.56±0.89 mmol/L, P=0.021), BE则显著低于稳定组(-3.67±2.66mmol/L vs 1.34±2.72mmol/L,P0.001);2.休克组患者IVC较稳定组比较有明显塌陷趋势,休克组IVC塌陷指数(T/AP)在4个层面上均显著大于稳定组(P0.05),其中休克组T/AP在IVC2最大(4.08±1.79),在IVC4层面最小(2.18±0.93)；休克组AO、SMA及SMV在其测量层面上所测得直径与稳定组相比差异均无统计学意义(P0.05)；3.CT增强扫描早期,休克组SMA的CT值显著低于稳定组(133.2±32.4HU vs 186.3±23.3HU, P=0.021),休克组AO及SMA的CT值与稳定组比较,差异均无统计学意义(P0.05)。而休克组IVC只在IVC1平面CT值显著高于稳定组(133.4±20.3HU vs 112.0±21.9HU, P=0.018)。在CT增强扫面延迟期,两组之间各腹部血管CT值之间差异均无统计学意义(P0.05)；4.CT增强扫描早期,休克组脾脏CT值显著低于稳定组(93±16HU vs 112±24HU, P=0.001),肾上腺CT值显著高于稳定组(153±35HU vs 131±24HU,P=0.007),而肝脏、胰腺、肾脏皮质、肾脏髓质与稳定组比较差异无统计学意义(P0.05)。增强扫描延迟期,休克组只有肾脏髓质CT值显著低于稳定组(193±57HU vs 228±53HU,P=0.014),而其他脏器CT值与稳定组比较差异无统计学意义(P0.05)；5.ROC曲线分析显示,在常规伤情评估及休克指标中,SI、ISS、Lac、BE的最佳诊断临界值分别为1.19、19.5分.2.75mmol/L及.2.88mmol/L,其中BE的AUC最大(0.866),其在最佳诊断临界值的SEN及SPE分别为88.2%和80.3%。而SI的AUC最小为0.688,其在最佳诊断临界值的SPE及SPE分别仅为55.9%和86.2%。在CT指标中,IVC塌陷指数(T/AP)、增强早期SMA、IVC、脾脏、肾上腺及延迟期肾髓质CT值的最佳诊断临界值分别为3.02.166HU.121HU.115HU、150HU、184HU。其中IVC塌陷指数(T/AP)的AUC最大为0.833,其在最佳诊断临界值的诊断SEN及SPE分别为73.5%和86.2%,而延迟期肾髓质CT值的AUC最小为0.677,其在最佳诊断临界值的SEN及SPE分别为47.1%和82.8%。6.整合六个CT指标得出CTSI方程表达式：CTSI=X1-0.040X2+0.254X3-0.331X4+0.455X5-0.196X6(其中X1代表IVC塌陷指数(T/AP),X2代表增强早期SMA的CT值,X3代表增强早期IVC的CT值,X4代表增强早期脾脏CT值,X5代表增强早期肾上腺CT值,X6代表增强延迟期肾脏髓质CT值)。通过ROC曲线分析,求得CTSI的最佳诊断临界值为21.235,AUC为0.9038,其SEN和SPE分别为92.1%和90.3%,总体预测准确度为91.7%。结论：1.休克组患者在入院时HR、SBP、Hgb及Hct与稳定组比较差异无统计学意义,而休克组患者具有比稳定组更高的ISS、SI、Lac及更低的BE；2.通过量化和比较稳定组与休克组患者的CT影像学数据,发现下腔静脉塌陷、增强早期下腔静脉强化早现、肠系膜上动脉及脾脏低灌注、肾上腺过度强化以及延迟期肾脏髓质强化减弱等CT征象对预测严重创伤患者早期低血容量性休克的发生具有一定价值；3.通过数学统计方法科学整合多个CT影像学指标,创新性提出"CT休克指数”(CTSI)的新概念,其在最佳诊断临界值21.235时的预测敏感度和特异度分别为92.1%和90.3%,预测准确度达到91.7%,具有潜在的临床应用价值；4.本研究证实了某些腹部CT征象可以作为预测严重创伤患者休克发生的指标,为CT影像学技术应用于严重创伤患者早期血流动力学的评估提供了前期具体数据支持,为后续开展大规模的临床前瞻性试验奠定了基础。
[Abstract]:Background and purpose: trauma is becoming the first public hazard in the modern world. According to statistics, the number of people who die of trauma in the world is as high as 5 million every year, accounting for 9% of the total number of deaths in the world. On average, 9.5 people die by accidental trauma per minute. In China, the number of traumatic deaths per year is as high as 700 thousand, and fifth in China. The cause of death. The treatment of trauma, especially severe trauma, has been an important problem in the medical field today. The patients with severe trauma are complicated, critical and quick to make accurate assessment of the patient's injury. The key.CT of severe trauma treatment has an unparalleled advantage in all parts of the whole body, in severe trauma. However, the CT examination must transfer critically ill patients to the radiology department and have a potential risk. The sudden deterioration in the hemodynamic state of the patient during or shortly after examination is the key link in the occurrence of Hugh. When the circulation blood is insufficient, the early experience activates the sympathetic nervous system and the renin angiotensin system to reduce the blood supply such as the gastrointestinal, kidney, skin and other organs to ensure the heart and the blood supply of the brain. The abdominal organs are one of the first to be sacrificed in the early stage of the shock, while the decrease in the blood supply of the abdominal organs will be enhanced on the CT. There will be signs of collapse of the aorta and the inferior vena cava when the blood volume is further reduced or not enough to support the large circulation. Based on the above changes in the shock pathophysiology and some CT signs in patients with hypovolumetric shock, the multislice spiral CT is used for the hemodynamics of the trauma patients. The assessment of early treatment for severe trauma patients will be a new idea. The extensive use of multislice spiral CT in early treatment of severe trauma patients can not only effectively shorten the time from admission to deterministic treatment, but also provide a more comprehensive understanding of the blood perfusion and recovery of the organs. On the basis of this, we hope to quantify the CT data of the abdominal vessels and the parenchymal viscera CT data by analyzing the data of the abdominal vessels and the parenchymal viscera after the injury of the patients with severe trauma, and divide the patients into the stable group and the shock group on the basis of the shock events of the trauma patients. Compare the CT data of the two groups. CT imaging findings can be used to assess the hemodynamic status of traumatic patients and provide specific data support for the assessment of the hemodynamic evaluation of patients with severe trauma with multi-slice spiral CT. Research objects and methods: select the whole army war trauma center of the Department of field surgery, Daping Hospital, Third Military Medical University, January 2008 - 2011 1 Medical records and imaging data of patients with severe trauma in February were divided into stable and shock groups according to the patient's admission and course records of 63 patients in 24h after CT examination. Through the imaging diagnosis workstation, the patient's CT imaging data were read and the length measuring ruler in the CT imaging tool was used to measure the length measurement ruler. Blood vessel diameter, length and so on, using the CT value measuring tool to measure the CT value of the blood vessels and tissues and organs in each phase. Compare the differences between the two groups of patients by statistical method. Then the shock group is used as the state scalar, and the ROC curve analysis is used to analyze the statistical difference between the groups. The best diagnosis point is obtained and the diagnosis is calculated. SEN, SPE, PPV, NPV and AUC are used to evaluate the diagnostic value of each diagnostic index. Finally, the diagnostic indexes of CT are integrated by Logistic regression, a joint CT diagnostic model is established, the model equation is obtained, and a new CT joint diagnostic index, CTSI (CT Shock, shock index), will be obtained by the method of normalization transformation into the data meter of the trauma patients. After calculating CTSI, the ROC curve was drawn as a new predictor to evaluate the diagnostic efficiency of the final prediction model. Results: there was no significant difference in the gender composition, age, injury to admission time, injury to CT examination time, average days of hospitalization and the average number of ICU days in the 1. shock group (34 people) and the stable group (29 people). (P0.05) the mortality of the shock group was significantly higher than that in the stable group (P0.001), and the average blood transfusion in the shock group was also significantly greater than that in the stable group (5986 + 6510ml vs 1083 + 2068ml, P0.001). The shock group had no statistically significant difference (P0.05) with the group of HR, SBP, Hgb and Hct compared with the stable group (30 + 8 22 + 6). 01, 1.17 + 0.37 vs 0.96 + 0.33, P=0.019). There was no statistical difference between the blood pH and the stable group (7.37 + 0.05 vs 7.35 + 0.05, P=0.019), while Lac was significantly higher than that in the stable group (3.27 + 0.69 mmol/L vs 2.56 + 0.89 mmol/L, P=0.021), BE was significantly lower than that of the stable group (-3.67 + 0.33 + + 7.37). In the 2. shock group, there was a significant collapse trend in the IVC group than the stable group. The IVC collapse index (T/AP) in the shock group was significantly greater than that in the stable group (P0.05) in the shock group (P0.05). The shock group was the largest (4.08 + 1.79) in the shock group (4.08 + 1.79) and the smallest (2.18 + 0.93) in the IVC4 level. The diameter of the shock group AO, SMA and SMV in the shock group was different from the stable group. The CT value of SMA in shock group was significantly lower than that of stable group (133.2 + 32.4HU vs 186.3 + 23.3HU, P=0.021) at the early stage of enhanced scan in shock group. The CT value of AO and SMA in shock group was not statistically significant compared with that of the stable group (P0.05), but the value of shock group was significantly higher than that of the stable group (133.4 + 112 + 2) in shock group (133.4 + 112 + 2) 1.9HU, P=0.018). There was no significant difference between the CT values of the abdominal vessels between the two groups (P0.05). The spleen CT value of the shock group was significantly lower than that of the stable group (93 + 16HU vs 112 + 24HU, P=0.001) at the early stage of 4.CT enhanced scan, and the adrenal CT value was significantly higher than that of the stable group (153 + 131 + 131), and the liver and pancreas There was no significant difference between the renal cortex and the renal medulla in the stable group (P0.05). Only the renal medulla CT value in the shock group was significantly lower than that in the stable group (193 + 57HU vs 228 + 53HU, P=0.014) in the shock group, while the CT value of other organs was not statistically significant (P0.05) compared with the stable group (P0.05), and the 5.ROC curve analysis showed that in the routine injury evaluation. The best critical diagnostic values for SI, ISS, Lac, and BE were 1.19,19.5.2.75mmol/L and.2.88mmol/L, respectively, of which BE AUC was the largest (0.866), and the minimum critical value of SEN and SPE were 88.2% and 0.688 respectively. In the IVC collapse index (T/AP), the optimal critical value for the diagnosis of CT in the early SMA, IVC, spleen, adrenal and delayed renal medulla was 3.02.166HU.121HU.115HU, 150HU, 184HU., and IVC collapse index (T/AP) was 0.833, respectively, which was 73.5% and 86.2% at the best diagnostic critical value, respectively. The minimum of AUC is 0.677. The expression of CTSI equation is derived from the SEN and SPE of the best diagnostic critical value and the integration of six CT indexes of 47.1% and 82.8%.6., respectively. CTSI=X1-0.040X2+0.254X3-0.331X4+0.455X5-0.196X6 (X1 represents IVC collapse index (T/AP), X2 represents the enhancement of the early SMA value. The CT value of the spleen, X5 represents the early adrenal CT value, and X6 represents the CT value of the renal medulla in the delayed stage. Through the ROC curve analysis, the optimal critical value for the diagnosis of CTSI is 21.235, AUC is 0.9038, and SEN and SPE are 92.1% and 90.3% respectively. The overall prediction accuracy is 91.7%. junction. 1. shock group patients are in hospital when they are hospitalized. There was no statistical difference in the group, but the patients in the shock group had higher ISS, SI, Lac and lower BE than the stable group. 2. by quantifying and comparing the CT imaging data of the stable group and the shock group, it was found that the inferior vena cava collapsed, the early inferior vena cava was enhanced early, the upper intestinal artery and the spleen were low perfusion, and the adrenal adrenalation was overstrengthened. CT signs, such as renal medullary enhancement and weakening in the delayed stage, have a certain value in predicting early hypovolemic shock in patients with severe trauma; 3. a new concept of "CT shock index" (CTSI) is innovatively proposed by mathematical statistics and a new concept of "CTSI", which is sensitive to the best diagnostic critical value of 21.235. The degree and specificity are 92.1% and 90.3%, respectively, and the prediction accuracy is 91.7%, which has potential clinical value. 4. this study confirms that some abdominal CT signs can be used as an indicator for predicting shock occurrence in severe trauma patients, and provide early concrete for the application of CT imaging techniques to the assessment of early hemodynamics in patients with severe trauma. Data support laid the foundation for the follow-up of large-scale clinical prospective trials.
【学位授予单位】：第三军医大学
【学位级别】：博士
【学位授予年份】：2013
【分类号】：R641

【参考文献】