影响急性创伤性凝血病预后相关因素的回归分析

发布时间：2018-04-08 15:18

本文选题：急性创伤性凝血病　切入点：预后　出处：《郑州大学》2017年硕士论文

【摘要】：目的急性创伤性凝血病在严重外伤患者的预后中起着重要作用,越来越受到急诊及重症医师的重视,因其发展机制尚未完全阐明,病理生理变化过程复杂多变,一直以来,影响其预后的相关因素尚未达成共识。本研究依托最新的《欧洲创伤诊疗指南》,针对有争议的相关因素,采用Logistic回归分析及Cox回归分析方法,进一步探讨影响急性创伤性凝血病患者预后的危险因素。方法(1)收集2015年2月—2016年12月在郑州大学第一附属医院收治的严重创伤患者896例,对符合急性创伤性凝血病诊断标准的80例患者纳入研究;(2)记录纳入研究患者的性别、年龄、创伤严重程度评分(ISS评分)、入院3小时平均基础体温、入院24h平均乳酸水平及碱缺失水平、入院72h内平均血糖波动度、是否输注高比例血液制品、是否应用氨甲环酸等指标,以及记录急性凝血病的确诊时间与凝血功能恢复正常的时间;(3)以急性创伤性凝血病的死亡率为因变量,以纳入的各相关因素为自变量,分别对其进行单因素及多因素的Logistic回归分析;(4)结合Logistic回归分析初筛结果,依据病情转归标准,对其达到转归标准所经历的时间进行Cox回归分析。(1)Logistic回归分析结果显示:急性创伤性凝血病患者的性别、年龄与预后无关;创伤严重程度评分(ISS评分)在单因素Logistic回归分析中无统计学意义,而在多因素Logistic回归分析中,结果有统计学意义(P=0.0420.05);在单因素Logistic回归分析中,入院3小时平均基础体温(P=0.0030.05)、入院24h平均乳酸水平(P=0.0120.05)、入院24h碱缺失水平(P=0.0370.05)均为影响创伤性凝血病患者预后的影响因素,而入院72h内平均血糖波动度、是否输注高比例血液制品、是否应用氨甲环酸在单因素Logistic回归分析中差异无统计学意义(P0.05),但是在多因素Logistic回归分析中,输注高比例血液制品(P=0.0080.05)及应用氨甲环酸(P=0.0130.05)是影响预后的危险因素,血糖波动度仍无统计学意义。(2)转归分析结果显示,对于创伤性凝血病患者,不同的入院3小时平均基础体温(T≥35℃、33℃≤T35℃、T33℃),其凝血功能恢复正常所经历的时间曲线,即转归曲线差异有统计学意义(Log-rank检验2χ=54.376,P=0.0120.05),同理,入院24h平均乳酸水平(Log-rank检验2χ=8.141,P=0.0040.05)、入院24h碱缺失水平(Log-rank检验2χ=14.587,P=0.0010.05)、是否输注高比例血液制品(Log-rank检验2χ=7.006,P=0.0080.05),其转归曲线差异均有统计学意义,而入院72h内平均血糖波动度及是否应用氨甲环酸其转归曲线差异不明显;而多变量Cox比例风险回归分析显示,入院3小时平均基础体温(RR=0.135,95%CI 0.078~0.233,P=0.021)、入院24小时乳酸水平(RR=0.249,95%CI 0.125~0.498,P=0.004)、入院24小时碱缺失水平(RR=0.258,95%CI 0.126~0.527,P=0.010)、入院72小时平均血糖波动幅度(RR=0.392,95%CI 0.227~0.677,P=0.001)、是否接受输注血液制品(RR=0.273,95%CI 0.157~0.475,P=0.023)、是否应用TXA(RR=0.467,95%CI 0.280~0.779,P=0.004)与病情转归有关。结果结论(1)性别、年龄不是影响急性创伤性凝血病患者预后的危险因素,在创伤性凝血病患者预后评估中,ISS评分的价值不高;入院极早期基础体温、酸碱平衡、血糖波动幅度、高比例成分输血、氨甲环酸是急性创伤性凝血病患者预后的独立影响因素。(2)维持入院3小时内平均基础体温大于35℃,控制入院72小时内平均血糖波动度小于3.9mmol/L,纠正酸碱失衡,急早期高比例成分输血及应用氨甲环酸可以明显缩短凝血功能恢复正常所需时间,减少其后期并发症的发生,促进病情早期向良性方向转归。
[Abstract]:Objective acute traumatic coagulopathy plays an important role in the prognosis of patients with severe trauma, more and more severe and emergency medical attention because of its development mechanism has not been fully elucidated, pathophysiological process is complex and changeable, has not yet reached a consensus, the related factors affecting the prognosis. This study is based on the new "European trauma guidelines >, according to the related factors of controversial, analysis using Logistic regression analysis and Cox regression, to further explore the risk factors influencing the prognosis of patients with acute traumatic coagulopathy. Methods (1) from February 2015 to December 2016 in 896 cases of severe trauma patients admitted to the First Affiliated Hospital of Zhengzhou University were included in the study, 80 patients with acute traumatic coagulation diagnostic criteria were included in the study; (2) record the patient's sex, age, injury severity score (ISS score), an average of 3 hours of admission The basal body temperature, admission 24h average level of lactic acid and alkali loss level within 72h after admission average blood glucose fluctuation, whether infusion of high proportion of blood products, whether the application of tranexamic acid and other indicators, and record the acute coagulopathy diagnosis time and coagulation function returned to normal time; (3) the dependent variable of acute traumatic coagulopathy the mortality rate, related factors included as independent variables, separately carried on the Logistic regression analysis of single factor and multi factor; (4) combined with Logistic regression analysis according to the results of screening, prognosis criteria, Cox regression analysis was conducted to reach to standard time. (1) the results of Logistic regression analysis display: acute traumatic coagulopathy in patients with gender, age and prognosis; injury severity score (ISS score) was not statistically significant in univariate Logistic regression analysis, and multivariate Logistic regression In the analysis, the results were statistically significant (P=0.0420.05); in the univariate Logistic regression analysis, 3 hours of admission average basal body temperature (P=0.0030.05), admission 24h (P=0.0120.05), the average level of lactic acid were 24h base deletion level (P=0.0370.05) factors are influence the prognosis of patients with traumatic blood disease, and the average 72h of admission the blood glucose fluctuation degree, a high proportion of the transfusion of blood products, whether the application of tranexamic acid was not statistically significant in the univariate regression analysis the difference of Logistic (P0.05), but in a multivariate Logistic regression analysis, a high proportion of blood products infusion (P=0.0080.05) and the application of tranexamic acid (P=0.0130.05) is the risk factors influencing the prognosis still, the blood glucose fluctuation was not statistically significant. (2) the outcome analysis showed that for patients with traumatic coagulopathy, different admission 3 hours average basal body temperature (T = 35 DEG C, 33 c c c = T35, T33), the coagulation The recovery time of normal curve through blood function, namely the outcome curve was statistically significant (Log-rank test 2 x =54.376, P=0.0120.05), in the same way, the average admission 24h lactate level (Log-rank test 2 x =8.141, P=0.0040.05), admission 24h base deficits (Log-rank test 2 x =14.587, P=0.0010.05), whether the infusion of high the proportion of blood products (Log-rank test 2 x =7.006, P=0.0080.05), the outcome curves were statistically significant difference, while the average blood glucose fluctuation within 72h after admission and whether the application of tranexamic acid in the development curve of the difference is not obvious; and multivariate Cox regression analysis showed that 3 hours of admission, the average temperature (RR=0.135,95%CI 0.078~0.233 P=0.021) 24 hours after admission, the levels of lactic acid (RR=0.249,95%CI 0.125~0.498, P=0.004), 24 hours of admission of alkali (RR=0.258,95%CI 0.126~0.527, P=0.010 deletion level), 72 hours of admission (average blood glucose fluctuation RR=0.392,95%CI 0.227~0.677, P=0.001), whether or not to accept the infusion of blood products (RR=0.273,95%CI 0.157~0.475, P=0.023 TXA (RR=0.467,95%CI), whether the application of 0.280~0.779, P=0.004) associated with disease outcome. Results and conclusions (1) gender, risk factors for the prognosis of patients with acute traumatic coagulopathy were not affected, in assessing the prognosis of patients with traumatic coagulopathy, ISS the value of the score is not high; at very early stage of basal body temperature, acid-base balance, blood glucose fluctuation, high proportion of blood component transfusion, tranexamic acid are independent prognostic factors in patients with acute traumatic coagulopathy. (2) to maintain the average temperature within 3 hours of admission is greater than 35 degrees, the average admission control of blood glucose fluctuation is less than 72 hours 3.9mmol/L, correcting acid-base imbalance, acute and early high proportion of component blood transfusion and application of tranexamic acid can significantly shorten the time required for normal blood clotting function, and reduce the post The occurrence of hair disease, promote the early stage of the disease to a benign direction.

【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R641

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