急性颈脊髓损伤继发低钠血症的临床分析

发布时间：2018-07-21 12:45

【摘要】：目的分析总结急性颈髓损伤后低钠血症的临床特征,并探究其发生的相关影响因素,可能的发生机制和治疗方式。方法研究对象为2013年1月~2016年5月我院骨科收治的颈椎外伤患者,排除严重影响水钠代谢的基础疾病以及合并颅脑外伤、胸腹部严重多发伤等重要脏器损伤后的颈脊髓损伤患者210例,颈髓损伤程度按美国脊髓损伤协会(ASIA)分级:完全性损伤28例(A级),不完全性损伤182例,其中B级18例,C级89例,D级75例;而选择颈椎外伤未并存颈髓损伤患者47例为对照组。动态监测血清钠、钾、氯、血清白蛋白等生化指标,血红蛋白、红细胞比容等血液细胞学指标,以及血压、心率,并获取所有数据。用单因素和多因素Logistic回归模型分析低钠血症的影响因素。并且根据监测结果和治疗反应对低钠血症的发生机制及治疗方法进行分析。结果115例急性颈髓损伤患者发生低钠血症(54.76%),其中56例130"f血钠135mmol/L即轻度低钠血症,50例120"f血钠130mmol/L即中度低钠血症,9例血钠120mmol/L即重度低钠血症;完全性损伤26例(92.86%),不完全性损伤89例(48.9%),其中B级83.33%(15/18),C级59.55%(53/89),D级28%(21/75)。对照组有3例患者发生血钠降低(6.38%),全为轻度低钠血症;颈髓损伤患者血钠均值(133.01±6.60)mmol/L,其中完全性损伤组(127.04±5.66)mmol/L,不完全性损伤组(133.92±6.26)mmol/L,均低于对照组(P0.01),且两者之间差异显著(P0.01)。颈髓损伤患者的血压、心率、血红蛋白以及红细胞比容与对照组比较,均存在明显差异,并且完全性颈髓损伤与不完全性损伤组之间也具有明显差异。单因素分析结果显示年龄、性别、脊髓损伤平面,甲强龙冲击以及血钾与低钠血症无明显相关关系,而脊髓损伤程度、合并感染、低蛋白血症、气管切开、红细胞比容以及血红蛋白是低钠血症非常显著的因素(P0.05);然而多因素分析结果提示仅由两个明确影响因素保留在Logistic回归模型中,分别是脊髓损伤程度,合并感染(P0.05)。结论低钠血症是常继发于颈脊髓损伤,发生率较高,其影响因素较多。颈髓严重损伤、合并感染是颈髓损伤患者发生低钠血症的主要危险因素。患者颈髓损伤程度越严重,往往血钠降低程度也十分严重。颈髓损伤后体内抗利尿激素(ADH)异常分泌,引起的低渗透性或高血容量性低钠血症也许为颈脊髓损伤继发低钠血症的主要发生机制之一。控制补液量和适度补钠是低钠血症安全有用的治疗措施。临床医师应着重关注颈髓损伤严重患者血钠情况,并积极预防感染,降低患者低钠血症发生率。
[Abstract]:Objective to analyze and summarize the clinical features of hyponatremia after acute cervical spinal cord injury, and to explore the related factors, possible mechanism and treatment of hyponatremia. Methods from January 2013 to May 2016, patients with cervical vertebra trauma treated in orthopedic department of our hospital were excluded from the basic diseases which seriously affected the metabolism of water and sodium and the patients with craniocerebral trauma. There were 210 cases of cervical spinal cord injury after severe multiple trauma of chest and abdomen. According to the American Association of Spinal Cord injury (Asia), the degree of cervical spinal cord injury was 28 cases of complete injury (Grade A) and 182 cases of incomplete injury. Among them, 18 cases were grade B, 89 cases were grade C and 75 cases were grade D, while 47 cases of cervical spinal cord injury without cervical spinal cord injury were selected as control group. Dynamic monitoring of serum sodium, potassium, chlorine, serum albumin and other biochemical indicators, hemoglobin, erythrocyte volume and other blood cytological indicators, as well as blood pressure, heart rate, and to obtain all the data. Univariate and multivariate logistic regression models were used to analyze the influencing factors of hyponatremia. The mechanism and treatment of hyponatremia were analyzed according to the monitoring results and therapeutic responses. Results among 115 patients with acute cervical spinal cord injury, hyponatremia occurred (54.76%). Among them, 56 (130 "f) had 135mmol / L of blood natrium (50 cases) with mild hyponatremia (50 cases) with 120" F "serum natrium 130 mmol / L (9 cases with moderate hyponatremia) with 120 mmol / L of serum sodium and 9 cases with severe hyponatremia. There were 26 cases of complete injury (92.86%) and 89 cases of incomplete injury (48.9%). Among them, B grade was 83.33% (15 / 18), C grade was 59.55% (53 / 89) and D grade was 28% (21 / 75). In the control group, the blood sodium decreased (6.38%) and the mean value of serum sodium was (133.01 卤6.60) mmol / L in the patients with cervical spinal cord injury, in which the complete injury group (127.04 卤5.66) mmol / L and the incomplete injury group (133.92 卤6.26) mmol / L were lower than the control group (P0.01), and the difference between the two groups was significant (P0.01). There were significant differences in blood pressure, heart rate, hemoglobin and erythrocyte volume between the patients with cervical spinal cord injury and the control group, and there was also significant difference between the complete cervical spinal cord injury group and the incomplete injury group. Univariate analysis showed that age, sex, spinal cord injury level, methylenolone shock and serum potassium were not significantly correlated with hyponatremia, while spinal cord injury degree, co-infection, hypoproteinemia, tracheotomy, RBC volume and hemoglobin were very significant factors of hyponatremia (P0.05); however, the results of multivariate analysis showed that only two definite influencing factors remained in Logistic regression model, which were the degree of spinal cord injury and co-infection (P0.05). Conclusion hyponatremia is often secondary to cervical spinal cord injury with a high incidence and many influencing factors. Severe cervical spinal cord injury and complicated infection are the main risk factors for hyponatremia in patients with cervical spinal cord injury. The more severe the cervical spinal cord injury, the more serious the decrease in blood sodium. Hypotonic or hypervolemic hyponatremia caused by abnormal secretion of ADH after cervical spinal cord injury may be one of the main mechanisms of hyponatremia secondary to cervical spinal cord injury. Control of fluid rehydration and moderate sodium supplementation are safe and useful therapeutic measures for hyponatremia. Clinicians should pay more attention to blood sodium in patients with severe cervical spinal cord injury, and actively prevent infection and reduce the incidence of hyponatremia.
【学位授予单位】：安徽医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R651.2

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