特重度成年烧伤患者休克期凝血特征及其预警价值的回顾性队列研究

马琪敏; 刘晓彬; 伍国胜; 侯文佳; 范晓明; 沈拓; 王康安; 朱峰

doi:10.3760/cma.j.cn501120-20200907-00402

特重度成年烧伤患者休克期凝血特征及其预警价值的回顾性队列研究

doi: 10.3760/cma.j.cn501120-20200907-00402

海军军医大学第一附属医院烧创伤重症监护病房,上海 200433

基金项目:

国家自然科学基金（81360292、81901960）

长海医院教学研究与改革重点项目（CHJG2019002）

国家重点研发计划"干细胞及转化研究"重点专项（2019YFA0110602）

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出版历程
- 收稿日期: 2020-09-07
- 网络出版日期: 2021-10-28
- 刊出日期: 2021-02-20

Retrospective cohort study on the coagulation characteristics of adult patients with extensively severe burn in shock stage and its alarming value

Intensive Care Unit of Burns and Trauma, the First Affiliated Hospital of Naval Medical University, Shanghai 200433, China

摘要

摘要:
目的研究特重度成年烧伤患者休克期凝血特征及其预警价值。方法将海军军医大学第一附属医院2014年1月—2019年12月收治的符合入选标准的37例特重度成年烧伤患者的病历资料进行回顾性队列研究，依据伤后60 d内预后将患者分为存活组23例[男17例、女6例，年龄41(31，51)岁]和死亡组14例[男11例、女3例，年龄50(43，58)岁]。统计2组患者的基本资料和休克期常规凝血指标凝血酶原时间(PT)、凝血酶时间(TT)、活化部分凝血酶原时间(APTT)、D-二聚体、纤维蛋白降解产物(FDP)、纤维蛋白原(FIB)、血小板计数(BPC)、国际标准化比值(INR)。对数据行Wilcoxon秩和检验、Fisher确切概率法检验，单因素和多因素logistic回归分析预后相关因素(α入选＝0.05、α排除＝0.1)，受试者操作特征(ROC)曲线分析筛选出风险因素。根据最佳阈值将所有患者再次分为高评分组和低评分组，Kaplan-Meier法行生存分析并进行Log-rank检验。结果死亡组患者的烧伤总面积明显大于存活组(
Z
＝2.980,
P
<0.01)，其余基本资料组间比较差异无统计学意义(
P
>0.05)。死亡组患者的PT [18.70(16.30，22.70)s]、APTT [46.45(41.00，57.10)s]和INR[1.55(1.30，1.96)]均明显高于存活组[16.10(14.30，16.90)s、40.80(36.20，42.80)s、1.30(1.10，1.40)，
Z
＝2.540、2.330、2.300，
P
<0.05]，其余资料组间比较差异无统计学意义(
P
>0.05)。单因素logistic回归分析显示，烧伤总面积、PT、APTT为特重度成年烧伤患者伤后60 d内死亡的相关因素(比值比＝1.190、1.214、1.109，95%置信区间＝1.053～1.346、1.008～1.461、1.012～1.215，
P
<0.05或
P
<0.01)，FDP与INR为特重度成年烧伤患者伤后60 d内死亡的潜在相关因素(比值比＝1.040、4.559，95%置信区间＝0.998～1.083、0.918～22.641，
P
<0.1)。多因素logistic回归建立aptt＋fdp＋烧伤总面积模型、aptt＋fdp模型。roc曲线分析显示，aptt＋fdp＋烧伤总面积模型评分的曲线下面积(auc)为0.944(95%置信区间＝0.873～1.000)，高于aptt＋fdp模型评分的auc -0.879="">-0.879 4)生存比明显低于低评分组(最佳阈值<-0.879 4)，
χ
²＝27.090,
P
<0.01。>-0.879 4的特重度成年烧伤患者，死亡风险显著增加。
- 烧伤 /
- 休克 /
- 凝血 /
- 预警
Abstract:
Objective To study the coagulation characteristics of adult patients with extensively severe burn in shock stage and its alarming value. Methods Retrospective cohort study was performed on medical records of 37 adult patients with extensively severe burn who were admitted to the First Affiliated Hospital of Naval Medical University from January 2014 to December 2019 and met the inclusion criteria. The patients were divided into survival group (
n
=23, 17 males and 6 females, aged 41 (31, 51) years) and death group (
n
=14, 11 males and 3 females, aged 50 (43, 58) years) according to the prognosis of within 60 d after burn. Basic data of patients in the two groups and their routine coagulation indexes during shock period including prothrombin time (PT), thrombin time, activated partial thromboplastin time (APTT), D-Dimer, fibrinogen degradation product (FDP), fibrinogen, platelet, and international normalized ratio (INR) were recorded. Data were statistically analyzed with Wilcoxon rank sum test and Fisher′s exact probability test, prognosis-related factors was analyzed with single factor and multivariate logistic regression analysis (α selected=0.05, α excluded=0.1), and receiver operating characteristic (ROC) curve analysis were established to screen out the risk factors. All the patients were grouped into high score group and low score group according to the optimal threshold value, Kaplan-Meier method was used for survival analysis and Log-rank test was performed between the two groups. Results Total burn surface area (TBSA) of patients in death group was obviously larger than that in survival group (
Z
=2.980,
P
<0.01), while there were no statistically significant difference in the other indexes between the two groups (
P
>0.05). Compared with those in survival group (16.10 (14.30, 16.90) s, 40.80 (36.20, 42.80) s, 1.30 (1.10, 1.40)), PT (18.70 (16.30, 22.70) s), APTT (46.45 (41.00, 57.10) s) and INR (1.55 (1.30, 1.96)) of patients in death group were significantly increased (
Z
=2.540, 2.330, 2.300,
P
<0.05), there were no statistically significant difference in the other indexes between the two groups (
P
>0.05). Single factor logistic regression analysis showed TBSA, PT, and APTT were factors related to death of adult patients with extensively severe burn within 60 d after burn (odds ratio (OR)=1.190, 1.214, 1.109, 95% confidence interval (CI)=1.053-1.346, 1.008-1.461, 1.012-1.215,
P
<0.05 or
P
<0.01). FDP and INR were potential factors related to death of adult patients with extensively severe burn within 60 d after burn (OR=1.040 and 4.559, 95% CI =0.998-1.083 and 0.918-22.641,
P
<0.1). Multivariate logistic stepwise regression was used to build models of APTT+ FDP+ TBSA and APTT+ FDP. Area under the curve (AUC) of APTT+ FDP+ TBSA model score was 0.944 (95% CI= 0.873-1.000), which was higher than AUC of APTT+ FDP model score (0.843, 95% CI=0.713-0.973) by ROC curve analysis. Optimal threshold value of APTT+ FDP+ TBSA model score was -0.879 4 with sensitivity of 100% (95% CI=100%-100%) and specificity of 87% (95% CI=74%-100%). Survival ratio of patients in high score group with optimal threshold value higher than -0.879 4 was significantly lower than that in low score group with optimal threshold value lower than -0.879 4,
χ
²=27.090,
P
<0.01. Conclusions The coagulation state of adult patients with extensively severe burn in shock stage is characterized with procoagulant and hemostatic dysfunctions accompanied by enhanced fibrinolytic activity. The risk of death is significantly increased in adult patients with extensively severe burn with APTT+ FDP+ TBSA model score higher than -0.879 4.
- Burns /
- Shock /
- Coagulation /
- Alarming