D-二聚体对成年烧伤患者下肢深静脉血栓形成的预测价值

张伟; 刘宝辉; 夏成德; 丘宁宁; 娄季鹤; 狄海萍; 薛继东; 李刚

doi:10.3760/cma.j.cn501120-20201021-00444

D-二聚体对成年烧伤患者下肢深静脉血栓形成的预测价值

doi: 10.3760/cma.j.cn501120-20201021-00444

1.
郑州市第一人民医院介入科，郑州　　450004
2.
郑州市第一人民医院烧伤科，郑州　　450004

基金项目:

河南省医学科技攻关联合共建项目 LHGJ20191001

详细信息

通讯作者:
夏成德，Email：xiachengde@tom.com

计量
- 文章访问数: 250
- HTML全文浏览量: 58
- PDF下载量: 62
- 被引次数: 0
出版历程
- 收稿日期: 2020-10-21

Predictive value of D-dimer for deep venous thrombosis of lower extremity in adult burn patients

1.
Department of Interventional Radiology, Zhengzhou First People′s Hospital, Zhengzhou 450004, China
2.
Department of Burns, Zhengzhou First People′s Hospital, Zhengzhou 450004, China

Funds:

Joint Construction Project of Medical Science and Technology in Henan Province of China LHGJ20191001

More Information

Corresponding author: Xia Chengde, Email: xiachengde@tom.com

摘要

摘要: 目的探讨D-二聚体对成年烧伤患者并发下肢深静脉血栓形成（DVT）的预测价值。方法采用回顾性病例系列研究方法。收集2015年1月1日—2019年12月31日郑州市第一人民医院烧伤科收治的符合入选标准的3 861例成年烧伤患者的临床资料。按住院期间是否并发下肢DVT，将患者分为DVT组（77例）和非DVT组（3 784例），收集并比较2组患者的性别、年龄、烧伤总面积、D-二聚体水平，入院时有无下肢烧伤、吸入性损伤，住院期间是否并发脓毒症/感染性休克及有无股静脉留置中心静脉导管（CVC）、外科手术史、输注浓缩红细胞。对数据行独立样本t检验、Mann-Whitney U检验、χ²检验。选取组间比较差异具有统计学意义的指标进行多因素logistic回归分析，筛选3 861例成年烧伤患者并发下肢DVT的独立危险因素。绘制独立危险因素预测3 861例成年烧伤患者并发下肢DVT的受试者操作特征（ROC）曲线，计算曲线下面积（AUC）、最佳阈值及最佳阈值下的敏感度、特异度。采用Delong检验对AUC的质量进行比较，采用χ²检验对最佳阈值下的敏感度和特异度进行比较。结果 2组患者性别及住院期间脓毒症/感染性休克发生情况、外科手术史比较，差异均无统计学意义（P>0.05）；2组患者年龄、烧伤总面积、D-二聚体水平，入院时下肢烧伤情况、吸入性损伤情况，住院期间股静脉留置CVC和输注浓缩红细胞情况比较，差异均有统计学意义（t=-8.17，Z值分别为-5.04、-10.83，χ²值分别为21.83、5.37、7.75、4.52，P<0.05或P<0.01）。多因素logistic回归分析显示，年龄、烧伤总面积和D-二聚体水平均是3 861例成年烧伤患者并发下肢DVT的独立危险因素（比值比分别为1.05、1.02、1.14，95%置信区间分别为1.04~1.06、1.00~1.03、1.10~1.20，P<0.05或P<0.01）。年龄、烧伤总面积和D-二聚体水平预测3 861例成年烧伤患者并发下肢DVT的ROC的AUC分别为0.74、0.67、0.86（95%置信区间分别为0.68~0.80、0.60~0.74、0.83~0.89，P值均<0.01），最佳阈值分别为50.5岁、10.5%体表总面积、1.845 mg/L，最佳阈值下的敏感度分别为71.4%、70.1%、87.0%，最佳阈值下的特异度分别为66.8%、67.2%、72.9%。D-二聚体水平的AUC质量及最佳阈值下的敏感度、特异度均优于年龄（z=3.29，χ²值分别为284.91、34.25，P<0.01）和烧伤总面积（z=4.98，χ²值分别为326.79，29.88，P<0.01），年龄、烧伤总面积间的AUC质量及最佳阈值下的敏感度、特异度均相近（P>0.05）。结论 D-二聚体水平是成年烧伤患者并发下肢DVT的独立危险因素，其AUC质量及最佳阈值下的敏感度、特异度优于年龄和烧伤总面积，对成年烧伤患者并发下肢DVT具有较好预测价值。
- 烧伤 /
- 下肢 /
- 静脉血栓形成 /
- 预测 /
- D-二聚体
Abstract: Objective To investigate the predictive value of D-dimer for deep venous thrombosis (DVT) of lower extremity in adult burn patients. Methods A retrospective case series study was conducted. The clinical data of 3 861 adult burn patients who met the inclusion criteria and were admitted to the Department of Burns of Zhengzhou First People's Hospital from January 1, 2015 to December 31, 2019 were collected. The patients were divided into DVT group (n=77) and non-DVT group (n=3 784) according to whether DVT of lower extremity occurred during hospitalization or not. Data of patients in the two groups were collected and compared, including the gender, age, total burn area, D-dimer level, with lower limb burn and inhalation injury or not on admission, with sepsis/septic shock, femoral vein indwelling central venous catheter (CVC), history of surgery, and infusion of concentrated red blood cells or not during hospitalization. Data were statistically analyzed with independent sample t test, Mann-Whitney U test, and chi-square test. The indicators with statistically significant differences between the two groups were analyzed with multivariate logistic regression analysis to screen the independent risk factors for DVT of lower extremity in 3 861 adult burn patients. The receiver operating characteristic (ROC) curve of the independent risk factors predicting DVT of lower extremity in 3 861 adult burn patients were drawn, and the area under the curve (AUC), the optimal threshold value, and the sensitivity and specificity under the optimal threshold value were calculated. The quality of the AUC was compared by Delong test, and the sensitivity and specificity under the optimal threshold value were compared using chi-square test. Results There were no statistically significant differences in gender, occurrence of sepsis/septic shock or history of surgery during hospitalization between patients in the two groups (P>0.05), while there were statistically significant differences in age, total burn area, D-dimer level, lower limb burn and inhalation injury on admission, and femoral vein indwelling CVC and infusion of concentrated red blood cells during hospitalization between patients in the two groups (t=-8.17, with Z values of -5.04 and -10.83, respectively, χ²values of 21.83, 5.37, 7.75, and 4.52, respectively, P<0.05 or P<0.01). Multivariate logistic regression analysis showed that age, total burn area, and D-dimer level were the independent risk factors for DVT of lower extremity in 3 861 adult burn patients (with odds ratios of 1.05, 1.02, and 1.14, respectively, 95% confidence intervals of 1.04-1.06, 1.00-1.03, and 1.10-1.20, respectively, P<0.05 or P<0.01). The AUCs of ROC of age, total burn area, and D-dimer level for predicting DVT of lower extremity in 3 861 adult burn patients were 0.74, 0.67, and 0.86, respectively (with 95% confidence intervals of 0.68-0.80, 0.60-0.74, and 0.83-0.89, respectively, P values<0.01), the optimal threshold values were 50.5 years old, 10.5% total body surface area, and 1.845 mg/L, respectively, the sensitivity under the optimal threshold values were 71.4%, 70.1%, and 87.0%, respectively, and the specificity under the optimal threshold values were 66.8%, 67.2%, and 72.9%, respectively. The AUC quality and sensitivity and specificity under the optimal threshold value of D-dimer level were significantly better than those of age (z=3.29, with χ² values of 284.91 and 34.25, respectively, P<0.01) and total burn area (z=4.98, with χ² values of 326.79 and 29.88, respectively, P<0.01), while the AUC quality and sensitivity and specificity under the optimal threshold values were similar between age and total burn area (P>0.05). Conclusions D-dimer level is an independent risk factor for DVT of lower extremity in adult burn patients, its AUC quality and sensitivity and specificity under the optimal threshold value are better than those of age and total burn area, and it has good predictive value for DVT of lower extremity in adult burn patients.
- Burns /
- Lower extremity /
- Venous thrombosis /
- Forecasting /
- D-dimer
张伟：设计研究、实施研究、撰写论文；刘宝辉：论文撰写、经费支持；夏成德：研究指导、论文修改、经费支持；丘宁宁、狄海萍、薛继东、李刚：实施研究、采集数据、分析/解释数据；娄季鹤：支持性贡献

所有作者均声明不存在利益冲突

HTML全文

1 3种独立危险因素预测3 861例成年烧伤患者并发下肢深静脉血栓形成的受试者操作特征曲线

下载: 全尺寸图片幻灯片

表1 2组成年烧伤患者临床资料比较

组别	例数	性别［例（%）］		年龄（岁，x¯±s）	烧伤总面积［%TBSA，M（Q₁，Q₃）］	下肢烧伤［例（%）］		股静脉留置CVC［例（%）］
组别	例数	男	女	年龄（岁，x¯±s）	烧伤总面积［%TBSA，M（Q₁，Q₃）］	有	无	有	无
非DVT组	3 784	2 508（66.3）	1 276（33.7）	44±16	7.00（4.00，17.00）	1 737（45.9）	2 047（54.1）	241（6.4）	3 543（93.6）
DVT组	77	45（58.4）	32（41.6）	59±17	16.00（8.00，45.00）	56（72.7）	21（27.3）	11（14.3）	66（85.7）
统计量值		χ²=2.07		t=-8.17	Z=-5.04	χ²=21.83		χ²=7.75
P值		0.150		<0.001	<0.001	<0.001		0.016
注：DVT为深静脉血栓形成，TBSA为体表总面积，CVC为中心静脉导管；DVT组、非DVT组D-二聚体水平分别为诊断DVT时的水平、住院期间检测的最高水平；股静脉留置CVC、脓毒症/感染性休克、外科手术史及输注浓缩红细胞情况为住院期间统计，其余指标为入院时统计

下载: 导出CSV

表2 3 861例成年烧伤患者并发下肢DVT的多因素logistic回归分析结果

因素	偏回归系数	标准误	比值比	95%置信区间	P值
年龄（岁）	0.05	0.01	1.05	1.04~1.06	<0.001
烧伤总面积（%TBSA）	0.02	0.01	1.02	1.00~1.03	0.021
下肢烧伤情况	0.23	0.31	1.26	0.68~2.33	0.461
股静脉留置CVC情况	-0.68	0.46	0.50	0.20~1.25	0.138
吸入性损伤情况	0.55	0.30	1.73	0.95~3.15	0.071
D-二聚体水平（mg/L）	0.13	0.02	1.14	1.10~1.20	<0.001
输注浓缩红细胞情况	0.44	0.30	1.55	0.87~2.77	0.139
注：DVT为深静脉血栓形成，TBSA为体表总面积，CVC为中心静脉导管

下载: 导出CSV

表3 3种独立危险因素预测3 861例成年烧伤患者并发下肢深静脉血栓形成的受试者操作特征曲线的曲线下面积质量及最佳阈值下敏感度和特异度比较

对比因素	曲线下面积					敏感度		特异度
对比因素	曲线下面积差值	标准误	95%置信区间	z值	P值	χ²值	P值	χ²值	P值
D-二聚体与年龄	0.12	0.04	0.05~0.19	3.29	0.001	284.91	<0.001	34.25	<0.001
D-二聚体与烧伤总面积	0.19	0.04	0.12~0.27	4.98	<0.001	326.79	<0.001	29.88	<0.001
年龄与烧伤总面积	0.07	0.05	-0.02~0.17	1.49	0.137	1.57	0.211	0.15	0.699

下载: 导出CSV

参考文献(31)

[1]	AhujaRB,BansalP,PradhanGS,et al.An analysis of deep vein thrombosis in burn patients (part 1): comparison of D-dimer and Doppler ultrasound as screening tools[J].Burns,2016,42(8):1686-1692.DOI: 10.1016/j.burns.2016.08.005.
[2]	WahlWL,BrandtMM,AhrnsK,et al.The utility of D-dimer levels in screening for thromboembolic complications in burn patients[J].J Burn Care Rehabil,2002,23(6):439-443.DOI: 10.1097/00004630-200211000-00010.
[3]	中华医学会外科学分会血管外科学组.深静脉血栓形成的诊断和治疗指南(第三版)[J].中华普通外科杂志,2017,32(9):807-812.DOI: 10.3760/cma.j.issn.1007-631X.2017.09.032.
[4]	胡钦胜,聂涌,沈彬,等.通过接收者操作特征曲线确定全髋关节置换术后D-二聚体警戒值[J/CD].中华关节外科杂志:电子版,2017,11(4):359-363.DOI: 10.3877/cma.j.issn.1674-134X.2017.04.006.
[5]	孙亚萌,张建政,刘智.老年骨折患者下肢深静脉血栓形成的危险因素及动态D-二聚体对其预测价值的分析[J].中国骨与关节杂志,2020,9(6):419-424.DOI: 10.3969/j.issn.2095-252X.2020.06.005.
[6]	苗旺,张书语,申楠楠,等.神经重症脑梗死患者急性期不同时段深静脉血栓关键预测指标的研究[J].中华老年医学杂志,2020,39(9):1020-1024.DOI: 10.3760/cma.j.issn.0254-9026.2020.09.007.
[7]	王勇,张洪亮,罗勤,等.出院前血浆D-二聚体水平对急性肺血栓栓塞症患者复发静脉血栓栓塞风险的预测价值[J].中国循环杂志,2019,34(10):984-989.DOI: 10.3969/j.issn.1000-3614.2019.10.009.
[8]	WiegeleM,SchadenE,KochS,et al.Thrombin generation in patients with severe thermal injury[J].Burns,2019,45(1):54-62.DOI: 10.1016/j.burns.2018.09.020.
[9]	Van HarenRM,ThorsonCM,ValleEJ,et al.Hypercoagulability after burn injury[J].J Trauma Acute Care Surg,2013,75(1):37-43; discussion 43.DOI: 10.1097/TA.0b013e3182984911.
[10]	PannucciCJ, ObiAT, TimminsBH, et al. Venous thromboembolism in patients with thermal injury: a review of risk assessment tools and current knowledge on the effectiveness and risks of mechanical and chemical prophylaxis[J]. Clin Plast Surg, 2017, 44(3): 573-581. DOI: 10.1016/j.cps.2017.02.002.
[11]	BarretJP,DziewulskiPG.Complications of the hypercoagulable status in burn injury[J].Burns,2006,32(8):1005-1008.DOI: 10.1016/j.burns.2006.02.018.
[12]	“D-二聚体检测”急诊临床应用专家共识组.“D-二聚体检测”急诊临床应用专家共识[J].中华急诊医学杂志,2013,22(8):827-836.DOI: 10.3760/cma.j.issn.1671-0282.2013.08.003.
[13]	高尚法, 袁继宝, 朱自江, 等. 老年烧伤患者凝血功能的检测及其临床意义[J]. 甘肃医药, 2017, 36(9): 714-717. DOI: 10.15975/j.cnki.Gsyy.2017.09.004.
[14]	刘泽世,呼瑞,刘二军,等.高压电烧伤对SD大鼠血栓调节蛋白、蛋白C、蛋白S及D二聚体的早期影响[J].实用医学杂志,2016,32(1):37-40.DOI: 10.3969/j.issn.1006-5725.2016.01.012.
[15]	侯智慧, 王凌峰, 谷明娟. D-二聚体测定在兔深二度重度烫伤后并发急性肺栓塞诊断中的指导意义[J]. 内蒙古医科大学学报, 2018, 40(4): 340-343. DOI: 10.16343/j.cnki.issn.2095-512x.2018.04.005.
[16]	WahlWL,BrandtMM,AhrnsKS,et al.Venous thrombosis incidence in burn patients: preliminary results of a prospective study[J].J Burn Care Rehabil,2002,23(2):97-102.DOI: 10.1097/00004630-200203000-00005.
[17]	WibbenmeyerLA, HoballahJJ, AmelonMJ, et al. The prevalence of venous thromboembolism of the lower extremity among thermally injured patients determined by duplex sonography[J]. J Trauma, 2003, 55(6): 1162-1167. DOI: 10.1097/01.TA.0000057149.42968.1D.
[18]	张伟,张俊峰,王觅,等.成年烧伤患者深静脉血栓的发生情况及危险因素[J].中华烧伤杂志,2020,36(1):54-57.DOI: 10.3760/cma.j.issn.1009-2587.2020.01.010.
[19]	高凤英,习耀锋,郑明霞,等.烧伤患者深静脉血栓发生情况及其影响因素[J].中华烧伤杂志,2016,32(3):176-180.DOI: 10.3760/cma.j.issn.1009-2587.2016.03.010.
[20]	OgerE,BressolletteL,NonentM,et al.High prevalence of asymptomatic deep vein thrombosis on admission in a medical unit among elderly patients[J].Thromb Haemost,2002,88(4):592-597.
[21]	SatahooSS,ParikhPP,NaranjoD,et al.Are burn patients really at risk for thrombotic events?[J].J Burn Care Res,2015,36(1):100-104.DOI: 10.1097/BCR.0000000000000093.
[22]	BuscheMN,HeroldC,KrämerR,et al.Evaluation of prophylactic anticoagulation, deep venous thrombosis, and heparin-induced thrombocytopenia in 21 burn centers in Germany, Austria, and Switzerland[J].Ann Plast Surg,2011,67(1):17-24.DOI: 10.1097/SAP.0b013e31821bd4bc.
[23]	VermaakPV, D'AstaF, ProvinsJ, et al. Thomboprophylaxis in adult and paediatric burn patients: a survey of practice in the United Kingdom[J]. Burns, 2019, 45(6): 1379-1385. DOI: 10.1016/j.burns.2019.04.003.
[24]	SikoraS,PappA.Venous thromboembolism in burn patients is not prevented by chemoprophylaxis[J].Burns,2017,43(6):1330-1334.DOI: 10.1016/j.burns.2017.03.014.
[25]	王艳琼,黄建琼,许学文,等.标准化静脉血栓栓塞症预防方案在烧伤患者中的应用研究[J].中国修复重建外科杂志,2019,33(6):726-729.DOI: 10.7507/1002-1892.201812061.
[26]	PengH, YueL, GaoH, et al. Risk assessment of deep venous thrombosis and its influencing factors in burn patients[J]. J Burn Care Res, 2020, 41(1): 113-120. DOI: 10.1093/jbcr/irz121.
[27]	LiQ,BaT,WangLF,et al.Stratification of venous thromboembolism risk in burn patients by Caprini score[J].Burns,2019,45(1):140-145.DOI: 10.1016/j.burns.2018.08.006.
[28]	PannucciCJ,OsborneNH,WahlWL.Venous thromboembolism in thermally injured patients: analysis of the National Burn Repository[J].J Burn Care Res,2011,32(1):6-12.DOI: 10.1097/BCR.0b013e318204b2ff.
[29]	LiuA, MinasianRA, ManiagoE, et al. Venous thromboembolism chemoprophylaxis in burn patients: a literature review and single-institution experience[J]. J Burn Care Res, 2021, 42(1): 18-22. DOI: 10.1093/jbcr/iraa143.
[30]	TracyLM,CameronPA,SingerY,et al.Venous thromboembolism prophylaxis practice and its association with outcomes in Australia and New Zealand burns patients[J/OL].Burns Trauma,2021,9:tkaa044[2022-02-17].https://pubmed.ncbi.nlm.nih.gov/33654696/.DOI: 10.1093/burnst/tkaa044.
[31]	AhujaRB,BansalP,PradhanGS,et al.An analysis of deep vein thrombosis in burn patients (part II): a randomized and controlled study of thrombo-prophylaxis with low molecular weight heparin[J].Burns,2016,42(8):1693-1698.DOI: 10.1016/j.burns.2016.08.007.