Analysis of the clinical characteristics and risk factors of postoperative atrial fibrillation in patients with critical burns
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摘要:
目的 探讨危重烧伤并发术后心房颤动（POAF）患者的临床特征并分析其危险因素。 方法 采用回顾性病例系列研究方法。2017年1月—2021年12月，暨南大学医学院附属广州红十字会医院收治符合入选标准的227例危重烧伤成年患者，其中男173例、女54例，年龄19~83（43±14）岁。收集患者入院年份，并计算各年份中并发POAF患者所占百分比。根据患者是否并发POAF，将其分为POAF组（17例）和非POAF组（210例），收集POAF组患者每次并发POAF前的手术方式、手术时长、术中失血量及POAF的发生时间和次数，术后患者体温、血压、血红蛋白、血糖、血乳酸、脓毒症及电解质情况，POAF类型、持续时间及处理方式等资料；收集并分析2组患者年龄、性别、受伤原因、烧伤总面积、Ⅲ度烧伤面积，入院时急性生理学和慢性健康状况评价Ⅱ（APACHEⅡ）评分、脓毒症相关性器官功能衰竭评价（SOFA）评分，合并高血压、糖尿病、其他类型心律失常等基础性疾病及脓毒症等一般资料情况；收集并分析2组患者机械通气时间、手术次数、住烧伤重症监护病房（BICU）时间等影响预后的因素和病死率。对数据行独立样本t检验、Mann-Whitney U检验、χ2检验或Kruskal-Wallis H检验。对2组比较中差异有统计学意义的一般资料的数据，行多因素logistic回归分析并筛选影响227例危重烧伤患者发生POAF的独立危险因素。 结果 2017—2021年危重烧伤患者并发POAF的百分比呈逐年上升趋势。POAF组患者并发POAF前的手术方式以四肢切削痂术为主、手术时长（3.5±1.2）h、术中失血量（365±148）mL。POAF组患者并发POAF的时间多集中于伤后1周内的术后6 h内。POAF组患者共并发POAF 25次，其中大部分患者仅发生1次；POAF发生时，患者多合并有低体温、贫血、高血糖、高血乳酸、脓毒症以及电解质紊乱，较少患者合并低血压；POAF的持续时间为（5±3）h，均为阵发性心房颤动；多数的POAF经胺碘酮干预后复律为窦性心律。2组患者均以火焰烧伤为主，其性别、年龄及入院时SOFA评分均相近（P>0.05）；POAF组患者入院时APACHEⅡ评分、烧伤总面积、Ⅲ度烧伤面积、脓毒症及合并糖尿病、高血压及其他类型心律失常的发生比例均明显高于/大于非POAF组（t=3.47，χ2值分别为7.44、10.86、12.63、14.65、6.49、7.52，P<0.05或P<0.01）。Ⅲ度烧伤面积、合并其他类型心律失常及脓毒症均为227例危重烧伤患者并发POAF的独立危险因素（比值比分别为4.45、0.04、3.06，95%置信区间分别为2.23~8.87、0.01~0.22、1.77~5.30，P<0.01）。与非POAF组相比，POAF组患者机械通气时间及住BICU时间均显著延长，手术次数明显增多，病死比例显著升高（Z=3.89，Z=2.57，t=3.41，χ2=3.72，P<0.05或P<0.01）。 结论 POAF为危重烧伤患者术后较常见并发症，其发生率呈逐年升高趋势，严重影响患者预后。Ⅲ度烧伤面积、合并其他类型心律失常及脓毒症均是危重烧伤患者并发POAF的高危因素。 Abstract:Objective To investigate the clinical characteristics and risk factors of postoperative atrial fibrillation (POAF) in patients with critical burns. Methods A retrospective case series study was conducted. From January 2017 to December 2021, two hundred and twenty-seven critically burned aldult patients who met the inclusion criteria were admitted to Guangzhou Red Cross Hospital of Jinan University, including 173 males and 54 females, aged 19-83 (43±14) years. The admission years of patients were collected, and the percentage of patients complicated with POAF in each year was calculated. According to whether the patients were complicated with POAF or not, they were divided into POAF group (n=17) and non-POAF group (n=210). Following data were collected in patients in POAF group, including operation methods, duration of operation, intraoperative blood loss before occurrence of POAF each time, occurrence time and times of POAF, postoperative body temperature, blood pressure, hemoglobin, blood glucose, blood lactate, sepsis, and electrolyte, and type, duration, and treatment of POAF. General data of patients in the two groups including age, gender, burn reason, total burn area, full-thickness burn area, acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) and sepsis-related organ failure evaluation (SOFA) scores on admission, combined with underlying diseases (hypertension, diabetes, and other types of arrhythmias), and sepsis were collected and analyzed. The mortality and factors influencing the prognosis of patients in the two groups such as mechanical ventilation time, operations times, and burn intensive care unit (BICU) length of stay were also collected and analyzed. Data were statistically analyzed with independent sample t test, Mann-Whitney U test, chi-square test or Kruskal-Wallis H test. The multivariate logistic regression analysis was performed on the general data with statistically significant differences between the two groups, and the independent risk factors influencing the onset of POAF in 227 patients with critical burns were screened. Results From 2017 to 2021, the percentage of critically burned patients complicated with POAF increased year by year. In POAF group, eschar debridement in limbs was the main surgical procedure prior to POAF complication, with the operation time of (3.5±1.2) h and the intraoperative blood loss volume of (365±148) mL.The POAF occurred 25 times in total in patients of POAF group, mostly within one week after the injury and within 6 hours after the operation with most of these patients having POAF only once. When POAF happened, the patients were often complicated with hypothermia, anemia, hyperglycemia, high blood lactate, sepsis, and electrolyte disturbance, and few patients had complications of hypotension. The POAF lasted (5±3) h, with all being paroxysmal atrial fibrillation, and most of POAF patients were reverted to sinus rhythm after amiodarone intervention. Most patients in the two groups suffered from flame burn, and the gender, age, and SOFA score on admission of patients in the two groups were similar (P>0.05); the APACHEⅡ score on admission, total burn area, full-thickness burn area, incidence proportion of sepsis, combined with diabetes and hypertension and other types of arrhythmias of patients in POAF group were significantly higher or larger than those in non-POAF group (t=3.47, with χ2 values of 7.44, 10.86, 12.63, 14.65, 6.49, and 7.52, respectively, P<0.05 or P<0.01). The full-thickness burn area, combined with other types of arrhythmias, and sepsis were the independent risk factors for POAF in 227 critically burned patients (with odds ratios of 4.45, 0.04, and 3.06, respectively, with 95% confidence intervals of 2.23-8.87, 0.01-0.22, and 1.77-5.30, respectively, P<0.01). Compared with those in non-POAF group, the mechanical ventilation time, BICU length of stay, number of operations, and mortality rate of patients in POAF group were significantly increased (Z=3.89, Z=2.57, t=3.41, χ2=3.72, P<0.05 or P<0.01). Conclusions POAF is a common postoperative complication in critically burned patients, and the incidence is increasing year by year, which seriously affects the prognosis of patients. The full-thickness burn area together with other types of arrhythmias and sepsis are the high-risk factors for POAF complication in patients with critical burns. -
Key words:
- Burns /
- Atrial fibrillation /
- Postoperative complications /
- Intensive care units /
- Risk factors
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参考文献
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表1 2组危重烧伤患者入院时一般资料比较
组别 例数 性别（例） 年龄（岁， 烧伤总面积（例） Ⅲ度烧伤面积（例） 男 女 30%~49%TBSA 50%~79%TBSA ≥80%TBSA <30%TBSA 30%~49%TBSA 50%~79%TBSA ≥80%TBSA POAF组 17 13 4 48±15 1 8 8 2 4 6 5 非POAF组 210 160 50 43±14 76 82 52 80 63 49 18 统计量值 χ2<0.01 t=1.79 χ2=7.44 χ2=10.86 P值 1.000 0.073 0.024 0.012 注：POAF为术后心房颤动，TBSA为体表总面积，APACHEⅡ为急性生理学和慢性健康状况评价Ⅱ，SOFA为脓毒症相关性器官功能衰竭评价 
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表2 多因素logistic回归分析227例危重烧伤患者并发POAF的独立危险因素
危险因素 回归系数 标准误 比值比 95%置信区间 P值 Ⅲ度烧伤面积（%TBSA） 1.49 0.35 4.45 2.23~8.87 <0.001 合并其他类型心律失常 -3.16 0.83 0.04 0.01~0.22 <0.001 脓毒症 1.12 0.28 3.06 1.77~5.30 <0.001 常量 -0.50 1.20 0.61 — 0.681 注：POAF为术后心房颤动，TBSA为体表总面积；“—”表示无此统计量值
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表3 2组危重烧伤患者预后因素比较
组别 例数 机械通气时间［d，M（Q1，Q3）］ 手术次数（次， 住BICU时间［d，M（Q1，Q3）］ 病死情况（例） POAF组 17 52（18，78） 5.6±2.1 64（45，94） 3 非POAF组 210 14（0，36） 3.6±2.5 41（29，61） 4 统计量值 Z=3.89 t=3.41 Z=2.57 χ2=3.72 P值 <0.001 0.001 0.010 <0.001 注：POAF为术后心房颤动，BICU为烧伤重症监护病房
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