严重烧伤伴吸入性损伤患者早期输液率对预后的影响及输液率的影响因素的多中心研究

黄圣宇; 马琪敏; 王玉松; 汤文彬; 褚志刚; 辛海明; 常刘; 李晓亮; 郭光华; 朱峰

doi:10.3760/cma.j.cn501225-20240409-00130

严重烧伤伴吸入性损伤患者早期输液率对预后的影响及输液率的影响因素的多中心研究

doi: 10.3760/cma.j.cn501225-20240409-00130

1.
南昌大学第一附属医院烧伤整形与创面修复医学中心,南昌　　330006
2.
同济大学附属东方医院重症医学科,上海　　200120
3.
海军军医大学第一附属医院烧创伤与创面修复科,上海　　200433
4.
暨南大学附属广州市红十字会医院烧伤整形科,广州　　510220
5.
武汉大学同仁医院暨武汉市第三医院烧伤科,武汉　　430060
6.
解放军第924医院烧伤整形科,桂林　　541002
7.
大连市第四人民医院烧伤整形科,大连　　116031
8.
郑州市第一人民医院烧伤科,郑州　　450004

基金项目:

国家重点研发计划 2019YFA0110601

浦东新区临床高峰学科 PWYgf2021-03

详细信息

通讯作者:
朱峰,Email：alexzhufeng0816@vip.sina.com

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出版历程
- 收稿日期: 2024-04-09

A multicenter study on the impact of the early infusion rate on prognosis and the factors of influencing the infusion rate in patients with severe burns and inhalation injury

1.
Medical Center of Burn Plastic and Wound Repair, the First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang330006, China
2.
Department of Critical Care Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai200120, China
3.
Department of Burn Trauma and Wound Repair, the First Affiliated Hospital of Naval Medical University, Shanghai200433, China
4.
Department of Burns and Plastic Surgery, Guangzhou Red Cross Hospital of Jinan University, Guangzhou510220, China
5.
Department of Burns, Tongren Hospital of Wuhan University ＆ Wuhan Third Hospital, Wuhan430060, China
6.
Department of Burns and Plastic Surgery, the 924th Hospital of PLA, Guilin541002, China
7.
Department of Burns and Plastic Surgery, the Fourth People's Hospital of Dalian, Dalian116031, China
8.
Department of Burns, Zhengzhou First People's Hospital, Zhengzhou450004, China

Funds:

National Key Research and Development Program 2019YFA0110601

Shanghai Pudong New Area Summit Construction Project PWYgf2021-03

More Information

Corresponding author: Zhu Feng, Email: alexzhufeng0816@vip.sina.com

摘要

摘要: 目的探讨严重烧伤伴吸入性损伤患者早期输液率对预后的影响及输液率的影响因素。方法该研究为回顾性病例系列研究。2015年1月—2020年12月,我国7个烧伤救治中心收治220例符合入选标准的严重烧伤伴吸入性损伤患者,其中大连市第四人民医院13例、海军军医大学第一附属医院26例、暨南大学附属广州市红十字会医院73例、解放军第924医院21例、南昌大学第一附属医院30例、武汉大学同仁医院暨武汉市第三医院30例、郑州市第一人民医院27例。患者中男163例、女57例,年龄为18~91岁。根据患者伤后28 d内存活情况,将患者分为存活组和死亡组,统计2组患者基本情况（性别、年龄、体重、体温等）、伤情（烧伤总面积、伤后入院时间等）、基础疾病情况、伤后液体复苏情况（伤后第1个24 h输液率、输注电解质溶液和胶体溶液比值等）、入院时实验室检查结果（血尿素氮、血肌酐、白蛋白、pH值、碱剩余、血乳酸、氧合指数等）、治疗情况（吸入氧体积分数、住院天数、进行肾脏替代治疗情况等）。采用单因素Cox回归分析调整协变量后,进行多因素Cox回归分析评估伤后第1个24 h输液率对患者死亡的影响。绘制伤后第1个24 h输液率预测死亡风险的受试者操作特征曲线,计算最大约登指数。按最大约登指数确定的伤后第1个24 h输液率预测死亡风险的界值[2.03 mL·kg^-1·%体表总面积（TBSA）^-1],将患者分为2组,比较2组患者死亡风险。分析前述临床资料与伤后第1个24 h输液率的相关性；采用单因素线性回归分析筛选自变量后,进行多因素线性回归分析筛选伤后第1个24 h输液率的独立影响因素。结果与存活组比较,死亡组患者年龄、烧伤总面积均明显增大（Z值分别为12.08、23.71,P<0.05）,伤后第1个24 h输液率、吸入氧体积分数与入院时血尿素氮、血肌酐、血乳酸（Z值分别为7.99、4.01、11.76、23.24、5.97,P<0.05）及进行肾脏替代治疗比例（P<0.05）均明显升高,入院时白蛋白、pH值、碱剩余均明显降低（t=2.72,Z值分别为8.18、9.70,P<0.05）,住院天数明显减少（Z=85.47,P<0.05）。调整协变量后,伤后第1个24 h输液率是患者死亡的独立影响因素（标准化风险比为1.69,95%置信区间为1.21~2.37,P<0.05）。输液率≥2.03 mL·kg^-1·%TBSA^-1组患者死亡风险明显高于输液率<2.03 mL·kg^-1·%TBSA^-1组（风险比为3.47,95%置信区间为1.48~8.13,P<0.05）。烧伤总面积、体重、吸入氧体积分数、体温、伤后入院时间、伤后第1个24 h输注电解质溶液和胶体溶液比值、入院时氧合指数<300与伤后第1个24 h输液率均存在明显相关性（r值分别为-0.192、-0.215、0.137、-0.162、-0.252、0.314,Z=4.48,P<0.05）。筛选自变量后,烧伤总面积、体重、伤后入院时间和入院时氧合指数<300均是伤后第1个24 h输液率的独立影响因素（标准化β值分别为-0.22、-0.22、-0.19、0.46,95%置信区间分别为-0.34~0.09、-0.34~0.10、-0.32~0.06、0.22~0.71,P<0.05）。结论严重烧伤伴吸入性损伤患者伤后第1个24 h输液率是死亡的独立影响因素,伤后第1个24 h输液率≥2.03 mL·kg^-1·%TBSA^-1时患者的死亡风险显著增加。烧伤总面积、体重、伤后入院时间和入院时氧合指数<300是严重烧伤伴吸入性损伤患者伤后第1个24 h输液率的独立影响因素。
- 烧伤 /
- 预后 /
- 影响因素分析 /
- 吸入性损伤 /
- 液体复苏 /
- 输液率
Abstract: Objective To investigate the impact of the early infusion rate on prognosis and the factors of influencing the infusion rate in patients with severe burns and inhalation injury. Methods This study was a retrospective case series research. From January 2015 to December 2020, 220 patients with severe burns and inhalation injury meeting the inclusion criteria were admitted to 7 burn treatment centers in China, including 13 cases in the Fourth People's Hospital of Dalian, 26 cases in the First Affiliated Hospital of Naval Medical University, 73 cases in Guangzhou Red Cross Hospital of Jinan University, 21 cases in the 924^th Hospital of PLA, 30 cases in the First Affiliated Hospital of Jiangxi Medical College of Nanchang University, 30 cases in Tongren Hospital of Wuhan University ＆ Wuhan Third Hospital, and 27 cases in Zhengzhou First People's Hospital. There were 163 males and 57 females, and their ages ranged from 18 to 91 years. The patients were divided into survival group and death group according to the survival within 28 d post injury. The following data of patients in the 2 groups were collected, including basic information (gender, age, body weight, body temperature, etc.), the injury characteristics (total burn area, post-injury admission time, etc.), the underlying diseases, the post-injury fluid resuscitation condition (infusion rate and ratio of infused electrolyte solution to colloid solution in the first 24 h post injury, etc.), the results of laboratory tests on admission (blood urea nitrogen, blood creatinine, albumin, pH value, base excess, blood lactate, oxygenation index, etc.), and treatment condition (inhaled oxygen volume fraction, hospitalization day, renal replacement therapy, etc.). After adjusting covariates using univariate Cox regression analysis, the multivariate Cox regression analysis was performed to evaluate the impact of infusion rate in the first 24 h post injury on patient death. The receiver operator characteristic curve for the infusion rate in the first 24 h post injury to predict the risk of death was plotted, and the maximum Youden index was calculated. Patients were divided into 2 groups according to the cutoff value (2.03 mL·kg^-1·% total body surface area (TBSA)^-1) for predicting risk of death by the infusion rate in the first 24 h post injury determined by the maximum Youden index, and the risk of death was compared between the 2 groups. The correlation between the previously mentioned clinical data and the infusion rate in the first 24 h post injury was analyzed; after the univariate linear regression analysis was used to screen the independent variables, the multivariate linear regression analysis was performed to screen the independent influential factors on the infusion rate in the first 24 h post injury. Results Compared with those in survival group, patients in death group had significantly higher age and total burn area (with Z values of 12.08 and 23.71, respectively, P<0.05), the infusion rate in the first 24 h post injury, inhaled oxygen volume fraction, and blood urea nitrogen, blood creatinine, blood lactic acid on admission (with Z values of 7.99, 4.01, 11.76, 23.24, and 5.97, respectively, P<0.05), and the proportion of patients treated with renal replacement therapy (P<0.05) were significantly higher, the albumin, pH value, and base excess on admission were significantly lower (t=2.72, with Z values of 8.18 and 9.70, respectively, P<0.05), and the hospitalization day was significantly reduced (Z=85.47, P<0.05). After adjusting covariates, the infusion rate in the first 24 h post injury was the independent influential factor on death (with standardized hazard ratio of 1.69, 95% confidence interval of 1.21-2.37, P<0.05). Patients in infusion rate ≥2.03 mL·kg^-1·%TBSA^-1 group had a significantly higher risk of death than those in infusion rate <2.03 mL·kg^-1·% TBSA^-1 group (with hazard ratio of 3.47, 95% confidence interval of 1.48-8.13, P<0.05). There was a significant correlation between total burn area, body weight, inhaled oxygen volume fraction, body temperature, post-injury admission time, the ratio of infused electrolyte solution to colloid solution in the first 24 h post injury, and oxygenation index <300 on admission and the infusion rate in the first 24 h post injury (with r values of -0.192, -0.215, 0.137, -0.162, -0.252, and 0.314, respectively, Z=4.48, P<0.05). After screening the independent variables, total burn area, body weight, post-injury admission time, and oxygenation index <300 on admission were the independent influential factors on the infusion rate in the first 24 h post injury (with standardized β values of -0.22, -0.22, -0.19, and 0.46, respectively, 95% confidence intervals of -0.34 to 0.09, -0.34 to 0.10, -0.32 to 0.06, and 0.22 to 0.71, respectively, P<0.05). Conclusions The infusion rate in the first 24 h post injury in patients with severe burns and inhalation injury is the independent factor of influencing death, and patients with infusion rate ≥2.03 mL·kg^-1·%TBSA^-1 in the first 24 h post injury have a significantly increased risk of death. The total burn area, body weight, post-injury admission time, and oxygenation index <300 on admission were the independent factors of influencing the infusion rate in the first 24 h post injury in patients with severe burns and inhalation injury.
- Burns /
- Prognosis /
- Root cause analysis /
- Inhalation injuries /
- Fluid resuscitation /
- Infusion rate
黄圣宇：提出研究主题,设计研究框架,采集、分析并解释数据,起草并修改文章；马琪敏、王玉松、汤文彬、褚志刚、辛海明、常刘、李晓亮：采集、分析数据,指导写作；郭光华：研究指导,对文章内容进行批判性审阅；朱峰：研究指导,论文审阅及修改,经费支持

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图 1 220例严重烧伤伴吸入性损伤患者伤后第1个24 h输液率和死亡风险非线性关系的限制性立方样条

注：红色实线表示不同输液率对应的风险比变化趋势,虚线为风险比为1的基线,实线背景有色区域为95%置信区间；TBSA为体表总面积

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图 2 220例严重烧伤伴吸入性损伤患者伤后第1个24 h输液率对死亡的预测价值。2A.受试者操作特征曲线；2B.Kaplan-Meier生存曲线

注：TBSA为体表总面积,实线背景有色区域为95%置信区间

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Table 1. 2组严重烧伤伴吸入性损伤患者基本情况与伤情及基础疾病情况比较

组别	例数	性别（例）		年龄[岁,M（Q₁,Q₃）]	体重[kg,M（Q₁,Q₃）]	伤后入院时间[h,M（Q₁,Q₃）]	烧伤总面积[%TBSA,M（Q₁,Q₃）]
组别	例数	男	女	年龄[岁,M（Q₁,Q₃）]	体重[kg,M（Q₁,Q₃）]	伤后入院时间[h,M（Q₁,Q₃）]	烧伤总面积[%TBSA,M（Q₁,Q₃）]
存活组	191	139	52	45.00（34.00,54.00）	65.00（60.00,75.00）	4.00（2.00,7.00）	63.00（50.00,82.50）
死亡组	29	24	5	56.00（46.00,62.00）	70.00（60.00,72.00）	4.00（2.00,6.00）	90.00（77.00,98.00）
统计量值		χ²=1.31		Z=12.08	Z=0.45	Z=0.62	Z=23.71
P值		0.253		<0.001	0.504	0.432	<0.001
注：TBSA为体表总面积；“—”表示无此项；1 mmHg=0.133 kPa

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Table 2. 2组严重烧伤伴吸入性损伤患者伤后液体复苏情况比较[M（Q₁,Q₃）]

组别	例数	院前输液量（mL）	伤后第1个24 h				伤后第2个24 h
组别	例数	院前输液量（mL）	输液率（mL·kg^-1·%TBSA^-1）	输入新鲜冰冻血浆量（mL）	输注电解质溶液和胶体溶液比值	尿量（mL·kg^-1·h^-1）	输液率（mL·kg^-1·%TBSA^-1）	输注电解质溶液和胶体溶液比值	尿量（mL·kg^-1·h^-1）
存活组	191	500.00（0,1 750.00）	1.97（1.63,2.43）	1 990（1 150, 3 000）	2.42（1.45,3.73）	1.18（0.80,1.70）	1.55（1.26,2.00）	2.33（1.47,3.66）	1.64（1.26,2.19）
死亡组	29	250.00（0,1 387.50）	2.49（2.04,3.30）	2 500（1 300, 3 000）	2.78（2.24,4.60）	0.99（0.81,1.39）	1.41（1.27,1.96）	2.28（1.10,3.65）	1.46（1.10,1.84）
Z值		0.45	7.99	1.38	1.63	1.77	0.14	0.17	3.07
P值		0.505	0.005	0.241	0.211	0.185	0.707	0.679	0.081
注：TBSA为体表总面积

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Table 3. 2组严重烧伤伴吸入性损伤患者治疗情况与入院时实验室检查结果比较

组别	例数	入院时接受机械通气（例）	吸入氧体积分数[%,M（Q₁,Q₃）]	住院天数[d,M（Q₁,Q₃）]	行肾脏替代治疗（例）	伤后第1次手术时间[d,M（Q₁,Q₃）]	血尿素氮[mmol/L,M（Q₁,Q₃）]
存活组	191	34	37.00（31.17,41.00）	48.00（30.00,75.00）	7	4.00（2.75,6.00）	6.30（4.95,7.40）
死亡组	29	4	41.00（33.00,45.76）	10.00（5.00,16.00）	7	4.00（3.75,5.25）	7.00（6.50,8.30）
统计量值		—	Z=4.01	Z=85.47	—	Z<0.01	Z=11.76
P值		0.595	0.047	<0.001	<0.001	0.977	<0.001
注：1 mmHg=0.133 kPa；“—”表示无此项；PaO₂为动脉血氧分压,SaO₂为动脉血氧饱和度,PaCO₂为动脉血二氧化碳分压

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Table 4. 220例严重烧伤伴吸入性损伤患者伤后第1个24 h输液率对死亡的影响的多因素Cox回归分析结果

多因素Cox回归模型	非标准化风险比（95%置信区间）	标准化风险比（95%置信区间）	P值
模型1	1.59（1.15~2.20）	1.51（1.13~2.01）	0.005
模型2	1.81（1.24~2.65）	1.69（1.21~2.37）	0.002
模型3	1.80（1.25~2.59）	1.68（1.22~2.32）	0.002
模型4	1.76（1.21~2.55）	1.65（1.19~2.29）	0.003
注：模型1为调整协变量前,模型2为调整单因素Cox回归分析筛选的协变量年龄、烧伤总面积、血肌酐、白蛋白、pH值、碱剩余、血乳酸后,模型3为调整逐步向后回归分析筛选的协变量年龄、烧伤总面积、血肌酐、碱剩余后,模型4为调整最小绝对值收缩和选择算法回归分析筛选的协变量年龄、烧伤总面积、血肌酐、pH值、碱剩余后

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Table 5. 220例严重烧伤伴吸入性损伤患者临床资料（连续性变量）和伤后第1个24 h输液率的相关性

变量	r值	P值
年龄（岁）	-0.064	0.348
烧伤总面积（%TBSA）	-0.192	0.004
体重（kg）	-0.215	0.001
平均动脉压（mmHg）	0.022	0.742
吸入氧体积分数（%）	0.137	0.042
脉搏（次/min）	0.054	0.428
体温（℃）	-0.162	0.016
血尿素氮（mmol/L）	0.080	0.239
血肌酐（mmol/L）	-0.034	0.615
白蛋白（g/L）	0.057	0.402
血钾（mmol/L）	-0.030	0.660
血钠（mmol/L）	0.126	0.062
血氯（mmol/L）	-0.003	0.960
pH值	-0.074	0.277
PaO₂（mmHg）	-0.056	0.406
SaO₂	-0.090	0.181
PaCO₂（mmHg）	0.084	0.216
碱剩余（mmol/L）	-0.014	0.832
血乳酸（mmol/L）	-0.131	0.053
血红蛋白（g/L）	0.021	0.751
伤后入院时间（h）	-0.252	<0.001
伤后第1个24 h输注电解质溶液和胶体溶液比值	0.314	<0.001
注：TBSA为体表总面积,PaO₂为动脉血氧分压,SaO₂为动脉血氧饱和度,PaCO₂为动脉血二氧化碳分压；1 mmHg=0.133 kPa；血尿素氮等实验室检查结果均是入院时的情况

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Table 6. 220例严重烧伤伴吸入性损伤患者临床资料（分类变量）和伤后第1个24 h输液率的相关性

变量	例数	输液率[ mL·kg^-1·%TBSA^-1,M（Q₁,Q₃）]	Z值	P值
性别
女	57	2.08（1.73,2.49）	0.65	0.419
男	163	1.98（1.64,2.50）	0.65	0.419
致伤原因
火焰烧伤	214	2.02（1.67,2.49）	0.08	0.782
热液烫伤	6	2.08（1.34,2.85）	0.08	0.782
入院时氧合指数<300
否	109	1.92（1.59,2.41）	4.48	0.036
是	111	2.12（1.73,2.75）	4.48	0.036
入院时机械通气
否	182	1.99（1.63,2.49）	0.61	0.367
是	38	2.10（1.74,2.72）	0.61	0.367
基础疾病
否	191	2.07（1.70,2.52）	1.99	0.160
是	29	1.78（1.50,2.36）	1.99	0.160
注：TBSA为体表总面积

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Table 7. 220例严重烧伤伴吸入性损伤患者伤后第1个24 h输液率影响因素的多因素线性回归分析阳性结果

变量	模型1			模型2			模型3			VIF值
变量	标准化β值	95%置信区间	P值	标准化β值	95%置信区间	P值	标准化β值	95%置信区间	P值	VIF值
烧伤总面积（%TBSA）	-0.22	-0.34~0.09	<0.001	-0.22	-0.34~0.09	<0.001	-0.22	-0.34~0.09	<0.001	1.10
体重（kg）	-0.22	-0.34~0.10	<0.001	-0.22	-0.34~0.10	<0.001	-0.23	-0.35~0.11	<0.001	1.02
伤后入院时间（h）	-0.19	-0.32~0.06	0.004	-0.19	-0.32~0.06	0.004	-0.21	-0.34~0.08	0.001	1.18
入院时氧合指数<300（例）	0.46	0.22~0.71	<0.001	0.46	0.22~0.71	<0.001	0.47	0.22~0.71	<0.001	1.30
注：TBSA为体表总面积,VIF为方差膨胀因子；模型1、2、3分别纳入单因素线性回归分析、逐步向后回归分析、最小绝对值收缩和选择算法回归分析筛选的影响伤后第1个24 h输液率的影响因素