Impact of trauma integration treatment system on the mortality of patients with severe trauma
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摘要: 目的 定量评估一体化创伤救治体系对危重创伤患者救治质量的影响。 方法 从笔者单位创伤中心创伤数据库中提取并统计分析2010年1月—2012年12月笔者单位收治的符合入选标准的危重创伤患者以下数据:性别、年龄;入院后基本情况,包括收缩压、舒张压、腋温、心率、损伤严重程度评分(ISS)、急性生理与慢性健康评估Ⅱ(APACHEⅡ)评分、格拉斯哥昏迷评分、首日尿量;入院后首次生理生化检测指标值,包括pH值、剩余碱、PaCO2、PaO2、标准碳酸氢根离子、白细胞计数、中性粒细胞、Hb、血小板计数、白蛋白、尿素氮、乳酸、血糖、血钠;手术情况、ICU住院时间、主要并发症(感染、ARDS、MODS/MOF)发生情况、死亡情况。采用单因素分析筛选出与患者死亡显著相关的暴露因素,纳入多因素Logistic回归建立风险校正病死率模型,计算3年间患者调整病死率的观察数/预期数(O/E)比值,并且采用泊松分布计算出O/E比值的95%置信区间(CI)。对数据行Student
t 检验、Wilcox检验、χ 2检验、Fisher确切概率法检验。 结果 共纳入3年间536例危重创伤患者,其中男438例(81.72%)、女98例(18.28%)。3年间患者性别、年龄、入院后基本情况比较,差异无统计学意义(χ 2=0.16,t 值为0.05~104.50,W 值为0.008~104.500,P 值均大于0.05)。3年间患者入院后首次生理生化检查指标pH值、剩余碱、PaCO2、PaO2、Hb、血小板计数、血钠比较,差异均无统计学意义(t 值为0.80~29.10,W 值为0.110、5.450,P 值均大于0.05);标准碳酸氢根离子、白细胞计数、中性粒细胞、白蛋白、尿素氮、乳酸、血糖比较,差异均有统计学意义(t 值为1 542.00~500 000.00,W 值为637.000~500 000.000,P <0.05或P <0.01)。3年间患者的手术情况、ICU住院时间、主要并发症(感染、ARDS、MODS/MOF)发生情况比较,差异均无统计学意义(χ 2值为0.48~2.43,W =2.100,P 值均大于0.05)。2010、2011、2012年患者病死率分别为11.9%(19/159)、11.2%(21/187)、7.4%(14/190),呈下降趋势,但差异无统计学意义(χ 2=2.43,P >0.05)。3年间危重创伤患者死亡相关风险因素为患者年龄、ISS、APACHEⅡ评分、首日尿量、血小板计数、白蛋白和血钠。2010、2011、2012年患者调整病死率O/E比值(95%CI)分别为0.727(0.460~1.180)、0.718(0.460~1.230)、0.460(0.270~0.840),呈逐年下降趋势。 结论 一体化创伤救治体系有助于提高危重创伤患者救治质量。Abstract: Objective To quantitatively evaluate the treatment quality of trauma integration treatment system in the patients with severe trauma. Methods Records of patients with severe trauma hospitalized in our department from January 2010 to December 2012 were extracted from trauma database and analyzed, including gender, age, basic situation after admission [including systolic pressure, diastolic pressure, axillary temperature, heart rate, Injury Severity Score (ISS), Acute Physiology and Chronic Health Evaluation (APACHE) Ⅱ score, Glasgow Coma Score, and urine volume on the first day], the first time determination values of physiological and biochemical indexes after admission (including pH value, base excess, PaCO2, PaO2, standard bicarbonate ion, leucocyte count, neutrophile granulocyte, hemoglobin, platelet count, albumin, urea nitrogen, lactic acid, blood glucose, and blood sodium), surgical situation, length of ICU stay, occurrence of major complications [including infection, acute respiratory distress syndrome (ARDS), multiple organ dysfunction syndrome (MODS)/multiple organ failure (MOF)], and death. Single factor analysis was used to screen death-associated exposure factors, then the exposure factors were brought into multivariate Logistic regression to establish adjustment mortality models to calculate observation/expectation (O/E) ratio of adjustment mortality of patients in these three years, and Poisson distribution was used to calculate the 95% confidence interval (CI) of O/E ratio. Data were processed with Studentt test, Wilcox test, chi-square test and or Fisher's exact test. Results A total of 536 patients with severe trauma were enrolled in these three years, with 438 male (81.72%) and 98 female (18.28%). There were no statistically significant differences in gender, age, and basic situation of patients after admission among these three years (χ 2=0.16, witht values from 0.05 to 104.50,W values from 0.008 to 104.500,P values above 0.05). There were no statistically significant differences in the first time determination values of physiological and biochemical indexes after admission including pH value, base excess, PaCO2, PaO2, hemoglobin, platelet count, and blood sodium of patients among these three years (witht values from 0.80 to 29.10,W values respectively 0.110 and 5.450,P values above 0.05), while there were statistically significant differences in standard bicarbonate ion, leucocyte count, neutrophile granulocyte, albumin, urea nitrogen, lactic acid, and blood glucose of patients among these three years (witht values from 1 542.00 to 500 000.00,W values from 637.000 to 500 000.000,P <0.05 orP <0.01). There were no statistically significant differences in surgical situation, length of ICU stay, and occurrence of major complications including infection, ARDS, and MODS/MOF in patients among these three years (withχ 2 values from 0.48 to 2.43,W =2.100,P values above 0.05). The mortality of patients in 2010, 2011, and 2012 were 11.9% (19/159), 11.2% (21/187), and 7.4% (14/190), respectively, showing a trend of decline, but there was no statistically significant difference (χ 2=2.43,P >0.05). Death-associated exposure factors were age, ISS, APACHE Ⅱ score, urea volume on the first day, platelet count, albumin, and blood sodium. The O/E ratio of adjustment mortality (95%CI) in 2010, 2011, and 2012 were 0.727 (0.460-1.180), 0.718 (0.460-1.230), and 0.460 (0.270-0.840), respectively, showing a trend of decline each year. Conclusions The trauma integration treatment system can improve the treatment quality of patients with severe trauma.-
Key words:
- Wounds and injuries /
- Mortality /
- Trauma centers /
- Treatment outcome /
- Observation/expectation ratio
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