Retrospective study on the myocardial damage of 252 patients with severe burn
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摘要: 目的 回顾性分析严重烧伤患者发生心肌损伤的危险因素及临床表现,为其防治提供依据。 方法 2010年1月—2015年6月,5家笔者单位收治符合入选标准的252例严重烧伤患者,按第三军医大学补液公式进行液体复苏。根据入院时治疗前心肌型肌酸激酶同工酶(CK-MB)水平,将患者分为非心肌损伤组(CK-MB<75 U/mL)118例和心肌损伤组(CK-MB≥75 U/mL)134例。统计2组患者性别、年龄、体质量、化学烧伤例数、伤后入院时间、烧伤总面积、Ⅲ度面积、吸入性损伤例数,入院时及伤后24、48 h Hb、血细胞比容、血乳酸,伤后24、48 h尿量、补液量,入院时及伤后24、48 h肌酐、尿素氮、总胆汁酸、二胺氧化酶水平,病死率。另外将患者按照烧伤总面积分为3组:小于50%TBSA组110例、大于或等于50%TBSA且小于80%TBSA组83例、大于或等于80%TBSA组59例,统计3组患者心肌损伤发生率。对数据行
χ 2检验、t 检验、Wilcoxon检验、重复测量方差分析,并进行Bonferroni校正。对252例患者基本资料行二分类logistic回归分析,筛选心肌损伤的独立危险因素;绘制252例患者烧伤总面积的受试者工作特征曲线,评估其对心肌损伤发生的预测效果。 结果 (1)2组患者年龄、体质量、化学烧伤例数、吸入性损伤例数、Ⅲ度面积比较,差异不明显(t 值分别为0.20、0.31,χ 2值分别为0.49、4.10,Z =1.42,P 值均大于0.05);性别、伤后入院时间、烧伤总面积比较,差异明显(χ 2=5.00,t 值分别为2.44、3.13,P <0.05或P <0.01)。(2)性别、伤后入院时间、烧伤总面积是影响患者心肌损伤的独立危险因素(比值比分别为2.608、3.620、1.030,95%置信区间分别为1.315~5.175、1.916~6.839、1.011~1.049,P 值均小于0.01)。(3)小于50%TBSA组、大于或等于50%TBSA且小于80%TBSA组、大于或等于80%TBSA组患者心肌损伤发生率分别为38.2%(42/110)、54.2%(45/83)、61.0%(36/59),总体比较差异明显(χ 2=9.46,P <0.05)。(4)对252例患者心肌损伤发生预测的烧伤总面积的受试者工作特征曲线下总面积为0.706(95%置信区间为0.641~0.772,P <0.01),烧伤总面积的最佳阈值为51.5%TBSA,其对心肌损伤发生预测的敏感度为62.6%、特异度为65.3%。(5)与非心肌损伤组比较,除伤后48 h Hb和血细胞比容无明显变化(t 值分别为-0.76、-0.61,P 值均大于0.05)外,心肌损伤组患者Hb、血细胞比容、血乳酸水平各时相点明显升高(t 值为-2.80~-2.06,P <0.05或P <0.01)。与非心肌损伤组比较,心肌损伤组患者尿量伤后24、48 h减少(t 值分别为2.05、3.68,P <0.05或P <0.01),补液量伤后24、48 h无明显变化(t 值分别为1.01、1.08,P 值均大于0.05)。(6)与非心肌损伤组比较,心肌损伤组患者肌酐水平入院时及伤后24、48 h明显升高(Z 值为-2.91~-1.99,P <0.05或P <0.01),尿素氮水平仅伤后24、48 h明显升高(t 值分别为-4.75、-5.24,P 值均小于0.01),总胆汁酸水平入院时及伤后24、48 h无明显变化(t 值为-0.81~-0.20,P 值均大于0.05),二胺氧化酶水平仅入院时、伤后24 h明显升高(t 值分别为-3.97、-2.02,P <0.05或P <0.01)。(7)非心肌损伤组患者病死率明显低于心肌损伤组(χ 2=5.81,P <0.05)。 结论 严重烧伤患者心肌损伤发生率高,烧伤总面积可预测严重烧伤患者心肌损伤的发生。严重烧伤伴心肌损伤的患者,休克期更容易出现有效循环容量减少、组织氧合障碍及其他脏器损伤。Abstract: Objective To retrospectively analyze the risk factors and clinical manifestations of myocardial damage of patients with severe burn in order to provide evidence for its prevention and treatment. Methods Two hundred and fifty-two patients with severe burn admitted to 5 burn centers from January 2010 to June 2015, conforming to the study criteria, were treated in accordance with the fluid resuscitation formula of the Third Military Medical University. According to the creatine kinase isoenzyme-MB (CK-MB) level before treatment on admission, patients were divided into non-myocardial damage group (n =118, CK-MB level less than 75 U/mL) and myocardial damage group (n =134, CK-MB level higher than or equal to 75 U/mL). Data of patients in two groups were collected and evaluated such as gender, age, body mass, number of patients with chemical burn, admission time after injury, total burn area, full-thickness burn area, number of patients with inhalation injury, levels of haemoglobin, hematocrit, and blood lactate on admission and at post injury hour (PIH) 24 and 48, volumes of urine output and fluid input at PIH 24 and 48, levels of creatinine, urea nitrogen, total bile acid, diamine oxidase on admission and at PIH 24 and 48, and mortality. Furthermore, patients were divided into three groups, i. e. less than 50% total body surface area (TBSA) group (n =110), larger than or equal to 50% TBSA and less than 80% TBSA group (n =83), and larger than or equal to 80% TBSA group (n =59) according to the total burn area, and the incidence rates of myocardial damage in patients of three groups were recorded. Data were processed with chi-square test,t test, Wilcoxon test, analysis of variance for repeated measurement, and the values ofP were adjusted by Bonferroni. Basic data of 252 patients were processed with binary logistic regression analysis. Receiver operating characteristic curve of total burn area of 252 patients was drawn to predict myocardial damage. Results (1) There were no statistically significant differences in age, body mass, number of patients with chemical burn, number of patients with inhalation injury, and full-thickness burn area between two groups (witht values respectively 0.20 and 0.31,χ 2 values respectively 0.49 and 4.10,Z =1.42,P values above 0.05). There were statistically significant differences in gender, admission time after injury, and total burn area of patients between two groups (χ 2=5.00, witht values respectively 2.44 and 3.13,P <0.05 orP <0.01). (2) Gender, admission time after injury, and total burn area were independent risk factors related to myocardial damage in the patients (with odds ratios respectively 2.608, 3.620, and 1.030; 95% confidence intervals respectively 1.315-5.175, 1.916-6.839, and 1.011-1.049;P values below 0.01). (3) The incidence rates of myocardial damage of patients in less than 50% TBSA group, larger than or equal to 50% TBSA and less than 80% TBSA group, and larger than or equal to 80% TBSA group were 38.2% (42/110), 54.2% (45/83), and 61.0% (36/59) respectively, and there was statistically significant difference among them (χ 2=9.46,P <0.05). (4) The total area under receiver operating characteristic curve of total burn area to predict myocardial damage of 252 patients was 0.706 (with 95% confidence interval 0.641-0.772,P <0.01), and 51.5% TBSA was chosen as the optimal threshold value, with sensitivity of 62.6% and specificity of 65.3%. (5) Compared with those in non-myocardial damage group, except the levels of haemoglobin and hematocrit at PIH 48 (witht values respectively -0.76 and -0.61,P values above 0.05), the levels of haemoglobin, hematocrit, and blood lactate of patients in myocardial damage group were significantly increased at each time point (witht values from -2.80 to -2.06,P <0.05 orP <0.01). Compared with those in non-myocardial damage group, the volume of urine output of patients was significantly declined (witht values respectively 2.05 and 3.68,P <0.05 orP <0.01), while the volume of fluid input of patients was not obviously changed in myocardial damage group at PIH 24 and 48 (witht values respectively 1.01 and 1.08,P values above 0.05). (6) Compared with those in non-myocardial damage group, the level of creatinine of patients was significantly increased on admission and at PIH 24 and 48 (withZ values from -2.91 to -1.99,P <0.05 orP <0.01), the level of urea nitrogen of patients was only significantly increased at PIH 24 and 48 (witht values respectively -4.75 and -5.24,P values below 0.01), the level of total bile acid of patients was not obviously changed on admission and at PIH 24 and 48 (witht values from -0.81 to -0.20,P values above 0.05), and the level of diamine oxidase of patients was only significantly increased on admission and PIH 24 in myocardial damage group (witht values respectively -3.97 and -2.02,P <0.05 orP <0.01). (7) Compared with that in myocardial damage group, the mortality of patients in non-myocardial damage group was significantly declined (χ 2=5.81,P <0.05). Conclusions Patients with severe burn have high incidence of myocardial damage, which may be predicted by total burn area. Severely burned patients with myocardial damage are more likely to suffer from decline of effective circulating volume, tissue oxygenation disorders, and damage in other organs in shock stage.-
Key words:
- Burns /
- Risk factors /
- Mortality /
- Myocardial damage
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