Establishment and validation of a risk prediction model for pulmonary embolism in severe burn patients
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摘要:
目的 筛选严重烧伤患者并发肺动脉栓塞的危险因素,据此构建风险预测模型并进行验证。 方法 该研究为回顾性病例系列研究。收集2021年3月—2023年3月武汉市第三医院烧伤科收治的符合入选标准的267例严重烧伤患者的临床资料,其中男159例、女108例,年龄18~82岁。根据是否并发肺动脉栓塞将患者分为肺动脉栓塞组（26例）与非肺动脉栓塞组（241例）,收集并比较2组患者性别、年龄、体重指数、治疗期间卧床时间、烧伤原因、入院时白蛋白水平、合并慢性阻塞性肺疾病（COPD）情况、合并糖尿病情况、合并高血压情况、合并吸入性损伤情况和入院时简明烧伤严重指数（ABSI）评分。对组间比较差异有统计学意义的指标进行单因素和多因素logistic回归分析,筛选267例严重烧伤患者并发肺动脉栓塞的独立危险因素,并据此构建列线图预测模型。通过受试者操作特征（ROC）曲线评估预测模型的性能,采用校准曲线和临床决策曲线分析法对预测模型进行验证。 结果 肺动脉栓塞组患者中>60岁、治疗期间卧床时间>7 d、合并COPD、合并糖尿病患者比例（χ2值分别为7.75、29.15、29.86、5.94）,入院时ABSI评分（t=6.01）均明显高于非肺动脉栓塞组（P<0.05）。2组患者其余资料比较,差异均无统计学意义（P>0.05）。单因素logistic回归分析显示,年龄、治疗期间卧床时间、合并COPD、合并糖尿病、入院时ABSI评分均为严重烧伤患者并发肺动脉栓塞的危险因素（比值比分别为3.40、14.87、17.78、2.80、1.88,95%置信区间分别为1.38~8.39、4.34~50.98、4.63~68.22、1.19~6.58、1.47~2.41,P<0.05）。多因素logistic回归分析显示,治疗期间卧床时间>7 d、合并COPD、入院时ABSI评分高均为严重烧伤患者并发肺动脉栓塞的独立危险因素（比值比分别为11.02、30.82、1.86,95%置信区间分别为2.76~43.98、3.55~267.33、1.38~2.50,P<0.05）。根据前述3个独立危险因素构建严重烧伤患者并发肺动脉栓塞风险列线图预测模型。预测模型的ROC曲线显示,ROC曲线下面积为0.91（95%置信区间为0.82~0.99）,取最佳阈值25%时,预测模型的敏感度为84.6%、特异度为93.4%；校准曲线显示,预测模型校准曲线在理想曲线附近,Cox回归的一致性指数为0.80（95%置信区间为0.74~0.87）；临床决策曲线显示,该模型的阈值概率范围为1%~98%,其净收益率>0。 结论 严重烧伤患者并发肺动脉栓塞的独立危险因素包括治疗期间卧床时间>7 d、合并COPD、入院时ABSI评分高,据此构建的列线图预测模型对严重烧伤患者并发肺动脉栓塞具有较佳的预测价值。 Abstract:Objective To screen the risk factors risk factors for pulmonary embolism in severe burn patients, based on which, a risk prediction model was established and validated. Methods This study was a retrospective case series study. The clinical data of 267 severe burn patients who met the inclusion criteria and were admitted to the Department of Burns of Wuhan Third Hospital from March 2021 to March 2023 were collected, including 159 males and 108 females, aged 18-82 years. The patients were divided into pulmonary embolism group (26 cases) and non-pulmonary embolism group (241 cases) according to whether they were complicated with pulmonary embolism. The following data of patients in the 2 groups were collected and compared, including gender, age, body mass index, bedtime during treatment, cause of burn, albumin level on admission, combination of chronic obstructive pulmonary disease (COPD), combination of diabetes mellitus, combination of hypertension, combination of inhalation injury, and the abbreviated burn severity index (ABSI) on admission. The indicators with statistically significant differences between the two groups were conducted with univariate and multivariate logistic regression analyses to identify the independent risk factors for pulmonary embolism in 267 severe burn patients. Based on these findings, a nomogram prediction model was constructed. The performance of the prediction model was evaluated by the receiver operating characteristic (ROC) curve, while its validation was conducted through calibration curve and clinical decision curve analysis. Results The proportions of beyond 60 years old, bedtime during treatment beyond 7 days, combination of COPD, and combination of diabetes (with χ2 values of 7.75, 29.15, 29.86, and 5.94, respectively), and ABSI score on admission (t=6.01) of patients in pulmonary embolism group were higher than those of non-pulmonary embolism group (P<0.05). There were no statistically significant differences in the other indicators between the two groups of patients (P>0.05). The univariate logistic regression analysis showed that, age, bedtime during treatment, combination of COPD, combination of diabetes, and ABSI score on admission were the risk factors for pulmonary embolism in severe burn patients (with odds ratios of 3.40, 14.87, 17.78, 2.80, and 1.88, respectively, 95% confidence intervals of 1.38-8.39, 4.34-50.98, 4.63-68.22, 1.19-6.58, and 1.47-2.41, respectively, P<0.05). The multivariate logistic regression analysis showed that, bedtime during treatment beyond 7 days, combination of COPD, and high ABSI score on admission were the independent risk factors for pulmonary embolism in severe burn patients (with odds ratios of 11.02, 30.82, and 1.86, respectively, 95% confidence intervals of 2.76-43.98, 3.55-267.33, and 1.38-2.50, respectively, P<0.05). Based on the three aforementioned independent risk factors, a nomogram prediction model for the risk of pulmonary embolism in severe burn patients was constructed. The ROC curve of prediction model showed that, the area under the ROC curve was 0.91 (with 95% confidence interval of 0.82-0.99). When the optimal cut-off value of 25% was taken, the sensitivity and specificity of prediction model was 84.6% and 93.4%, respectively. The calibration curve showed that, the calibration curve of prediction model was around the ideal curve, with a consistency index of 0.80 in Cox regression (with 95% confidence interval of 0.74-0.87). The clinical decision curve showed that the threshold probability value of the prediction model was in the range of 1% to 98%, with net return rate over 0. Conclusions The independent risk factors for pulmonary embolism in severe burn patients include bedtime during treatment beyond 7 days, combination of COPD, and high ABSI score on admission. The nomogram prediction model constructed based on this has a good ability to predict pulmonary embolism in severe burn patients. -
Key words:
- Burns /
- Risk factors /
- Nomograms /
- Pulmonary embolism
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参考文献
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Table 1. 2组严重烧伤患者临床资料比较
组别 例数 性别（例） 年龄（例） 体重指数（例） 治疗期间卧床时间（例） 入院时白蛋白水平（例） 合并COPD（例） 男 女 >60岁 ≤60岁 ≥24 kg/m2 <24 kg/m2 >7 d ≤7 d >35 g/L ≤35 g/L 是 否 肺动脉栓塞组 26 13 13 19 7 14 12 23 3 16 10 6 20 非肺动脉栓塞组 241 146 95 107 134 170 71 82 159 176 65 4 237 统计量值 χ2=1.09 χ2=7.75 χ2=3.05 χ2=29.15 χ2=1.53 χ2=29.86 P值 0.296 0.005 0.081 <0.001 0.216 <0.001 注：COPD为慢性阻塞性肺疾病,ABSI为简明烧伤严重指数 
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Table 2. 267例严重烧伤患者并发肺动脉栓塞的单因素和多因素logistic回归分析结果
自变量 单因素 多因素 回归系数 标准误 比值比 95%置信区间 P值 回归系数 标准误 比值比 95%置信区间 P值 年龄（岁） 1.22 0.46 3.40 1.38~8.39 P值 0.94 0.61 2.56 0.78~8.45 0.123 治疗期间卧床时间（>7 d） 2.70 0.63 14.87 4.34~50.98 0.008 2.40 0.71 11.02 2.76~43.98 0.001 合并COPD 2.88 0.69 17.78 4.63~68.22 <0.001 3.43 1.10 30.82 3.55~267.33 0.002 合并糖尿病 1.03 0.44 2.80 1.19~6.58 <0.001 0.68 0.63 1.97 0.58~6.69 0.279 入院时ABSI评分（10.7~14.9分） 0.63 0.13 1.88 1.47~2.41 <0.001 0.62 0.15 1.86 1.38~2.50 <0.001 注：COPD为慢性阻塞性肺疾病,ABSI为简明烧伤严重指数
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