Analysis of risk factors for atrial fibrillation in adult patients with critically severe burns after the first surgery
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摘要:
目的 探讨成年特重度烧伤患者首次手术后发生心房颤动的危险因素。 方法 该研究为回顾性病例系列研究。2018年1月1日—2023年3月31日,武汉大学同仁医院暨武汉市第三医院烧伤科收治211例符合入选标准的成年特重度烧伤患者,其中男158例、女53例,年龄24~81岁。根据首次手术后是否发生心房颤动,将患者分为术后心房颤动（POAF）组（23例）和非POAF组（188例）。收集POAF组患者首次手术后心房颤动的发生时间、持续时间、治疗方式以及发生次数>1次的患者数。收集2组患者一般资料,包括性别、年龄、烧伤类型、烧伤总面积、Ⅲ度烧伤面积、吸入性损伤情况、基础疾病情况、机械通气情况、脓毒症情况；首次手术前电解质紊乱情况及血液指标水平；手术时长和手术方式等首次手术相关情况；首次手术中容量变化及生命体征,包括液体输注总量、输血总量、失血量、低血压和低体温情况；术后低体温情况；首次手术前和手术后第1天的炎症指标水平,包括降钙素原水平、白细胞计数、中性粒细胞计数、淋巴细胞计数、血小板计数、中性粒细胞与淋巴细胞比值（NLR）、血小板计数与淋巴细胞比值；入院30 d内死亡情况。筛选成年特重度烧伤患者首次手术后发生心房颤动的独立危险因素。 结果 POAF组患者发生心房颤动的时间为首次手术后2（2,4）h,心房颤动的持续时间为16（6,26）h。予21例患者静脉注射胺碘酮治疗,予2例患者心脏电复律治疗,治疗后所有患者心房颤动转为窦性心律。3例患者心房颤动发生次数>1次。POAF组患者的年龄为59（42,70）岁、烧伤总面积为90%（70%,94%）体表总面积（TBSA）,均明显大于非POAF组患者的48（38,56）岁、70%（60%,83%）TBSA（Z值分别为-2.64、-3.56,P<0.05）。与非POAF组比较,POAF组患者吸入性损伤发生率更高（χ2=4.45,P<0.05）,首次手术中液体输注总量和输血总量均明显增多（Z值分别为-3.98、-3.75,P<0.05）,首次手术中低体温和术后低体温发生率均明显升高（χ2值分别为8.24、18.72,P<0.05）,首次手术前及手术后第1天降钙素原水平、首次手术后第1天NLR均明显升高（Z值分别为-3.03、-2.19、-2.18,P<0.05）,首次手术前及手术后第1天淋巴细胞计数（Z值分别为-2.07、-2.60,P<0.05）、血小板计数（Z值分别为-3.35、-3.58,P<0.05）均明显降低,入院30 d内病死率明显升高（χ2=4.03,P<0.05）。2组患者其余指标比较,差异均无统计学意义（P>0.05）。多因素logistic回归分析显示,年龄、烧伤总面积和术中低体温均是成年特重度烧伤患者首次手术后发生心房颤动的独立危险因素（比值比分别为1.08、1.07、4.18,95%置信区间分别为1.03~1.12、1.03~1.11、1.48~11.80,P<0.05）。 结论 年龄、烧伤总面积和术中低体温为成年特重度烧伤患者首次手术后发生心房颤动的独立危险因素,发生心房颤动的患者死亡风险增加。 Abstract:Objective To explore the risk factors for atrial fibrillation in adult patients with critically severe burns after the first surgery. Methods This study was a retrospective case series study. From January 1, 2018 to March 31, 2023, 211 adult patients with critically severe burns were admitted to the Department of Burns of Tongren Hospital of Wuhan University & Wuhan Third Hospital and met the inclusion criteria, including 158 males and 53 females, aged 24-81 years. According to whether atrial fibrillation occurred after the first surgery, the patients were divided into postoperative atrial fibrillation (POAF) group (23 cases) and non-POAF group (188 cases). The following indexes of patients in POAF group were collected, including the onset time, duration, treatment method, and number of patients with more than once of atrial fibrillation after the first surgery. The following data of the two groups of patients were collected, including general data, such as gender, age, burn type, total burn area, full-thickness burn area, inhalation injury, underlying diseases, mechanical ventilation, and sepsis; electrolyte imbalance and blood index level before the first surgery; the first surgery-related information such as surgical length and surgical method; volume changes and vital signs during the first surgery, such as total volume of fluid infusion, total volume of blood transfusion, volume of blood loss, hypotension, and hypothermia; postoperative hypothermia; inflammatory index levels before the first surgery and on the first day after the first surgery, such as procalcitonin levels, white blood cell count, neutrophil count, lymphocyte count, platelet count, neutrophil to lymphocyte ratio (NLR), platelet count to lymphocyte ratio (PLR); mortality within 30 days of admission. The independent risk factors for occurrence of atrial fibrillation in adult patients with critically severe burns after the first surgery were screened. Results The onset time of atrial fibrillation of patients in POAF group was 2 (2, 4) hours after the first surgery, and the duration of atrial fibrillation was 16 (6, 26) hours. Twenty-one patients were treated with intravenous injection of amiodarone, two patients were treated with cardiac electrical cardioversion, and atrial fibrillation of all patients converted to sinus rhythm after treatment. Three patients experienced atrial fibrillation more than once. The age was 59 (42, 70) years and the total burn area was 90% (70%, 94%) total body surface area (TBSA) in patients in POAF group, which were significantly higher than 48 (38, 56) years and 70% (60%, 83%) TBSA in non-POAF group (with Z values of -2.64 and -3.56, respectively, P<0.05). Compared with those in non-POAF group, the incidence rate of inhalation injury of patients in POAF group was significantly higher (χ2=4.45, P<0.05), the total volumes of fluid infusion and blood transfusion during the first surgery were significantly increased (with Z values of -3.98 and -3.75, respectively, P<0.05), the incidence rates of hypothermia during the first surgery and hypothermia after the first surgery were significantly increased (with χ2 values of 8.24 and 18.72, respectively, P<0.05), the levels of procalcitonin before the first surgery and on the first day after the first surgery, as well as the NLR on the first day after the first surgery were significantly increased (with Z values of -3.03, -2.19, and -2.18, respectively, P<0.05), the lymphocyte count (with Z values of -2.07 and -2.60, respectively, P<0.05) and platelet count (with Z values of -3.35 and -3.58, respectively, P<0.05) were significantly reduced before the first surgery and on the first day after the first surgery, and the mortality rate within 30 days of admission was significantly higher (χ2=4.03, P<0.05). There were no statistically significant differences in other indexes between the two groups of patients (P>0.05). Multivariate logistic regression analysis showed that age, total burn area, and intraoperative hypothermia were independent risk factors for the occurrence of atrial fibrillation in adult patients with critically severe burns after the first surgery (with odds ratios of 1.08, 1.07, and 4.18, 95% confidence intervals of 1.03-1.12, 1.03-1.11, and 1.48-11.80, respectively, P<0.05). Conclusions Age, total burn area, and intraoperative hypothermia are independent risk factors for the occurrence of atrial fibrillation in adult patients with critically severe burns after the first surgery. Patients with atrial fibrillation have an increased risk of death. -
Key words:
- Burns /
- Atrial fibrillation /
- Risk factors /
- Postoperative complications
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蒋南红：研究设计和论文撰写；谢卫国：研究指导、论文修改和经费支持；王德运、褚志刚：对文章的知识性内容作批判性审阅；席毛毛：统计学分析；周锦秀、李凤：数据采集和整理所有作者均声明不存在利益冲突
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参考文献
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Table 1. 2组成年特重度烧伤患者一般资料比较
组别 例数 性别（例） 年龄[岁,M（Q1,Q3）] 烧伤类型（例） 烧伤总面积[%TBSA,M（Q1,Q3）] Ⅲ度烧伤面积[%TBSA,M（Q1,Q3）] 男 女 火焰烧伤 热液烫伤 电烧伤 化学烧伤 POAF组 23 20 3 59（42,70） 20 2 1 0 90（70,94） 45（32,62） 非POAF组 188 138 50 48（38,56） 160 11 16 1 70（60,83） 35（22,49） 统计量值 χ2=3.54 Z=-2.64 — Z=-3.56 Z=-1.86 P值 0.060 0.008 0.811 <0.001 0.063 注：POAF为术后心房颤动,TBSA为体表总面积；机械通气时间及脓毒症情况为首次手术前的情况；“—”表示无此统计量值 
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Table 2. 2组成年特重度烧伤患者首次手术前电解质紊乱情况及血液指标比较
组别 例数 低镁血症（例） 低钾血症（例） 低钙血症（例） 高钠血症（例） 低蛋白血症（例） 贫血（例） 肌酸激酶同工酶[U/L,M（Q1,Q3）] POAF组 23 5 2 18 7 17 7 48（30,77） 非POAF组 188 37 41 125 26 153 66 44（30,75） 统计量值 — χ2=1.44 χ2=1.30 χ2=3.12 χ2=0.33 χ2=0.20 Z=-0.47 P值 >0.999 0.230 0.254 0.078 0.565 0.657 0.641 注：POAF为术后心房颤动；“—”表示无此统计量值
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Table 3. 2组成年特重度烧伤患者首次手术相关情况比较
组别 例数 伤后手术时间[d,M（Q1,Q3）] 手术时长[min,M（Q1,Q3）] 手术方式 手术面积[%TBSA,M（Q1,Q3）] 皮片移植面积[%TBSA,M（Q1,Q3）] 切削痂+自体皮移植（例） 清创+猪ADM移植（例） POAF组 23 3（2,5） 180（150,180） 18 5 40（26,48） 35（25,40） 非POAF组 188 3（1,4） 180（120,180） 122 66 42（34,50） 39（30,43） 统计量值 Z=-1.25 Z=-0.59 χ2=1.64 Z=-0.99 Z=-1.71 P值 0.212 0.555 0.200 0.320 0.088 注：POAF为术后心房颤动,ADM为脱细胞真皮基质
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Table 4. 2组成年特重度烧伤患者首次手术中容量变化和生命体征及术后低体温发生情况比较
组别 例数 术中液体输注总量[mL,M（Q1,Q3）] 术中输血总量[mL,M（Q1,Q3）] 术中失血量[mL,M（Q1,Q3）] 术中低血压（例） 术中低体温（例） 术后低体温（例） POAF组 23 2 300（2 100,2 600） 1 600（1 300,1 700） 400（300,500） 13 16 19 非POAF组 188 1 725（1 300,2 200） 800（400,1 275） 300（100,400） 116 72 67 统计量值 Z=-3.98 Z=-3.75 Z=-1.79 χ2=0.23 χ2=8.24 χ2=18.72 P值 <0.001 <0.001 0.074 0.630 0.004 <0.001 注：POAF为术后心房颤动
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Table 5. 2组成年特重度烧伤患者首次手术前及手术后第1天炎症指标水平比较[M(Q1,Q3)]
组别 例数 降钙素原（ng/mL） 白细胞计数（×109/L） 中性粒细胞计数（×109/L） 术前 术后第1天 术前 术后第1天 术前 术后第1天 POAF组 23 2.41（0.64,3.59） 1.86（0.56,4.37） 10.1（6.4,17.7） 7.5（4.3,13.6） 8.6（5.1,14.5） 6.4（3.8,10.3） 非POAF组 188 0.90（0.22,2.00） 0.79（0.26,2.52） 14.6（9.4,19.2） 8.8（6.2,12.3） 11.5（6.9,16.6） 6.7（4.9,9.6） Z值 -3.03 -2.19 -1.70 -1.24 -1.82 -0.39 P值 0.002 0.029 0.090 0.214 0.069 0.699 注：POAF为术后心房颤动,NLR为中性粒细胞与淋巴细胞比值,PLR为血小板计数与淋巴细胞比值
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Table 6. 成年特重度烧伤患者首次手术后发生心房颤动的多因素logistic回归分析结果
自变量 回归系数 标准误 比值比 95%置信区间 P值 年龄（岁） 0.07 0.02 1.08 1.03~1.12 0.001 烧伤总面积 （%TBSA） 0.06 0.02 1.07 1.03~1.11 0.001 术中低体温 1.43 0.53 4.18 1.48~11.80 0.007 注：TBSA为体表总面积
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