本文選題：PICC相關(guān)性血栓 + 危險因素��； 參考：《天津醫(yī)科大學(xué)》2017年碩士論文

【摘要】：目的探索和分析PICC相關(guān)性上肢靜脈血栓形成的相關(guān)危險因素,構(gòu)建PICC相關(guān)性上肢靜脈血栓風(fēng)險評估模型并對其進行評價,為臨床PICC相關(guān)性血栓的評估、預(yù)防提供參考。同時,對二維超聲及血流顯像技術(shù)下難以確切診斷但臨床考慮靜脈血栓的患者實施超聲造影,以探討實施超聲造影在PICC相關(guān)性血栓診斷中的應(yīng)用價值。方法收集2015年4月-2017年1月于天津市某三級甲等綜合醫(yī)院留置PICC導(dǎo)管的所有符合納入排除標(biāo)準(zhǔn)的患者為研究對象,并依據(jù)研究對象納入的先后時間順序分為訓(xùn)練樣本和驗證樣本。從置管當(dāng)天開始對研究對象實施為期一個月的B超隨訪。隨訪時間順應(yīng)PICC導(dǎo)管維護要求,每7天一次于導(dǎo)管換藥前進行,共計隨訪4次。收集資料包括:患者一般資料、置管穿刺過程相關(guān)信息、身體疾病和病史相關(guān)信息、部分臨床化驗結(jié)果信息以及置管側(cè)肢體臨床表現(xiàn)狀況。采用常規(guī)多普勒超聲技術(shù)對患者上肢靜脈的血栓形成狀況進行診斷。對于常規(guī)多普勒超聲難以判斷者,實施超聲造影檢查并保存造影圖像,以明確血栓形成狀況。研究依據(jù)有無靜脈血栓形成,將訓(xùn)練樣本和驗證樣本的研究對象分為無血栓組和有血栓組,使用SPSS18.0軟件對數(shù)據(jù)進行分析和處理。采用?2檢驗、t檢驗以及Mann-Whitney U檢驗對訓(xùn)練樣本各因素變量進行分析,找出存在統(tǒng)計學(xué)差異的變量。然后,利用二分類Logistic回歸分析篩選出獨立危險因素并建立PICC相關(guān)性血栓風(fēng)險評估模型,依據(jù)優(yōu)勢比對模型各因素賦值,并且對血栓形成風(fēng)險度進行了分級。利用靈敏度、特異度以及ROC曲線分別在訓(xùn)練樣本和驗證樣本中對模型進行驗證和評價。最后,對PICC導(dǎo)管超聲造影的圖像資料進行分析,初步總結(jié)和分析超聲造影在PICC相關(guān)性血栓中的應(yīng)用價值。結(jié)果1.研究共納入研究對象375例,訓(xùn)練樣本275例,驗證樣本100例,共計發(fā)生血栓72例(訓(xùn)練樣本53例,驗證樣本19例),靜脈血栓總發(fā)生率為19.20%。2.訓(xùn)練樣本單因素分析表明,與PICC相關(guān)性血栓形成有關(guān)的因素為肥胖與否、疾病診斷、血栓史、化療史、主要輸注內(nèi)容物、導(dǎo)管尖端位置、CVC或PICC導(dǎo)管置入史、糖尿病、活動能力(KPS評分)以及D-二聚體(≥0.5mg/L)。3.采用Logistic回歸對訓(xùn)練樣本中有統(tǒng)計學(xué)差異的因素的進一步分析得出,PICC相關(guān)性血栓形成的獨立危險因素包括:是否肥胖(OR=3.449,95%CI:1.634-7.493,P=0.001);糖尿病(OR=3.016,95%CI:1.342-6.775,P=0.008);血栓史(OR=2.887,95%CI:1.256-6.632,P=0.012);化療史(OR=2.268,95%CI:1.070-4.808,P=0.033);D-二聚體(OR=2.283,95%CI:1.132-4.604,P=0.021)。4.依據(jù)Logistic回歸分析的OR值(四舍五入法)對模型各獨立因素進行風(fēng)險積分賦值,分別為肥胖(BMI≥25kg/m2)3分;糖尿病3分;血栓史3分;化療史2分,D-二聚體(≥0.5mg/L)2分。同時,建立的評估模型為:Y=肥胖×3+糖尿病×3+血栓史×3+化療史×2+D-二聚體(≥0.5mg/L)×2-3.19。5.通過計算訓(xùn)練樣本中有血栓組和無血栓組的95%置信區(qū)間,得出血栓形成的危險度分級:3分為低危級;3-5分為中危級;5分為高危級。6.訓(xùn)練樣本和驗證樣本的ROC曲線分析:在訓(xùn)練樣本中采用ROC曲線分析PICC相關(guān)性血栓風(fēng)險評估模型的曲線下面積為0.753(95%CI:0.676-0.830),靈敏度為0.632,特異度為:0.797,最佳截斷值為4.5分。在驗證樣本中,PICC相關(guān)性血栓風(fēng)險評估模型的ROC曲線下面積為0.758(95%CI:0.684-0.883),靈敏度為0.784,特異度為:0.691,最佳截斷值同樣為4.5分。說明模型的預(yù)測效果呈中等水平。7.PICC超聲造影的診斷效果及應(yīng)用價值:超聲造影檢查可對存在彩色外溢、低流速下無明顯血流信號、臨床癥狀嚴(yán)重等PICC相關(guān)性血栓可疑者做出準(zhǔn)確診斷。結(jié)論1.本研究得出肥胖、糖尿病、血栓史、化療史以及D-二聚體(≥0.5mg/L)五項因素是影響PICC相關(guān)性血栓形成的獨立危險因素。2.依據(jù)上述因素構(gòu)建所的PICC相關(guān)性血栓風(fēng)險評估模型具有較好的評估效果,并且危險分級明確�？稍谝欢ǔ潭壬蠈颊叩撵o脈血栓發(fā)生風(fēng)險進行評估。3.超聲造影和常規(guī)超聲在PICC相關(guān)性血栓的診斷上各有優(yōu)勢,對于臨床懷疑PICC相關(guān)性血栓但常規(guī)超聲不能確診血栓形成狀況者,可進一步實施超聲造影檢查,其過程安全,結(jié)果可靠,值得推廣應(yīng)用。
[Abstract]:Objective to explore and analyze the related risk factors of PICC related upper limb venous thrombosis, to construct and evaluate the risk assessment model of PICC related upper limb venous thrombosis, and to provide reference for the evaluation of clinical PICC related thrombus and prevention. The patients with thrombus were performed by contrast-enhanced ultrasound to explore the application value of contrast-enhanced ultrasound in the diagnosis of PICC related thrombus. Methods all the patients who had retained the PICC catheter in a class three class a general hospital in Tianjin, April 2015, -2017 years, were collected for the study of the image, and the time and the time of the study were included. The sequence was divided into training samples and validation samples. The subjects were followed up for one month from the day of catheterization. The follow-up time was followed by the PICC catheter maintenance requirements, every 7 days before the catheterization, a total of 4 times. The data included the general information of the patients, the related information of the catheterization process, the physical disease and the history of the disease. Relevant information, some clinical test results information and the clinical manifestation of the lateral limb of the tube. Conventional Doppler ultrasound technique was used to diagnose the condition of the thrombosis of the upper limb veins. For those who were difficult to judge the conventional Doppler ultrasound, the ultrasound examination and preservation of the image were carried out to clarify the status of thrombus formation. There were no venous thrombosis. The subjects of training samples and samples were divided into non thrombus group and thrombus group. The data were analyzed and processed using SPSS18.0 software. 2 test, t test and Mann-Whitney U test were used to analyze the variables of the training samples to find out the variables with statistical differences. Two Logistic regression analysis was used to screen out independent risk factors and establish a PICC related thrombus risk assessment model. According to the advantages of the model, the risk degree of thrombus formation was graded. The sensitivity, specificity and ROC curve were used to verify and evaluate the model in the training sample and the validation sample respectively. Finally, the image data of PICC catheter ultrasonography were analyzed, and the application value of ultrasound contrast in PICC related thrombosis was preliminarily summarized and analyzed. Results 1. the study included 375 subjects, 275 training samples and 100 samples, 72 cases of thrombosis (training samples 53 cases, 19 samples), and the total incidence of venous thrombosis. The single factor analysis for 19.20%.2. training samples showed that the factors related to PICC related thrombosis were obesity or not, disease diagnosis, thrombus history, chemotherapy history, main infusion content, catheter tip position, CVC or PICC catheter implantation history, diabetes, activity ability (KPS score) and D- two polymer (0.5mg/L).3. using Logistic regression to training Further analysis of factors with statistical differences found that independent risk factors for PICC related thrombosis include obesity (OR=3.449,95%CI:1.634-7.493, P=0.001); diabetes (OR=3.016,95%CI:1.342-6.775, P=0.008); thrombotic history (OR=2.887,95%CI:1.256-6.632, P=0.012); chemotherapy history (OR=2.268,95%CI:1.070-4.808, P=0.033). D- two polymer (OR=2.283,95%CI:1.132-4.604, P=0.021).4. was based on the OR value of Logistic regression analysis (four RMS and five entry method) to evaluate the risk integral of the model independent factors, including obesity (BMI > 25kg/m2) 3 points, diabetes 3 points, thrombus history 3; chemotherapy history 2, D- two polymer (> 0.5mg/L) 2. Meanwhile, the evaluation model was: Y= obesity * * 3+ diabetes mellitus x 3+ thrombosis history * 3+ chemotherapy history * 2+D- two polymer (> 0.5mg/L) x 2-3.19.5. through calculating the training samples with thrombus group and non thrombus group, the risk degree of thrombosis is classified: 3 is low risk grade; 3-5 is medium danger grade; 5 is the ROC curve analysis of high risk class.6. training sample and verification sample: in training sample The area under the curve of ROC curve analysis of PICC related thrombus risk assessment model was 0.753 (95%CI:0.676-0.830), the sensitivity was 0.632, the specificity was 0.797, and the best truncated value was 4.5. In the verified samples, the area of the ROC curve of the PICC related thrombus risk assessment model was 0.758 (95%CI:0.684-0.883) and the sensitivity was 0.784. The difference is: 0.691, the best truncation value is also 4.5 points. It shows that the prediction effect of the model is the diagnostic effect and the application value of the medium level.7.PICC sonography: the ultrasonic contrast examination can make the accurate diagnosis of the suspected PICC phase thrombus in the presence of color spillover, low flow rate and serious clinical symptoms. Conclusion 1. studies It is concluded that obesity, diabetes, thrombus history, chemotherapy history, and D- two polymer (> 0.5mg/L) are independent risk factors affecting the formation of PICC related thrombosis..2. based on the above factors has a better evaluation effect on the PICC related thrombus risk assessment model, and the risk classification is clear. To a certain extent, the patient can be used. The risk of venous thrombosis is evaluated by.3. ultrasound and conventional ultrasound in the diagnosis of PICC related thrombus. For the clinical suspected PICC related thrombus but the conventional ultrasound can not diagnose the thrombus formation, the ultrasound examination can be further carried out, the process is safe and the result is reliable. It is worth popularizing.
【學(xué)位授予單位】：天津醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R472

【參考文獻】

相關(guān)期刊論文 前10條

1 陳曉潔;汪永堅;俞菁菁;祝亞男;;Autar量表在預(yù)防乳腺癌術(shù)后并發(fā)下肢深靜脈血栓形成應(yīng)用的效果觀察[J];護理研究;2016年19期

2 鄭毅;張艷容;謝明星;魯成發(fā);王斌;;超聲造影定量分析技術(shù)對下肢深靜脈血栓置管溶栓術(shù)的療效評價[J];臨床超聲醫(yī)學(xué)雜志;2016年06期

3 董彥君;于悅;李中文;代莉莉;;B超聯(lián)合二維血流顯像技術(shù)引導(dǎo)下PICC置管臨床效果及并發(fā)癥發(fā)生情況研究[J];河北醫(yī)藥;2016年12期

4 袁越;王洋;張淑香;;Caprini風(fēng)險評估模型在預(yù)防靜脈血栓栓塞癥中的初步應(yīng)用[J];中國實用護理雜志;2016年18期

5 徐留海;曾勇;黃衛(wèi);王茂朋;闕詳勇;易春艷;;基于Caprini血栓風(fēng)險模型評估膝關(guān)節(jié)鏡手術(shù)患者深靜脈血栓形成的風(fēng)險性[J];中國組織工程研究;2016年17期

6 章希睿;張明博;桑茂棟;王廣志;唐杰;;醫(yī)學(xué)超聲造影成像的新技術(shù)研究進展[J];中國生物醫(yī)學(xué)工程學(xué)報;2016年02期

7 詹韻韻;彭梅;姜凡;張新書;李婭榮;;彩色多普勒超聲在經(jīng)上肢靜脈置入中心靜脈導(dǎo)管術(shù)后隨訪中的應(yīng)用[J];臨床超聲醫(yī)學(xué)雜志;2015年05期

8 栗晨;栗玉彬;王輝;;彩色多普勒血流成像結(jié)合超聲造影鑒別門靜脈栓子的性質(zhì)[J];中國老年學(xué)雜志;2015年06期

9 張秀玲;柳建華;;彩超對腫瘤患者PICC術(shù)后上肢靜脈血栓的診斷價值[J];臨床醫(yī)學(xué)工程;2015年02期

10 楊茵茵;;探討PICC拔管前行置管側(cè)上肢靜脈彩色多普勒超聲以確認(rèn)有無導(dǎo)管相關(guān)性上肢靜脈血栓的必要性[J];中國實用醫(yī)藥;2014年35期

，

本文編號：2029846