發(fā)布時間：2018-09-05 08:24

【摘要】：目的:探討急性重度有機磷農(nóng)藥中毒(acute severe organophosphorus pesticide poisoning,ASOPP)患者的早期臨床指標(biāo)與預(yù)后的相關(guān)性,為ASOPP的治療和預(yù)后判斷提供參考。方法:選取2014年1月至2016年12月間就診于吉林大學(xué)第一醫(yī)院二部急救醫(yī)學(xué)科的急性有機磷農(nóng)藥中毒(acute organophosphorus pesticide poisoning,AOPP)患者213例。根據(jù)納入與排除標(biāo)準(zhǔn)篩選得到符合研究標(biāo)準(zhǔn)的ASOPP患者130例,收集患者的預(yù)后、性別、年齡、服藥劑量、服藥種類、服藥至洗胃時間、是否血液灌流治療(HP),入院即刻的血常規(guī)、膽堿酯酶、血糖、丙氨酸氨基轉(zhuǎn)移酶(ALT)、總膽紅素(TBIL)、肌酐(CRE)、尿素氮(BUN)、肌酸激酶同工酶、血淀粉酶、動脈血酸堿度(PH)、動脈血乳酸(Lac)、動脈血氧分壓(Pa O2)、動脈血二氧化碳分壓(Pa CO2)、動脈血碳酸氫根(HCO3-)、血鈣檢測結(jié)果,記錄臟器損害的種類和數(shù)目、格拉斯哥昏迷指數(shù)(GCS)評分及急性生理與慢性健康評分II(APACHE II)的臨床資料。根據(jù)預(yù)后將患者分為存活組(n=107)與死亡組(n=23),應(yīng)用單因素分析比較兩組上述指標(biāo)的差異,應(yīng)用Spearman相關(guān)分析分析經(jīng)單因素分析后差異有統(tǒng)計學(xué)意義的指標(biāo)與預(yù)后的相關(guān)程度,將與預(yù)后相關(guān)程度強的指標(biāo)繪制成受試者工作特征曲線(ROC曲線),用以評估各指標(biāo)對ASOPP患者預(yù)后的預(yù)測價值。結(jié)果:(1)130例ASOPP患者中,存活107例,死亡23例,病死率17.69%,男性61例(46.9%),女性69例(53.1%),男:女=0.88:1;存活組男性47例(43.9%),女性60例(56.1%),死亡組男性14例(60.9%),女性9例(39.1%),兩組性別比較差異無統(tǒng)計學(xué)意義(P0.05);兩組患者年齡在14~84歲之間,平均年齡47.21±16.50歲,中毒人群中以青年人居多58例(44.62%),中毒死亡人群中以老年人居多13例(56.52%);死亡組平均年齡58±18.638歲,存活組平均年齡44.89±15.121歲,兩組年齡比較差異有顯著性統(tǒng)計學(xué)意義(P0.01);(2)130例ASOPP患者,服藥劑量在10~500ml之間,平均服藥劑量102.19±88.388ml;存活組的服藥劑量為50(50,100)ml,死亡組的服藥劑量為100(100,250)ml,死亡組的服藥劑量多于存活組,兩組比較差異有顯著性統(tǒng)計學(xué)意義(P0.01);(3)死亡組的服藥至洗胃時間長于存活組,HP所占比例低于存活組,兩組比較差異均有顯著性統(tǒng)計學(xué)意義(均P0.01);(4)入院即刻的實驗室檢查中,死亡組的膽堿酯酶、血鈣、PH、Pa O2、HCO3-水平均低于存活組,兩組比較差異均有顯著性統(tǒng)計學(xué)意義(均P0.01);死亡組的血糖、ALT、CRE、血淀粉酶、肌酸激酶同工酶、Lac、Pa CO2水平均高于存活組,兩組比較差異均有統(tǒng)計學(xué)意義(均P0.05);(5)死亡組的GCS評分明顯低于存活組,APACHE II評分高于存活組,兩組比較差異均有顯著性統(tǒng)計學(xué)意義(均P0.01);(6)ASOPP時,損害的主要臟器種類包括腦、肺、心臟、循環(huán)、肝臟、腎、胰腺、胃腸道,以腦、肺、心臟最常受累,其次為胰腺;存活組臟器損害發(fā)生率由高到低的臟器種類為:腦、肺、胰腺、心臟、肝臟、循環(huán)、腎,死亡組臟器損害發(fā)生率由高到低的臟器種類為:腦、心臟、肺、胃腸道、循環(huán)、胰腺、肝臟、腎;兩組胰腺損害的發(fā)生率差異無統(tǒng)計學(xué)意義(P0.05),余臟器損害發(fā)生率死亡組均高于存活組,兩組比較差異均有顯著性統(tǒng)計學(xué)意義(均P0.01);死亡組早期同時出現(xiàn)臟器損害的個數(shù)為4(4,5)個,明顯高于存活組的臟器損害數(shù)目1(0,1)個,兩組比較差異有顯著性統(tǒng)計學(xué)意義(P0.01);(7)Spearman相關(guān)分析提示與預(yù)后相關(guān)性強(相關(guān)系數(shù)r的絕對值0.4)的指標(biāo)為血糖(r=0.417)、血鈣(r=-0.415)、PH(r=-0.469)、Lac(r=0.469)、Pa O2(r=-0.409)、GCS評分(r=-0.649)、APACHE II評分(r=0.592)、臟器損害數(shù)目(r=0.661),差異均有顯著性統(tǒng)計學(xué)意義(均P0.01);其中血糖、Lac、APACHE II評分、臟器損害數(shù)目均與預(yù)后呈正相關(guān),血鈣、PH、Pa O2、GCS評分均與預(yù)后呈負(fù)相關(guān);(8)用于評估各指標(biāo)對ASOPP患者預(yù)后的預(yù)測價值的ROC曲線下面積(AUC)由大到小依次為:臟器損害數(shù)目[AUC=0.981,可信區(qū)間(95%CI)=0.959~1.0,P0.01]、GCS評分[AUC=0.951,可信區(qū)間(95%CI)=0.913~0.989,P0.01]、APACHE II評分[AUC=0.947,可信區(qū)間(95%CI)=0.906~0.988,P0.01]、Lac[AUC=0.855,可信區(qū)間(95%CI)=0.781~0.928,P0.01]、PH[AUC=0.855,可信區(qū)間(95%CI)=0.752~0.958,P0.01]、血糖[AUC=0.815,可信區(qū)間(95%CI)=0.720~0.911,P0.01]、血鈣[AUC=0.813,可信區(qū)間(95%CI)=0.734~0.893,P0.01]、Pa O2[AUC=0.810,可信區(qū)間(95%CI)=0.721~0.898,P0.01]。結(jié)論:(1)ASOPP時,年齡、服藥劑量、服藥至洗胃時間、入院即刻的膽堿酯酶、血糖、ALT、CRE、血鈣、血淀粉酶、肌酸激酶同工酶、PH、Lac、Pa O2、Pa CO2、HCO3-、GCS評分、APACHE II評分、臟器損害數(shù)目為評估預(yù)后的早期預(yù)警指標(biāo);(2)經(jīng)ROC曲線分析,對預(yù)后有較高預(yù)測價值的指標(biāo)為臟器損害數(shù)目、GCS評分、APACHE II評分,其次為PH、Lac、血糖、血鈣、Pa O2;(3)HP可降低ASOPP的病死率;(4)ASOPP時,臟器損害以腦、肺、心臟最常受累,死亡組臟器損害的發(fā)生率較高。
[Abstract]:Objective: To investigate the correlation between early clinical parameters and prognosis in patients with acute severe organophosphorus pesticide poisoning (ASOPP), and to provide reference for the treatment and prognosis of ASOPP. 213 patients with acute organophosphorus pesticide poisoning (AOPP) were selected according to inclusion and exclusion criteria. 130 patients with ASOPP were selected according to inclusion and exclusion criteria. Regular, cholinesterase, blood glucose, alanine aminotransferase (ALT), total bilirubin (TBIL), creatinine (CRE), urea nitrogen (BUN), creatine kinase isozyme, blood amylase, arterial acidity (PH), arterial lactic acid (Lac), arterial partial pressure of oxygen (PaO 2), arterial partial pressure of carbon dioxide (PaCO 2), arterial bicarbonate (HCO 3 -), blood calcium test results were recorded. Types and number of organ damage, Glasgow Coma Index (GCS) score, and Acute Physiological and Chronic Health Score II (APACHE II) clinical data. Patients were divided into survival group (n = 107) and death group (n = 23) according to prognosis. The differences of the above indexes between the two groups were compared by univariate analysis and Spearman correlation analysis. Results: (1) Among 130 ASOPP patients, 107 survived, 23 died, the mortality was 17.69%, 61 males (46.9%) and 69 females (69%). There were 47 males (43.9%) and 60 females (56.1%) in the survival group, 14 males (60.9%) and 9 females (39.1%) in the death group. There was no significant gender difference between the two groups (P 0.05). The age of the two groups was between 14 and 84 years old, with an average age of 47.21 [16.50 years old]. There were 58 cases (44.62%) in the poisoning group and 58 cases (44.62%) in the poisoning death group. 13 cases (56.52%) were elderly, the average age of death group was 58 (+ 18.638) years, the average age of survival group was 44.89 (+ 15.121) years, the difference between the two groups was statistically significant (P 0.01); (2) 130 cases of ASOPP patients, the dosage of medication was 10-500 ml, the average dosage of medication was 102.19 (+ 88.388 ml); the dosage of medication of survival group was 50 (50, 100) ml, and the death rate was 50 (50, 100) ml). The dosage of HP in the death group was 100 (100,250) ml, and the dosage of HP in the death group was more than that in the survival group, the difference was statistically significant (P 0.01); (3) The time from taking medicine to gastric lavage in the death group was longer than that in the survival group, and the proportion of HP in the survival group was lower than that in the survival group, the difference between the two groups was statistically significant (P 0.01); (4) The laboratory immediately after admission was significantly different (P 0.01). During the examination, the levels of cholinesterase, serum calcium, PH, PaO 2, HCO 3 - in the death group were lower than those in the survival group, and the differences between the two groups were statistically significant (all P 0.01); the levels of blood glucose, ALT, CRE, blood amylase, creatine kinase isoenzyme, Lac, PaCO 2 in the death group were higher than those in the survival group, and the differences between the two groups were statistically significant (all P 0.05); (5) The levels of blood glucose, ALT, CRE, creatine kinase isoenzyme The GCS score of ASOPP group was significantly lower than that of the survival group, APACHE II score was higher than that of the survival group, and there was significant difference between the two groups (all P 0.01); (6) When ASOPP, the main types of organ damage included brain, lung, heart, circulation, liver, kidney, pancreas, gastrointestinal tract, brain, lung, heart most frequently involved, followed by pancreas; the incidence of organ damage in the survival group was due to pancreas. The types of organs from high to low were brain, lung, pancreas, heart, liver, circulation, kidney and death group, the incidence of organ damage from high to low were brain, heart, lung, gastrointestinal tract, circulation, pancreas, liver, kidney; the incidence of pancreas damage was not statistically significant between the two groups (P 0.05). The incidence of residual organ damage in death group was higher than that in survival group. There were significant differences between the two groups (all P 0.01); the number of early simultaneous organ damage in the death group was 4 (4,5), which was significantly higher than that in the survival group (0,1), and there was significant difference between the two groups (P 0.01); (7) Spearman correlation analysis indicated a strong correlation with prognosis (absolute value of correlation coefficient R 0.4). Blood glucose (r = 0.417), serum calcium (r = - 0.415), PH (r = - 0.469), Lac (r = 0.469), PaO 2 (r = - 0.409), GCS score (r = - 0.649), APACHE II score (r = - 0.592), organ damage number (r = 0.661), the differences were statistically significant (all P 0.01); blood glucose, Lac, APACHE II score, organ damage number were positively correlated with prognosis, blood calcium, PH, PHO 2, and organ damage number. GCS scores were negatively correlated with prognosis; (8) The area under the ROC curve (AUC) used to evaluate the prognostic value of each index for ASOPP patients was in turn the number of organ damage [AUC = 0.981, confidence interval (95% CI) = 0.959-1.0, P 0.01], GCS score [AUC = 0.951, confidence interval (95% CI) = 0.913-0.989, P 0.01], APACHE II score [AUC = 0.947, P 0.947, P 0.01]. 鍖洪棿(95%CI)=0.906~0.988,P0.01],Lac[AUC=0.855,鍙俊鍖洪棿(95%CI)=0.781~0.928,P0.01],PH[AUC=0.855,鍙俊鍖洪棿(95%CI)=0.752~0.958,P0.01],琛，

本文編號：2223726