【摘要】：背景創(chuàng)傷性腦損傷是臨床上較常見的急危重癥,是導(dǎo)致兒童死亡和致殘的重要原因。腦創(chuàng)傷后由于顱內(nèi)血腫、腦水腫等,導(dǎo)致顱內(nèi)壓升高,腦血流的自動調(diào)節(jié)功能受損,腦灌注壓下降,造成繼發(fā)性腦缺血缺氧。利用腦組織氧代謝能早期發(fā)現(xiàn)和治療腦缺血和缺氧,維持腦氧供需的平衡,減輕顱腦創(chuàng)傷后的繼發(fā)性損害,從而改善病人的預(yù)后。乳酸酸中毒在危重癥患者中常見,血液乳酸水平可反映細(xì)胞缺氧和組織低灌注的程度,是評價氧代謝的重要指標(biāo),高乳酸血癥與危重患者的死亡密切相關(guān)。目的探討入院早期血乳酸值對中重型創(chuàng)傷性腦損傷(TBI)患兒死亡的影響及乳酸與危重癥評分、GCS評分、凝血功能之間的相關(guān)關(guān)系。方法1.回顧性納入2011年05月至2014年10月在重慶醫(yī)科大學(xué)附屬兒童醫(yī)院重癥醫(yī)學(xué)科治療的中重型TBI[入院GCS昏迷評分(GCS)≤13分]患兒;2.根據(jù)預(yù)后分為死亡組和存活組;截取年齡、性別、體重、住院時間、入院早期實驗室指標(biāo)(血乳酸、血鉀、血鈉、PLT計數(shù)、PT、APTT、TT、FIB、D-二聚體)和血壓、危重癥評分等;3.用SPSS 21.0統(tǒng)計軟件進行數(shù)據(jù)統(tǒng)計,行兩組間單因素和多因素分析;入院早期血乳酸水平行受試者工作曲線分析,考察血乳酸預(yù)測死亡的最佳界值及其敏感度和特異度;行乳酸與危重癥評分、GCS評分、凝血功能的相關(guān)性分析。結(jié)果1.共109例患兒納入分析。其中存活92例,死亡17例。2.死亡組患兒入院中位血乳酸值、入院中位24小時內(nèi)血乳酸峰值、合并其它臟器損傷率、入院GCS評分≤8和低血壓發(fā)生率明顯高于存活組(4.90 vs.0.80mmo/L,5.00 vs.0.90mmol/L,76.47%vs.42.49%,94.12%vs.45.65%,76.47%vs.7.61%;P值均0.05),凝血功能指標(biāo)PT值、中位APTT值、TT值高于存活組(18.20±5.00s vs.13.76±1.89s,36.90 vs.28.60s,26.41±8.18s vs.19.05±2.60s;P值0.05);而死亡組中位總住院天數(shù)、中位FIB值、入院血鉀低于存活組(2.00 vs.20.00 d,0.54 vs.1.40mg/L,3.38±0.52 vs.3.68±0.57mmol/L;P值均0.05)。3.采用ROC曲線分析發(fā)現(xiàn)入院血乳酸水平是中重型創(chuàng)傷性腦損傷患兒死亡的預(yù)測因子(AUC:0.949,95%CI 0.889 to 0.982,P0.001),乳酸界值為2.5mmo/L,敏感度為88.24%,特異度為90.22%。4.多因素Logistic回歸分析發(fā)現(xiàn)入院乳酸值(OR=1.597;95%CI:1.064-2.399;P=0.024)是中重度創(chuàng)傷性腦損傷患兒死亡的獨立危險因素;而入院GCS≤8、合并其它臟器損傷、血鉀水平和危重癥評分并不是此類患兒死亡的獨立危險因素。5.中重型TBI患兒入院血乳酸水平與危重癥評分、CGS評分呈負(fù)相關(guān)。乳酸水平越高,危重癥評分越低、GCS評分亦越低,提示病情越危重。結(jié)論1.入院早期血乳酸水平可以預(yù)測中重型創(chuàng)傷性腦損傷患兒預(yù)后;2.入院早期高乳酸是中重型創(chuàng)傷性腦損傷患兒死亡的獨立危險因素;3.中重型創(chuàng)傷性腦損傷患兒的早期血乳酸水平與危重癥評分、GCS評分、凝血功能呈顯著相關(guān)性。
[Abstract]:Background traumatic brain injury (TBI) is an important cause of death and disability in children. After brain trauma, intracranial hematoma, brain edema and so on lead to the increase of intracranial pressure, the impairment of automatic regulation of cerebral blood flow, and the decrease of cerebral perfusion pressure, resulting in secondary cerebral ischemia and hypoxia. The early detection and treatment of cerebral ischemia and hypoxia by oxygen metabolism in brain tissue can maintain the balance of cerebral oxygen supply and demand, alleviate the secondary damage after traumatic brain injury, and improve the prognosis of patients. Lactate acidosis is common in critically ill patients. The level of blood lactic acid can reflect the degree of cell hypoxia and tissue hypoperfusion. It is an important index to evaluate oxygen metabolism. Hyperlactic acidemia is closely related to the death of critically ill patients. Objective to investigate the effect of early blood lactic acid on the death of children with moderate and severe traumatic brain injury (TBI) and the correlation between lactic acid and critical grade score (GCS) and coagulation function. Method 1. From May 2011 to October 2014, the patients with moderate and severe TBI [admission GCS coma score (GCS) 鈮，

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