本文選題：急性創(chuàng)傷性凝血病　切入點(diǎn)：預(yù)后　出處：《鄭州大學(xué)》2017年碩士論文

【摘要】：目的急性創(chuàng)傷性凝血病在嚴(yán)重外傷患者的預(yù)后中起著重要作用,越來(lái)越受到急診及重癥醫(yī)師的重視,因其發(fā)展機(jī)制尚未完全闡明,病理生理變化過(guò)程復(fù)雜多變,一直以來(lái),影響其預(yù)后的相關(guān)因素尚未達(dá)成共識(shí)。本研究依托最新的《歐洲創(chuàng)傷診療指南》,針對(duì)有爭(zhēng)議的相關(guān)因素,采用Logistic回歸分析及Cox回歸分析方法,進(jìn)一步探討影響急性創(chuàng)傷性凝血病患者預(yù)后的危險(xiǎn)因素。方法(1)收集2015年2月—2016年12月在鄭州大學(xué)第一附屬醫(yī)院收治的嚴(yán)重創(chuàng)傷患者896例,對(duì)符合急性創(chuàng)傷性凝血病診斷標(biāo)準(zhǔn)的80例患者納入研究;(2)記錄納入研究患者的性別、年齡、創(chuàng)傷嚴(yán)重程度評(píng)分(ISS評(píng)分)、入院3小時(shí)平均基礎(chǔ)體溫、入院24h平均乳酸水平及堿缺失水平、入院72h內(nèi)平均血糖波動(dòng)度、是否輸注高比例血液制品、是否應(yīng)用氨甲環(huán)酸等指標(biāo),以及記錄急性凝血病的確診時(shí)間與凝血功能恢復(fù)正常的時(shí)間;(3)以急性創(chuàng)傷性凝血病的死亡率為因變量,以納入的各相關(guān)因素為自變量,分別對(duì)其進(jìn)行單因素及多因素的Logistic回歸分析;(4)結(jié)合Logistic回歸分析初篩結(jié)果,依據(jù)病情轉(zhuǎn)歸標(biāo)準(zhǔn),對(duì)其達(dá)到轉(zhuǎn)歸標(biāo)準(zhǔn)所經(jīng)歷的時(shí)間進(jìn)行Cox回歸分析。(1)Logistic回歸分析結(jié)果顯示:急性創(chuàng)傷性凝血病患者的性別、年齡與預(yù)后無(wú)關(guān);創(chuàng)傷嚴(yán)重程度評(píng)分(ISS評(píng)分)在單因素Logistic回歸分析中無(wú)統(tǒng)計(jì)學(xué)意義,而在多因素Logistic回歸分析中,結(jié)果有統(tǒng)計(jì)學(xué)意義(P=0.0420.05);在單因素Logistic回歸分析中,入院3小時(shí)平均基礎(chǔ)體溫(P=0.0030.05)、入院24h平均乳酸水平(P=0.0120.05)、入院24h堿缺失水平(P=0.0370.05)均為影響創(chuàng)傷性凝血病患者預(yù)后的影響因素,而入院72h內(nèi)平均血糖波動(dòng)度、是否輸注高比例血液制品、是否應(yīng)用氨甲環(huán)酸在單因素Logistic回歸分析中差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05),但是在多因素Logistic回歸分析中,輸注高比例血液制品(P=0.0080.05)及應(yīng)用氨甲環(huán)酸(P=0.0130.05)是影響預(yù)后的危險(xiǎn)因素,血糖波動(dòng)度仍無(wú)統(tǒng)計(jì)學(xué)意義。(2)轉(zhuǎn)歸分析結(jié)果顯示,對(duì)于創(chuàng)傷性凝血病患者,不同的入院3小時(shí)平均基礎(chǔ)體溫(T≥35℃、33℃≤T35℃、T33℃),其凝血功能恢復(fù)正常所經(jīng)歷的時(shí)間曲線,即轉(zhuǎn)歸曲線差異有統(tǒng)計(jì)學(xué)意義(Log-rank檢驗(yàn)2χ=54.376,P=0.0120.05),同理,入院24h平均乳酸水平(Log-rank檢驗(yàn)2χ=8.141,P=0.0040.05)、入院24h堿缺失水平(Log-rank檢驗(yàn)2χ=14.587,P=0.0010.05)、是否輸注高比例血液制品(Log-rank檢驗(yàn)2χ=7.006,P=0.0080.05),其轉(zhuǎn)歸曲線差異均有統(tǒng)計(jì)學(xué)意義,而入院72h內(nèi)平均血糖波動(dòng)度及是否應(yīng)用氨甲環(huán)酸其轉(zhuǎn)歸曲線差異不明顯;而多變量Cox比例風(fēng)險(xiǎn)回歸分析顯示,入院3小時(shí)平均基礎(chǔ)體溫(RR=0.135,95%CI 0.078~0.233,P=0.021)、入院24小時(shí)乳酸水平(RR=0.249,95%CI 0.125~0.498,P=0.004)、入院24小時(shí)堿缺失水平(RR=0.258,95%CI 0.126~0.527,P=0.010)、入院72小時(shí)平均血糖波動(dòng)幅度(RR=0.392,95%CI 0.227~0.677,P=0.001)、是否接受輸注血液制品(RR=0.273,95%CI 0.157~0.475,P=0.023)、是否應(yīng)用TXA(RR=0.467,95%CI 0.280~0.779,P=0.004)與病情轉(zhuǎn)歸有關(guān)。結(jié)果結(jié)論(1)性別、年齡不是影響急性創(chuàng)傷性凝血病患者預(yù)后的危險(xiǎn)因素,在創(chuàng)傷性凝血病患者預(yù)后評(píng)估中,ISS評(píng)分的價(jià)值不高;入院極早期基礎(chǔ)體溫、酸堿平衡、血糖波動(dòng)幅度、高比例成分輸血、氨甲環(huán)酸是急性創(chuàng)傷性凝血病患者預(yù)后的獨(dú)立影響因素。(2)維持入院3小時(shí)內(nèi)平均基礎(chǔ)體溫大于35℃,控制入院72小時(shí)內(nèi)平均血糖波動(dòng)度小于3.9mmol/L,糾正酸堿失衡,急早期高比例成分輸血及應(yīng)用氨甲環(huán)酸可以明顯縮短凝血功能恢復(fù)正常所需時(shí)間,減少其后期并發(fā)癥的發(fā)生,促進(jìn)病情早期向良性方向轉(zhuǎn)歸。
[Abstract]:Objective acute traumatic coagulopathy plays an important role in the prognosis of patients with severe trauma, more and more severe and emergency medical attention because of its development mechanism has not been fully elucidated, pathophysiological process is complex and changeable, has not yet reached a consensus, the related factors affecting the prognosis. This study is based on the new "European trauma guidelines >, according to the related factors of controversial, analysis using Logistic regression analysis and Cox regression, to further explore the risk factors influencing the prognosis of patients with acute traumatic coagulopathy. Methods (1) from February 2015 to December 2016 in 896 cases of severe trauma patients admitted to the First Affiliated Hospital of Zhengzhou University were included in the study, 80 patients with acute traumatic coagulation diagnostic criteria were included in the study; (2) record the patient's sex, age, injury severity score (ISS score), an average of 3 hours of admission The basal body temperature, admission 24h average level of lactic acid and alkali loss level within 72h after admission average blood glucose fluctuation, whether infusion of high proportion of blood products, whether the application of tranexamic acid and other indicators, and record the acute coagulopathy diagnosis time and coagulation function returned to normal time; (3) the dependent variable of acute traumatic coagulopathy the mortality rate, related factors included as independent variables, separately carried on the Logistic regression analysis of single factor and multi factor; (4) combined with Logistic regression analysis according to the results of screening, prognosis criteria, Cox regression analysis was conducted to reach to standard time. (1) the results of Logistic regression analysis display: acute traumatic coagulopathy in patients with gender, age and prognosis; injury severity score (ISS score) was not statistically significant in univariate Logistic regression analysis, and multivariate Logistic regression In the analysis, the results were statistically significant (P=0.0420.05); in the univariate Logistic regression analysis, 3 hours of admission average basal body temperature (P=0.0030.05), admission 24h (P=0.0120.05), the average level of lactic acid were 24h base deletion level (P=0.0370.05) factors are influence the prognosis of patients with traumatic blood disease, and the average 72h of admission the blood glucose fluctuation degree, a high proportion of the transfusion of blood products, whether the application of tranexamic acid was not statistically significant in the univariate regression analysis the difference of Logistic (P0.05), but in a multivariate Logistic regression analysis, a high proportion of blood products infusion (P=0.0080.05) and the application of tranexamic acid (P=0.0130.05) is the risk factors influencing the prognosis still, the blood glucose fluctuation was not statistically significant. (2) the outcome analysis showed that for patients with traumatic coagulopathy, different admission 3 hours average basal body temperature (T = 35 DEG C, 33 c c c = T35, T33), the coagulation The recovery time of normal curve through blood function, namely the outcome curve was statistically significant (Log-rank test 2 x =54.376, P=0.0120.05), in the same way, the average admission 24h lactate level (Log-rank test 2 x =8.141, P=0.0040.05), admission 24h base deficits (Log-rank test 2 x =14.587, P=0.0010.05), whether the infusion of high the proportion of blood products (Log-rank test 2 x =7.006, P=0.0080.05), the outcome curves were statistically significant difference, while the average blood glucose fluctuation within 72h after admission and whether the application of tranexamic acid in the development curve of the difference is not obvious; and multivariate Cox regression analysis showed that 3 hours of admission, the average temperature (RR=0.135,95%CI 0.078~0.233 P=0.021) 24 hours after admission, the levels of lactic acid (RR=0.249,95%CI 0.125~0.498, P=0.004), 24 hours of admission of alkali (RR=0.258,95%CI 0.126~0.527, P=0.010 deletion level), 72 hours of admission (average blood glucose fluctuation RR=0.392,95%CI 0.227~0.677, P=0.001), whether or not to accept the infusion of blood products (RR=0.273,95%CI 0.157~0.475, P=0.023 TXA (RR=0.467,95%CI), whether the application of 0.280~0.779, P=0.004) associated with disease outcome. Results and conclusions (1) gender, risk factors for the prognosis of patients with acute traumatic coagulopathy were not affected, in assessing the prognosis of patients with traumatic coagulopathy, ISS the value of the score is not high; at very early stage of basal body temperature, acid-base balance, blood glucose fluctuation, high proportion of blood component transfusion, tranexamic acid are independent prognostic factors in patients with acute traumatic coagulopathy. (2) to maintain the average temperature within 3 hours of admission is greater than 35 degrees, the average admission control of blood glucose fluctuation is less than 72 hours 3.9mmol/L, correcting acid-base imbalance, acute and early high proportion of component blood transfusion and application of tranexamic acid can significantly shorten the time required for normal blood clotting function, and reduce the post The occurrence of hair disease, promote the early stage of the disease to a benign direction.

【學(xué)位授予單位】：鄭州大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R641

【參考文獻(xiàn)】

相關(guān)期刊論文 前2條

1 胡世華;蔣文新;楊艷霞;蘇民;鄧明漢;;等比例成分輸血在嚴(yán)重多發(fā)傷合并創(chuàng)傷性凝血病中的臨床應(yīng)用[J];重慶醫(yī)學(xué);2015年01期

2 蘇暄;;賈偉平:“中國(guó)證據(jù)”直示血糖波動(dòng)特征[J];中國(guó)醫(yī)藥科學(xué);2014年12期

，

本文編號(hào)：1722177