【摘要】：目的研究中西醫(yī)結(jié)合治療毒蛇咬傷的方法及與影響毒蛇咬傷患者預(yù)后有關(guān)的獨(dú)立危險(xiǎn)因素,為提前判斷患者預(yù)后及規(guī)范臨床診治提供理論依據(jù)。方法回顧性分析2013年4月~2014年11月,安徽中醫(yī)藥大學(xué)第一附屬醫(yī)院急診科病房收治的232例毒蛇咬傷患者的一般資料及臨床指標(biāo),入選病例標(biāo)準(zhǔn)參照2011年中醫(yī)外科學(xué)術(shù)年會(huì)制定的中西醫(yī)結(jié)合治療毒蛇咬傷的評(píng)分及診斷國(guó)際標(biāo)準(zhǔn)[1]。根據(jù)患者出院前最后一次復(fù)查的血常規(guī)、凝血常規(guī)、心肌酶、肝酶、腎功能、炎癥指標(biāo)等實(shí)驗(yàn)室指標(biāo)及毒蛇咬傷患者癥狀與體征評(píng)分,將患者分為好轉(zhuǎn)組(81例)、痊愈組(151例),對(duì)兩組患者的臨床資料進(jìn)行單因素分析,計(jì)量資料進(jìn)行兩獨(dú)立樣本t檢驗(yàn),計(jì)數(shù)資料采用?2檢驗(yàn),再將可能影響預(yù)后的危險(xiǎn)因素逐步引入logistic回歸分析,P0.05的危險(xiǎn)因素進(jìn)入回歸模型,得出獨(dú)立危險(xiǎn)因素與logistic回歸方程,并檢驗(yàn)回歸模型顯著性。最后對(duì)獨(dú)立危險(xiǎn)因素繪制受試者工作特征曲線(ROC曲線),通過(guò)ROC曲線分析各指標(biāo)在預(yù)測(cè)毒蛇咬傷患者病情輕重及預(yù)后上的價(jià)值。結(jié)果1.好轉(zhuǎn)組:包括出院前最后一次復(fù)查的血清酶學(xué)指標(biāo)未完全恢復(fù)正常,但未達(dá)到MODS診斷標(biāo)準(zhǔn),全身與局部癥狀明顯減輕、傷口基本愈合、積分指數(shù)為30%~89%的患者。共81例(34.9%),其中男性44例(54.3%),女性37例(45.7%),平均年齡(68.3±9.3)歲;痊愈組:包括復(fù)查的血清酶學(xué)指標(biāo)在正常范圍內(nèi),全身與局部癥狀消失、傷口愈合、傷肢功能恢復(fù)、積分指數(shù)≥90%的患者。共151例(65.1%),男性81例(53.6%),女性70例(46.4%),平均年齡(50.4±15.6)歲。兩組患者的的性別無(wú)統(tǒng)計(jì)學(xué)意義,年齡存在顯著差異(P0.01)。2.臨床觀察指標(biāo):毒蛇咬傷好轉(zhuǎn)組患者與痊愈組患者比較,丙氨酸氨基轉(zhuǎn)移酶[(45.6±17.9)U/L vs(38.7±13.4)U/L P0.01],天門(mén)冬氨酸氨基轉(zhuǎn)移酶[(57.1±13.2)U/L vs(46.8±15.8)U/L P㧐0.05],尿素氮[(21.4±9.7)mmol/L vs(18.5±11.3)mmol/LP㩳0.05],血肌酐[(234.7±132.4)μmol/L vs(12.4±63.6)μmol/L P㧐0.05],肌酸激酶[(368.4±163.5)U/L vs(228.9±136.7)U/L P0.01],肌酸激酶同工酶[(23.9±13.4)U/L vs(18.9±5.7)U/L P0.01],總膽紅素[(15.7±6.6)μmol/L vs(18.9±5.7)μmol/L P㩳0.05],超敏C-反應(yīng)蛋白[(23.7±11.4)mg/L vs(16.67±4.69)mg/L P㧐0.05],乳酸脫氫酶[(183.4±51.7)U/L vs(134.5±22.1)U/L P㧐0.05],白細(xì)胞計(jì)數(shù)[(14.9±5.4)×109/L vs(13.7±4.3)×109/L P㩳0.05],凝血酶原時(shí)間[(15.8±3.7)s vs(15.3±2.9)s P㧐0.05],部分凝血酶原時(shí)間[(41.5±13.7)s vs(39.8±12.1)s P㧐0.05]。3.單因素分析結(jié)果顯示:兩組毒蛇咬傷患者的年齡、丙氨酸氨基轉(zhuǎn)移酶、尿素氮、肌酸激酶、肌酸激酶同工酶、總膽紅素、白細(xì)胞計(jì)數(shù),7個(gè)指標(biāo)間差異有統(tǒng)計(jì)學(xué)意義(均P0.05);天門(mén)冬氨酸氨基轉(zhuǎn)移酶、血肌酐、超敏C-反應(yīng)蛋白、乳酸脫氫酶、凝血酶原時(shí)間、部分凝血酶原時(shí)間在兩組差異中無(wú)統(tǒng)計(jì)學(xué)意義(均P0.05)。4.與預(yù)后相關(guān)的多因素分析:根據(jù)單因素分析的結(jié)果,選取其中P0.05的7個(gè)可能影響毒蛇咬傷患者病情及預(yù)后的危險(xiǎn)因素根據(jù)臨床檢驗(yàn)標(biāo)準(zhǔn)賦值后引入Logistic回歸。以0.05為剔除變量的顯著性水準(zhǔn),最后進(jìn)入回歸方程的危險(xiǎn)因素有:年齡(60歲)、丙氨酸氨基轉(zhuǎn)移酶(50 U/L)、肌酸激酶同工酶(24U/L)。5.毒蛇咬傷預(yù)后的危險(xiǎn)因素的ROC曲線下面積分別為:年齡0.895,丙氨酸氨基轉(zhuǎn)移酶0.842,肌酸激酶同工酶0.858。6.年齡,丙氨酸氨基轉(zhuǎn)移酶,肌酸激酶同工酶預(yù)測(cè)效能分析:最佳截?cái)嘀捣謩e為61.4歲60U/L 27U/L;靈敏度分別為82.7%63.0%71.6%;特異度分別為84.1%95.4%96.7%;約登(Youden)指數(shù)分別為0.6682 0.5833 0.6829?結(jié)論單因素分析顯示天門(mén)冬氨酸氨基轉(zhuǎn)移酶、血肌酐、超敏C-反應(yīng)蛋白、乳酸脫氫酶、凝血酶原時(shí)間、部分凝血酶原時(shí)間為影響毒蛇咬傷患者預(yù)后的非危險(xiǎn)因素;年齡、丙氨酸氨基轉(zhuǎn)移酶升高、尿素氮升高、肌酸激酶升高、肌酸激酶同工酶升高、總膽紅素升高、白細(xì)胞計(jì)數(shù)增多為影響毒蛇咬傷患者預(yù)后的危險(xiǎn)因素。多因素logistic回歸分析顯示患者年齡(60歲)、丙氨酸氨基轉(zhuǎn)移酶(50 U/L)、肌酸激酶同工酶(24U/L)這3個(gè)變量進(jìn)入回歸模型,是影響毒蛇咬傷患者預(yù)后的獨(dú)立危險(xiǎn)因素。
[Abstract]:Objective To study the method of the combination of traditional Chinese and western medicine in the treatment of venomous snake bite and the independent risk factors related to the prognosis of the patients with venomous snake bite. Methods The general data and clinical indicators of 232 venomous snake bite patients were analyzed retrospectively from April 2013 to November 2014 in the first Affiliated Hospital of Anhui University of Traditional Medicine. The selected case standard refers to the scoring and diagnosis international standard[1] of the Chinese and western medicine combined with the traditional Chinese and western medicine for the treatment of venomous snake bite in 2011. The patients were divided into the improvement group (81 cases) and the recovery group (151 cases) according to the blood routine, the blood routine, the blood routine, the myocardial enzyme, the liver enzyme, the renal function, the inflammation index and other laboratory indexes before the discharge of the patient and the symptoms and the sign scores of the venomous snake bite patients. The clinical data of two groups of patients were analyzed, and two independent samples of t-test and counting data were used to count the data. 2. The risk factors that could affect the prognosis were gradually introduced into the logistic regression analysis, and the risk factors of P0.05 were introduced into the regression model, and the independent risk factors and the logistic regression equation were obtained, and the significance of the regression model was examined. Finally, the working characteristic curve (ROC curve) of the subject was drawn on the independent risk factors, and the value of each index in predicting the severity and the prognosis of the venomous snake bite was analyzed by the ROC curve. Results 1. The improvement group: The serum enzyme study index, including the last review before discharge, did not return to normal, but did not reach the MODS diagnosis standard, the whole body and the local symptoms were significantly reduced, the wound basically healed, and the integral index was 30% to 89% of the patients. A total of 81 cases (34.9%) were male, including 44 (54.3%),37 (45.7%), mean age (68.3, 9.3), and the recovery group: including the reexamination of the serum enzymic index in the normal range, the disappearance of the whole body and the local symptoms, the healing of the wound, the recovery of the function of the injured limb, The integration index was 90% of the patients. There were 151 (65.1%),81 (53.6%),70 (46.4%) and average (50.4, 15.6) years. There was no significant difference in the sex of the two groups (P0.01). Clinical observation index: compared with the recovery group, alanine aminotransferase[(45.6-17.9) U/ L vs (38.7-13.4) U/ L P0.01], aspartate aminotransferase[(57.1-13.2) U/ L vs (46.8[15.8) U/ L P-0.05], urea nitrogen[(21.4-9.7) mmol/ L vs (18.5[11.3) mmol/ L-0.05], [(234.7-132.4) umol/ L vs (12.4-63.6). mu.mol/ L P-0.05], creatine kinase[(368.4-163.5) U/ L vs (228.9-136.7) U/ L P0.01], creatine kinase isoenzyme[(23.9-13.4) U/ L vs (18.9-5.7) U/ L P0.01], total bilirubin[(15.7-6.6). mu.mol/ L vs (18.9-5.7). mu.mol/ L P-0.05], hypersensitive C-reactive protein[(23.7-11.4) mg/ L vs (16.67-4.69) mg/ L P-0.05], lactate dehydrogenase[(183.4-51.7) U/ L vs (134.5-22.1) U/ L P-0.05], white blood cell count[(14.9-5.4)[109/ L vs (13.7[4.3)[109/ L] P-0.05], prothrombin time[(15.8[3.7) s vs (15.3[2.9) s P-0.05], Partial thromboplastin time[(41.5-13.7) s vs (39.8-12.1) s P-0.05].3. The results of single factor analysis showed that the age, alanine aminotransferase, urea nitrogen, creatine kinase, creatine kinase isoenzyme, total bilirubin, white blood cell count and 7 indexes of the two groups of venomous snake bite were statistically significant (all P0.05); and the aspartate aminotransferase, There was no significant difference between the two groups (P0.05). Multi-factor analysis related to prognosis: according to the results of single factor analysis,7 of the risk factors that may affect the condition and prognosis of the patients with venomous snake bite may be selected according to the result of single factor analysis. Logistic regression is introduced according to the value of clinical test standard. The risk factors of the regression equation were: age (60 years), alanine aminotransferase (50U/ L) and creatine kinase isoenzyme (24U/ L). The area under the ROC curve of the risk factors for the prognosis of the venomous snake bite were: age 0.895, alanine aminotransferase 0.842, and creatine kinase isoenzyme 0.858.6. The best cut-off values were 61.4 and 6U/ L 27U/ L, the sensitivity was 82.7% 63.0% 71.6%, the specificity was 84.1% 95.4% 96.7%, and the denden index was 0.6682 0.5833 0.6829, respectively. Conclusion The single-factor analysis shows the non-risk factors of the prognosis of the patients with the venomous snake bite, including the aspartate aminotransferase, the blood myocarcin, the hypersensitive C-reactive protein, the lactate dehydrogenase, the prothrombin time and the partial thromboplastin time. The increase of urea nitrogen, the increase of creatine kinase, the increase of the isoenzyme of creatine kinase, the increase of total bilirubin and the increase of white blood cell count are the risk factors that affect the prognosis of the patients with venomous snake bite. Logistic regression analysis of multiple factors showed that the three variables of age (60 years), alanine aminotransferase (50 U/ L) and creatine kinase isoenzyme (24U/ L) entered the regression model, which was an independent risk factor that affected the prognosis of the patients with venomous snake bite.
【學(xué)位授予單位】：安徽中醫(yī)藥大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2016
【分類號(hào)】：R269

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