严重创伤性肝损伤患者死亡危险因素分析及早期预测模型的建立与验证  

Assessment of risk factors and development and validation of an early prediction model for mortality in patients with severe traumatic liver injury

作　　者：刘冰 王晓梅 宋创业 刘晓宁 苗建军 李晓武 尚培中 Liu Bing;Wang Xiaomei;Song Chuangye;Liu Xiaoning;Miao Jianjun;Li Xiaowu;Shang Peizhong(Department of General Surgery,Hospital of PLA 81st Group Army,Zhangjiakou 075000,China;Department of Intensive Care Unit,Hospital of PLA 81st Group Army,Zhangjiakou 075000,China)

机构地区：[1]陆军第八十一集团军医院普通外科,张家口075000 [2]陆军第八十一集团军医院重症医学科,张家口075000

出　　处：《中华创伤杂志》2023年第6期528-537,共10页Chinese Journal of Trauma

摘　　要：目的探讨严重创伤性肝损伤(TLI)患者死亡相关的危险因素,建立死亡风险早期预测模型并进行验证。方法采用回顾性队列研究分析重症监护医疗信息集-Ⅳ(MIMIC-Ⅳ)数据库中进入ICU治疗的273例严重TLI患者临床资料,其中男176例,女97例;年龄18~83岁[35.6(25.7,57.5)岁]。根据患者是否院内死亡分为两组,其中生存组253例(92.7%),死亡组20例(7.3%)。比较两组患者性别、年龄、致伤原因、损伤类型、治疗方式、是否大量输血、合并症、进入ICU 24 h内首次检测的生命体征和实验室指标。采用单因素分析评估上述指标与严重TLI患者死亡的相关性,多因素Logistic逐步回归分析确定严重TLI患者死亡的独立危险因素。采用Lasso回归筛选严重TLI患者的死亡预测因子,多因素Logistic回归分析结果构建列线图死亡风险预测模型。采用受试者工作特征曲线下面积(AUC)评价模型的区分度,Hosmer-Lemeshow拟合优度检验和校准曲线评价模型的校准度,临床决策曲线分析(DCA)评价模型的临床适用性。Bootstrap法重复抽样200次进行模型的内部验证,选择急诊重症监护室合作研究数据库(eICU-CRD)中的严重TLI患者(163例)对模型进行外部验证。最后比较列线图模型与其他创伤或重症评分的预测效能。结果单因素分析结果显示,年龄、致伤原因、大量输血、合并慢性肝病、进入ICU 24 h内首次检测的体温、收缩压、舒张压、平均动脉压、休克指数、血小板、红细胞分布宽度(RDW)、平均红细胞血红蛋白浓度(MCHC)、血糖、血尿素氮、肌酐、阴离子间隙、碳酸氢盐、凝血酶原时间(PT)、部分活化凝血活酶时间(APTT)、国际标准化比值(INR)等指标与严重TLI患者死亡有一定相关性(P<0.05或0.01)。多因素Logistic逐步回归分析结果表明,年龄(OR=1.08,95%CI 1.03,1.12,P<0.01)、体温<36℃(OR=8.00,95%CI 2.17,29.53,P<0.01)、休克指数(OR=9.59,95%CI 1.76,52.18,P<0.01)Objective To investigate the risk factors associated with mortality in patients with severe traumatic liver injury(TLI)and to establish and validate an early prediction model for mortality.Methods A retrospective cohort study was conducted to analyze the clinical data of 273 patients with severe TLI admitted to the ICU from the medical information mart for the intensive care-IV(MIMIC-IV)database.The cohort consisted of 176 males and 97 females,with age ranging from 18 to 83 years[35.6 years(25.7,57.5)years].The patients were divided into two groups based on in-hospital mortality:the survival group(253 patients,92.7%)and the death group(20 patients,7.3%).The two groups were compared with regards to gender,age,cause and type of injury,treatment method,massive blood transfusion,comorbidities as well as vital signs and laboratory tests measured within 24 hours of ICU admission.Univariate analysis was used to screen for risk factors associated with mortality in severe TLI patients.Independent risk factors for mortality were determined using multivariate Logistic regression analysis.Lasso regression was used to screen for predictors of mortality,and a nomogram prognostic model was then established through a multivariate Logistic regression analysis.The area under the receiver operating characteristic(ROC)curve(AUC)was used to evaluate the discrimination of the model,while the Hosmer-Lemeshow goodness-of-fit test and calibration curve were used to evaluate the calibration of the model.The model′s clinical applicability was evaluated through decision curve analysis(DCA).Internal validation was performed by the 200 Bootstrap samples,and external validation was performed by using 163 patients with severe TLI from the emergency ICU collaborative research database(eICU-CRD).Finally,the predictive efficacy of the nomogram model was compared to other trauma or severity scores.Results Univariate analysis showed that the age,cause of injury,massive blood transfusion,chronic liver disease and laboratory tests measured within 24

关 键 词：肝 创伤和损伤 死亡 危险因素 列线图 

分 类 号：R575[医药卫生—消化系统]