早期累积液体平衡和血电解质水平对重型创伤性脑损伤患者短期预后的影响  

Impacts of early cumulative fluid balance and serum electrolyte level on the short-term prognosis of patients with severe traumatic brain injury

作　　者：孙小鸽 杨宏富[1] 马宁 刘启龙[1] 王遣 崔秋敏 李平娜 孙荣青[1] SUN Xiaoge;YANG Hongfu;MA Ning;LIU Qilong;WANG Qian;CUI Qiumin;LI Pingna;SUN Rongqing(Department of Intensive Care Unit,the First Affiliated Hospital of Zhengzhou University,Zhengzhou,Henan 450052,China)

机构地区：[1]郑州大学第一附属医院重症医学科,河南郑州450052

出　　处：《中华实用诊断与治疗杂志》2024年第6期568-573,共6页Journal of Chinese Practical Diagnosis and Therapy

基　　金：国家临床重点专科建设项目(2011-873);河南省省直医疗机构服务能力提升工程专科建设项目(豫卫医[2017]66号);河南省医学教育研究项目(Wjlx2020392);河南省医学科技攻关计划联合共建项目(LHGJ20190213)。

摘　　要：目的 观察重型创伤性脑损伤(sTBI)患者早期累积液体平衡和血清电解质水平变化,探讨二者对sTBI患者短期预后的影响。方法 2022年1月—2023年12月郑州大学第一附属医院诊治sTBI患者121例,根据入院28 d内生存情况分为生存组83例和死亡组38例。比较2组入院时急性生理学与慢性健康状况Ⅱ(APACHEⅡ)评分、入院72 h内液体出入量情况(第1、2、3个24 h液体总入量、总出量,48、72 h累积液体平衡,48、72 h液体积累指数)、入院72 h内动脉血气电解质水平(入院时及入院48 h、72 h血钠、血氯水平,入院48、72 h血钠、血氯变化值)。采用多因素logistic回归分析sTBI患者入院28 d内预后不良的影响因素;绘制ROC曲线,评估入院48、72 h影响因素及相应的回归模型预测sTBI患者入院28 d内预后不良的效能;采用Hosmer-Lemeshow拟合优度检验评价模型的校准能力。结果 121例sTBI患者28 d内病死率为31.4%。死亡组APACHEⅡ评分[23.50(22.00,28.00)分]高于生存组[16.00(14.00,19.00)分](Z=7.378,P<0.001)。死亡组第1、2、3个24 h液体总入量,48、72 h累积液体平衡,48、72 h液体积累指数,入院时及入院48、72 h血钠、血氯水平,入院48、72 h血钠、血氯变化值均高于生存组(P<0.05),第1、2、3个24 h液体总出量与生存组比较差异均无统计学意义(P>0.05)。以入院48 h影响因素为自变量,APACHEⅡ评分(OR=1.370,95%CI:1.099~1.707,P=0.005)、48 h液体积累指数(OR=2.463,95%CI:1.336~4.541,P=0.004)、入院48 h血钠变化值(OR=1.235,95%CI:1.045~1.461,P=0.013)是sTBI患者入院28 d内预后不良的影响因素。回归模型1公式为:ln(p/1-p)分别为APACHEⅡ评分、48 h液体积累指数、入院48 h血钠变化值。APACHEⅡ评分、48 h液体积累指数、入院48 h血钠变化值、回归模型1分别以21.00分、0.104、5.5 mmol/L、0.234为最佳截断值,预测sTBI患者入院28 d内预后不良的AUC分别为0.918(95%CI:0.870~0.966,P<0.001)、0.905(95%CI:0.841~0.968Objective To observe the changes of early cumulative fluid balance and serum electrolyte level in patients with severe traumatic brain injury(sTBI),and to explore their impacts on the short-term prognosis of sTBI patients.Methods Totally 121 patients with sTBI were treated in the First Affiliated Hospital of Zhengzhou University from January,2022 to December,2023,and were divided into survival group(n=83)and death group(n=38)based on the prognosis within 28 d after admission.The acute physiology and chronic health evaluationⅡ(APACHEⅡ)scores on admission,fluid intake and outflow in 72 h after admission(total fluid intake and outflow in the first,second and third24 h,cumulative fluid balance in 48 and 72 h,fluid accumulation index in 48 and 72 h),arterial blood gas electrolyte levels in 72 h after admission(blood sodium and chlorine levels on admission and in 48 and 72 h after admission,and changes in blood sodium and chlorine levels in 48 and 72 h after admission)were compared between two groups.Multivariate logistic regression analysis was done to identify the influencing factors of poor prognosis in sTBI patients within 28 d after admission.ROC curves were plotted to evaluate the efficiencies of influencing factors in 48 and 72 h after admission and corresponding regression models on predicting poor prognosis of sTBI patients within 28 d after admission.The Hosmer-Lemeshow goodness of fit test was done to evaluate the calibration ability of the model.Results The mortality rate within 28 d in 121 patients with sTBI was 31.4%.The APACHE II score was higher in death group[23.50(22.00,28.00)]than that in survival group[16.00(14.00,19.00)](Z=7.378,P<0.001).The volumes of total fluid intake in the first,second and third 24 h,the cumulative fluid balance in 48 and 72 h,the fluid accumulation indexes in 48 and 72 h,the blood sodium and chlorine levels on admission and in 48 and 72 h after admission,and the changes in blood sodium and chlorine levels in 48 and 72 h after admission were higher in death group than thos

关 键 词：重型创伤性脑损伤 累积液体平衡 液体积累指数 血电解质 APACHEⅡ评分 

分 类 号：R651.15[医药卫生—外科学]