重型颅脑损伤患者去骨瓣减压前后红细胞压积差值对预后的影响
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摘要
目的探索行去骨瓣减压术的重型颅脑损伤患者手术前后红细胞压积差值对1个月内预后的影响及其影响因素。方法选取2013至2017年在汕头大学医学院第二附属医院急诊科及神经外科救治的重型颅脑损伤且行去骨瓣减压术的142例患者进行回顾性研究,其中男性106例,女性36例;年龄18～74岁,平均(43.68±13.93)岁。多因素逻辑回归分析影响患者1个月内短期预后的因素,用ROC曲线定量分析手术前后红细胞压积差值对患者短期预后的影响,多元线性回归分析影响手术前后红细胞压积差值的因素。结果患者1个月内的病死率为29.62%(41/142),多因素逻辑回归分析发现年龄(OR 1.070 [95%CI 1.026～1.116],P<0.05)、格拉斯哥昏迷评分(GCS)(OR 0.701 [95%CI 0.549～0.894],P<0.05)、术后红细胞压积(OR 0.841 [95%CI 0.723～0.979],P<0.05)和手术前后红细胞压积差值(OR 1.246 [95%CI 1.056～1.471],P<0.05)是影响患者短期预后的独立危险因素。多因素线性回归分析发现损伤严重度评分(ISS)(β=0.263,P<0.05)、术前红细胞压积(β=0.373,P<0.05),手术时间(β=1.268,P<0.05)、术中晶体输入量(β=0.002,P<0.05)和术中胶体输入量(β=0.002,P<0.05)是影响手术前后红细胞压积差值变化的独立影响因素。ROC曲线上手术前后红细胞压积差值的最佳预测值是14%(敏感度76.2%,特异度26.0%,曲线下面积0.792),手术前后红细胞压积差值>14%的患者,病死率高达43%。结论手术前后红细胞压积差值是影响重型颅脑损伤患者短期预后的独立危险因素,通过控制手术时间或术前适当稀释血液等方法减少手术前后红细胞压积差值,可能对患者的短期预后有益。
Objective To determine the predictive value of the change in hematocrit(Hct) before and after decompressive craniectomy on short-term prognosis of traumatic brain injury patients and to elucidate the influential factors of the delta Hct. Methods Records of 142 head-injured patients, who underwent unilateral decompressive craniectomy in our hospital, were retrospectively collected between 2013 and 2017. Among them, there were 106 males and 36 females,whose age ranged from 18 to 74 years with the average age of 43.68 years. Multivariate logistic regression analysis was used to determine the factors that affected short-term(within one month) prognosis. Delta Hct(postoperative Hct minus initial Hct) and other factors were applied to predict the 30-day outcome. Sensitivity,specificity and receiver operating characteristic curves were calculated for delta Hct vs. short-term mortality. Multiple linear regression was used to study factors influencing the delta Hct. Results The short-term mortality was 29.62%(41/142). Multivariate logistic regression analysis showed that age(OR 1.070 [95% CI 1.026-1.116], P<0.05), GCS score(OR 0.701 [95% CI 0.549-0.894], P<0.05), postoperative Hct(OR 0.841 [95% CI 0.723-0.979], P<0.05) and delta Hct(OR 1.246 [95% CI 1.056-1.471], P<0.05) were independent risk factors for short-term death. Multiple linear regression showed that the ISS score(β=0.263, P<0.05), initial Hct(β=0.373, P<0.05), the time of operation(β=1.268, P<0.05), crystal quantity(β=0.002, P<0.05) and colloid quantity(β=0.002, P<0.05) were independent influential factors of the delta Hct. We found the best critical value of delta Hct was 14%(sensitivity 76.2%, specificity 26.0%, AUC 0.792)and the short-term mortality of decompressive craniectomy patients was 43% if greater than 14%. Conclusions The delta Hct, postoperative Hct, GCS score and age are independent risk factors for short-term mortality. By controlling the duration of operation or appropriately diluting blood before operation and administering limited fluid resuscitation, we can lower delta Hct during the operation, which may improve the short-term prognosis for those patients.
Objective To determine the predictive value of the change in hematocrit(Hct) before and after decompressive craniectomy on short-term prognosis of traumatic brain injury patients and to elucidate the influential factors of the delta Hct. Methods Records of 142 head-injured patients, who underwent unilateral decompressive craniectomy in our hospital, were retrospectively collected between 2013 and 2017. Among them, there were 106 males and 36 females,whose age ranged from 18 to 74 years with the average age of 43.68 years. Multivariate logistic regression analysis was used to determine the factors that affected short-term(within one month) prognosis. Delta Hct(postoperative Hct minus initial Hct) and other factors were applied to predict the 30-day outcome. Sensitivity,specificity and receiver operating characteristic curves were calculated for delta Hct vs. short-term mortality. Multiple linear regression was used to study factors influencing the delta Hct. Results The short-term mortality was 29.62%(41/142). Multivariate logistic regression analysis showed that age(OR 1.070 [95% CI 1.026-1.116], P<0.05), GCS score(OR 0.701 [95% CI 0.549-0.894], P<0.05), postoperative Hct(OR 0.841 [95% CI 0.723-0.979], P<0.05) and delta Hct(OR 1.246 [95% CI 1.056-1.471], P<0.05) were independent risk factors for short-term death. Multiple linear regression showed that the ISS score(β=0.263, P<0.05), initial Hct(β=0.373, P<0.05), the time of operation(β=1.268, P<0.05), crystal quantity(β=0.002, P<0.05) and colloid quantity(β=0.002, P<0.05) were independent influential factors of the delta Hct. We found the best critical value of delta Hct was 14%(sensitivity 76.2%, specificity 26.0%, AUC 0.792)and the short-term mortality of decompressive craniectomy patients was 43% if greater than 14%. Conclusions The delta Hct, postoperative Hct, GCS score and age are independent risk factors for short-term mortality. By controlling the duration of operation or appropriately diluting blood before operation and administering limited fluid resuscitation, we can lower delta Hct during the operation, which may improve the short-term prognosis for those patients.
引文
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8 Boutin A,Chasse M,Shemilt M,et al.Red blood cell transfusion in patients with traumatic brain injury:a systematic review and meta- analysis[J].Transfus Med Rev,2016,30(1):15- 24.
9 Anglin CO,SPence JS,Warner MA,et al.Effects of platelet and plasma transfusion on outcome in traumatic brain injury patients with moderate bleeding diatheses[J].J Neurosurg,2013,118(3):676- 686.
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11 Rosenfeld JV,Maas AI,Bragge P,et al.Early management of severe traumatic brain injury[J].Lancet,2012,380(9847):1088- 1098.
12 Mercier E,Boutin A,Lauzier F,et al.Predictive value of S- 100beta protein for prognosis in patients with moderate and severe traumatic brain injury:systematic review and meta- analysis[J].BMJ,2013,346:f1757.
13 Montenigro PH,CorP DT,Stein TD,et al.Chronic traumatic encephalopathy:historical origins and current perspective[J].Annu Rev Clin Psychol,2015,11:309- 330.
14 Nyam TE,Ao KH,Hung SY,et al.FOUR score predicts early outcome in patients after traumatic brain injury[J].Neurocrit Care,2017,26(2):225- 231.
15 Sun H,Lingsma HF,Steyerberg EW,et al.External validation of the international mission for prognosis and analysis of clinical trials in traumatic brain injury:prognostic models for traumatic brain injury on the study of the neuroprotective activity of progesterone in severe traumatic brain injuries trial[J].J Neurotrauma,2016,33(16):1535- 1543.
16 Thorson CM,Van Haren RM,Ryan ML,et al.Admission hematocrit and transfusion requirements after trauma[J].J Am Coll Surg,2013,216(1):65- 73.
17 Carney N,Totten AM,O'Reilly C,et al.Guidelines for the management of severe traumatic brain injury,fourth edition[J].Neurosurgery,2017,80(1):6- 15.
18 Fletcher JJ,Bergman K,Blostein PA,et al.Fluid balance,complications,and brain tissue oxygen tension monitoring following severe traumatic brain injury[J].Neurocrit Care,2010,13(1):47- 56.
19 Vedantam A,Robertson CS,GoPinath SP.Quantitative cerebral blood flow using xenon- enhanced CT after decompressive craniectomy in traumatic brain injury[J].J Neurosurg,2018,129(1):241- 246.
20 Emami P,Czorlich P,Fritzsche FS,et al.Impact of glasgow coma scale score and pupil parameters on mortality rate and outcome in pediatric and adult severe traumatic brain injury:a retrospective,multicenter cohort study[J].J Neurosurg,2017,126(3):760- 767.
21 Rossaint R,Bouillon B,Cerny V,et al.The european guideline on management of major bleeding and coagulopathy following trauma:fourth edition[J].Crit Care,2016,20:100.
22 Naqash IA,Draboo MA,Lone AQ,et al.Evaluation of acute normovolemic hemodilution and autotransfusion in neurosurgical patients undergoing excision of intracranial meningioma[J].J Anaesthesiol Clin Pharmacol,2011,27(1):54- 58.
23 Barile L,Fominskiy E,Di Tomasso N,et al.Acute Normovolemic hemodilution reduces allogeneic red blood cell transfusion in cardiac surgery:a systematic review and meta- analysis of randomized trials[J].Anesth Analg,2017,124(3):743- 752.
2 Kolias AG,KirkPatrick PJ,Hutchinson PJ.Decompressive craniectomy:past,present and future[J].Nat Rev Neurol,2013,9(7):405- 415.
3 Khan AD,Elseth AJ,Head B,et al.Indicators of survival and favorable functional outcomes after decompressive craniectomy:a multi- institutional retrospective study[J].Am Surg,2017,83(8):836- 841.
4 Kolias AG,Adams H,Timofeev I,et al.Decompressive craniectomy following traumatic brain injury:developing the evidence base[J].Br J Neurosurg,2016,30(2):246- 250.
5 Huang YH,Lee TC,Lee TH,et al.Thirty- day mortality in traumatically brain- injured patients undergoing decompressive craniectomy[J].J Neurosurg,2013,118(6):1329- 1335.
6 Shutter LA,Timmons SD.Intracranial pressure rescued by decompressive surgery after traumatic brain injury[J].N Engl J Med,2016,375(12):1183- 1184.
7 Thorson CM,Ryan ML,Van Haren RM,et al.Change in hematocrit during trauma assessment predicts bleeding even with ongoing fluid resuscitation[J].Am Surg,2013,79(4):398- 406.
8 Boutin A,Chasse M,Shemilt M,et al.Red blood cell transfusion in patients with traumatic brain injury:a systematic review and meta- analysis[J].Transfus Med Rev,2016,30(1):15- 24.
9 Anglin CO,SPence JS,Warner MA,et al.Effects of platelet and plasma transfusion on outcome in traumatic brain injury patients with moderate bleeding diatheses[J].J Neurosurg,2013,118(3):676- 686.
10 Jiang JY,Chinese Head Trauma Study Collaborators.Head trauma in China[J].Injury,2013,44(11):1453- 1457.
11 Rosenfeld JV,Maas AI,Bragge P,et al.Early management of severe traumatic brain injury[J].Lancet,2012,380(9847):1088- 1098.
12 Mercier E,Boutin A,Lauzier F,et al.Predictive value of S- 100beta protein for prognosis in patients with moderate and severe traumatic brain injury:systematic review and meta- analysis[J].BMJ,2013,346:f1757.
13 Montenigro PH,CorP DT,Stein TD,et al.Chronic traumatic encephalopathy:historical origins and current perspective[J].Annu Rev Clin Psychol,2015,11:309- 330.
14 Nyam TE,Ao KH,Hung SY,et al.FOUR score predicts early outcome in patients after traumatic brain injury[J].Neurocrit Care,2017,26(2):225- 231.
15 Sun H,Lingsma HF,Steyerberg EW,et al.External validation of the international mission for prognosis and analysis of clinical trials in traumatic brain injury:prognostic models for traumatic brain injury on the study of the neuroprotective activity of progesterone in severe traumatic brain injuries trial[J].J Neurotrauma,2016,33(16):1535- 1543.
16 Thorson CM,Van Haren RM,Ryan ML,et al.Admission hematocrit and transfusion requirements after trauma[J].J Am Coll Surg,2013,216(1):65- 73.
17 Carney N,Totten AM,O'Reilly C,et al.Guidelines for the management of severe traumatic brain injury,fourth edition[J].Neurosurgery,2017,80(1):6- 15.
18 Fletcher JJ,Bergman K,Blostein PA,et al.Fluid balance,complications,and brain tissue oxygen tension monitoring following severe traumatic brain injury[J].Neurocrit Care,2010,13(1):47- 56.
19 Vedantam A,Robertson CS,GoPinath SP.Quantitative cerebral blood flow using xenon- enhanced CT after decompressive craniectomy in traumatic brain injury[J].J Neurosurg,2018,129(1):241- 246.
20 Emami P,Czorlich P,Fritzsche FS,et al.Impact of glasgow coma scale score and pupil parameters on mortality rate and outcome in pediatric and adult severe traumatic brain injury:a retrospective,multicenter cohort study[J].J Neurosurg,2017,126(3):760- 767.
21 Rossaint R,Bouillon B,Cerny V,et al.The european guideline on management of major bleeding and coagulopathy following trauma:fourth edition[J].Crit Care,2016,20:100.
22 Naqash IA,Draboo MA,Lone AQ,et al.Evaluation of acute normovolemic hemodilution and autotransfusion in neurosurgical patients undergoing excision of intracranial meningioma[J].J Anaesthesiol Clin Pharmacol,2011,27(1):54- 58.
23 Barile L,Fominskiy E,Di Tomasso N,et al.Acute Normovolemic hemodilution reduces allogeneic red blood cell transfusion in cardiac surgery:a systematic review and meta- analysis of randomized trials[J].Anesth Analg,2017,124(3):743- 752.