希恩综合征并发垂体危象患者精神异常的影响因素分析

Influencing Factors for Mental Disorders Occurring in Sheehan's Syndrome Patients with Pituitary Crisis

背景希恩综合征患者在救治过程中出现精神异常的案例时有报道,并发垂体危象者表现更为突出,这给进一步的救治带来困难,目前关于希恩综合征并发垂体危象患者发生精神异常相关影响因素的研究较少。目的探讨希恩综合征并发垂体危象的患者治疗过程中发生精神异常的影响因素。方法选取2010年1月—2019年8月于遵义医科大学附属医院内分泌科住院治疗的并发垂体危象的希恩综合征患者47例为研究对象,根据是否发生精神异常分为精神异常组(PS组,n=20)及非精神异常组(NPS组,n=27)。测量患者血压、身高、体质量,计算其体质指数(BMI),采集治疗前肘静脉血测血红蛋白、血清钠离子、血糖、游离三碘甲状腺原氨酸(FT3)、游离甲状腺素(FT4)、促甲状腺激素(TSH)、卵泡刺激素(FSH)、黄体生成素(LH)、催乳素(PRL)、雌二醇(E2)、生长激素(GH)、促肾上腺皮质激素(ACTH)、皮质醇(COR),空腹采集静脉血测总胆固醇(TC)、三酰甘油(TG),收集首个24 h氢化可的松(HC)用量及发生精神异常前HC的累积用量,并比较两组间有无差异。采用二元Logistic回归分析探讨发生精神异常的影响因素,采用受试者工作特征(ROC)曲线评价血清钠离子水平、24 h HC及血清钠离子联合24 h HC对希恩综合征并发垂体危象患者出现精神异常的预测价值。结果PS组SBP、血清钠离子水平低于NPS组,而ACTH、24 h HC、发生精神异常前HC的累积用量高于NPS组(P<0.05)。二元Logistic回归分析结果显示,血清钠离子水平〔OR=0.848,95%CI(0.761,0.945)〕、24 h HC〔OR=1.066,95%CI(1.006,1.130)〕是发生精神异常的影响因素(P<0.05)。24 h HC预测精神异常发生的ROC曲线下面积(AUC)为0.756〔95%CI(0.614,0.897),P<0.01〕,最佳截断值为135.0 mg,灵敏度为0.750,特异度为0.667;血清钠离子预测精神异常发生的AUC为0.744〔95%CI(0.599,0.890),P<0.01〕,最佳截断值为119.6 mmol/L,灵敏度为0.741,特异度为0.700;两者联合预测精神异常发生的AUC为0.855〔95%CI(0.748,0.961),P<0.01〕,灵敏度为0.899,特异度为0.650。2例患者入院前4 h HC用量为100 mg,后20 h缓慢静脉滴注HC,总量达350 mg,未发生精神异常。结论首个24 h较高量的HC及较低水平的血清钠离子可能与希恩综合征并发垂体危象患者精神异常的发生有关,起始小剂量激素并控制给药速度可能降低其发生精神异常的风险。

Background It is reported that mental disorders occur in some Sheehan's Syndrome(SS)patients during treatment,which is more prevalent in those with pituitary crisis,bringing difficulties to further treatment.At present,there are few studies on the influencing factors of mental disorders in patients with SS and pituitary crisis.Objective To investigate the influencing factors of mental disorders in SS patients with pituitary crisis during treatment.Methods A total of 47 SS patients with pituitary crisis from the Affiliated Hospital of Zunyi Medical University were enrolled from January 2010 to August 2019,and were divided into psychiatric symptoms group(PS group,n=20)and normal psychiatric symptoms group(NPS group,n=27)by the prevalence of mental disorders.Blood pressure,height and body weight,calculated BMI,and levels of parameters〔hemoglobin,serum sodium ion,glucose,free triiodothyronine,free thyroxine,thyroid stimulating hormone,follicular hormon,luteinizing hormone,prolactin,estradiol,growth hormone,adrenocorticotropic hormone(ACTH)and cortisol〕in the blood sample withdrawn from forearm veins,blood lipid parameters(total cholesterol and triglyceride)in the fasting peripheral venous blood sample were collected.The dosage of hydrocortisone(HC)in the first 24 hours of treatment and the dosage of HC before the mean occurrence time of mental disorders were also collected.Binary Logistic regression was used to explore the influencing factors of mental disorders.ROC analysis was conducted to evaluate the values of serum sodium ion,HC in the first 24 hours of treatment and the combination of them in predicting mental disorders.Results Compared with NPS group,the mean levels of systolic blood pressure and serum sodium ion in PS group were significantly decreased(P<0.05),but ACTH HC in the first 24 hours of treatment and the mean dosage of HC before the mean occurrence time of mental disorders were significantly increased(P<0.05).Binary Logistic regression analysis showed that HC in the first 24 hours of treatment〔OR=1.066,95%CI(1.006,1.130)〕and serum sodium ion〔OR=0.848,95%CI(0.761,0.945)〕were associated with mental disorders(P<0.05).For predicting mental disorders,the AUC of HC in the first 24 hours of treatment was 0.756〔95%CI(0.614,0.897),P<0.01〕,with 0.750 sensitivity and 0.667 specificity when the optimal cutoff value was chosen as 135.0 mg.The AUC of serum sodium ion level was 0.744〔95%CI(0.599,0.890),P<0.01〕,with 0.741 sensitivity and 0.700 specificity when the optimal cutoff value was chosen as 119.6 mmol/L.And the AUC of the combination of these two indicators was 0.855〔95%CI(0.748,0.961),P<0.01〕,and the sensitivity and specificity were 89.9%and 65.0%,respectively.Two cases received 350 mg HC in total but without mental disorders,the first 100 mg was administered within four hours before admission,and the remaining 350 mg was administered by slow intravenous drip infusion within 20 hours after admission Conclusion Higher dose of HC in the first 24 hours of treatment and lower level of serum sodium ion may increase the risk of mental disorders in SS patients with pituitary crisis.Starting with a small dose of hormone and controlling the rate of administration may reduce the risk of mental disorders.