影响创伤性膈疝或膈肌损伤病死率的危险因素分析——附51例报告

Analysis of risk factors influencing mortality in traumatic diaphragmatic hernia or diaphragmatic injury

目的：探讨影响创伤性膈疝（traumatic diaphragmatic hernia，TDH）或膈肌损伤痛死率的危险因素。方法：收集51例TDH或膈肌损伤患者的临床资料，对死亡者（死亡组）与存活者（存活组）的临床资料进行对照研究，对12种相关因素进行统计学分析。结果：51例中，死亡9例，病死率为18％，死于早期（入院24h内）失血性休克4例，死于术后严重并发症5例，其中严重感染并ARDS2例、严重感染1例、ARDS1例、MODS1例。经统计学分析，2组间的年龄、损伤严重度记分分值、围手术期输血量、入院时有休克表现、术后并发症、入院时收缩压、脾脏损伤等级共7个因素的比较差异有统计学意义（均为P〈0．01），经多因素回归分析，围手术期输血量等于或大于1400mL、脾脏损伤等于或大于Ⅲ级等2个危险因素是TDH或膈肌损伤死亡的独立预测指标（比数比分别为41、74，P〈0．05—0．01）。结论：TDH或膈肌损伤患者术前有严重合并伤尤其是脾脏严重损伤，围手术期大量出血或术后出现严重并发症，提示预后较差。

Objective： To investigate the risk factors influencing mortality in traumatic diaphragmatic hernia （TDH） or diaphragmatic injury. Methods： Collecting the clinical data from the 51 patients admitted with TDH or diaphragmatic injury, and a contrast study was performed for exploring possible risk factors among 12 variables in the survival group and the death group by using statistic analysis. Results： Nine of fifty-one patients died and mortality was 18%, 4 patients died of hemorrhagic shock at early stage （ 〈24 h） and 5 patients died of postoperative sever complications, including sever infections and ARDS （ n = 2 ）, sever infections （ n = 1 ）, ARDS （ n = 1 ） and MODS（n = 1 ）. Age, injury serverity score（ISS）, volume of transfusion in perioperative period, on admission in shock, postoperative complications, systolic pressure and spleen injury scale etc 7 factors were different statistically between the two groups（ both P 〈 0. 01 ）by statistics analysis. Logistic regression analysis demonstrated that volume of transfusion during perioperative period ≥ 1 400 mL（ OR = 41 ） and spleen injury scale ≥ Ⅲ （ OR=74） were both the independent predictors for mortality in TDH or diaphragmatic injury （P 〈 0. 05 - 0. 01 ）. Conclusion： Sever associated injuries preoperatively especially sever splenic injury, bleeding too mach during perioperative period and sever complications postoperatively prompt bad prognosis in TDH or diaphragmatic injury patients.