骨科手术后肺栓塞死亡的危险因素研究

Prognostic factors for patients with pulmonary thromboembolism after orthopaedic surgery

目的:分析骨科手术后急性肺栓塞临床特征并探讨其死亡预测因素。方法:收集1997年5月至2010年5月北京积水潭医院骨折、关节置换、脊椎疾病、骨肿瘤手术后确诊的肺栓塞(pulmonary thromboembolism,PTE)患者134例,按住院期间是否死亡分为死亡组(n=28)和存活组(n=106)。分别分析其临床症状、心电图、动脉血气、X线胸片、超声心动图特征以及丙氨酸转氨酶(alanine transaminase,ALT)、天冬氨酸转氨酶(aspartate aminotransferase,AST)、γ谷氨酰转肽酶(gamma-glutamyl transpeptidase,γ-GT)、乳酸脱氢酶(lactate dehydrogenase,LDH)、肌酸激酶(creatine kinase,CK)、肌酸激酶同工酶(creatine kinase isoenzyme,CK-MB)的变化,并比较两组间差异。将单因素分析中差异有统计学意义的指标进行多因素Logistic回归分析,评价住院期间死亡的相关因素。结果:死亡组平均年龄高于存活组(P=0.043),晕厥和血压降低发生率也高于存活组(P=0.009,P=0.041),而动脉血氧分压p(O2)低于存活组(P=0.035);心电图出现右束支传导阻滞、SⅠQⅢTⅢ、超声心动图显示肺动脉高压和右心室运动功能障碍的比例死亡组均高于存活组(P=0.018,P=0.030,P=0.042和P=0.038);死亡组与存活组比较,ALT、LDH、CK-MB升高发生率差异有统计学意义(P=0.042,P=0.035,P=0.017);多因素回归分析显示死亡预测因子包括年龄(OR1.182,95%CI1.010～1.383,P=0.036)、低氧血症(OR1.128,95% CI1.018～1.249,P=0.022)、血压降低(OR3.346,95%CI1.116～10.031,P=0.031)、右心功能不全(OR4.083,95% CI1.040～16.035,P=0.044)和CK-MB升高(OR3.466,95% CI1.054～11.400,P=0.041)。结论:骨科手术后死于急性肺栓塞者血清ALT、LDH和CK-MB升高发生率高于存活者,患者年龄、低氧血症、低血压和右心功能不全是住院期间死亡的危险因素,血清CK-MB水平可能有助于急性PTE的危险分层。

Objective：To determine risk factors associated with failure of endoscopic therapy in acute non-variceal upper gastrointestinal bleeding （ANVUGIB）. Methods： This was a retrospective cohort study of 223 patients admitted to Peking University Third Hospital between 1 January 2005 and 31 December 2009,with acute non-variceal upper gastrointestinal bleeding. Data on clinical presentation,laboratory test,endoscopic findings,and treatment outcomes were collected. Risk factors for treatment fai-lure were identified using multivariable Logistic regression with backward selection. Results： Therapeutic failure rate was 19.3%（43/223）. In univariate analysis,the two groups had significant difference in age,history of gastrointestinal bleeding,ASA,shock,haemoglobin level,Hct,PLT,time of endocopic treatment,gastric ulcer,duodenal ulcer,lesion size and active spurting of blood. Multivariate Logistic regression analysis revealed that shock [odds ratio （OR） 3.058,95% confidence interval （CI） 1.295-7.221],history of gastrointestinal bleeding （OR 2.809,95% CI 1.207-6.539）,PLT〉100×109/L （OR 0.067,95% CI 0.009-0.497）,active spurting of blood（OR 10.390,95%CI 2.835-38.080）and lesion size ≥2.0 cm（OR 7.111,95%CI 1.628-31.069）were risk factors associated with failure of endoscopic therapy . The number of comorbidities〉1 （OR 9.580,95%CI 1.383-66.390）and active spurting of blood （OR 9.971,95%CI 1.820-54.621）were factors related with need for surgical intervention or death. Conclusion： Patients with shock,history of gastrointestinal bleeding,PLT〈100×109 /L,active spurting of blood and large lesion size,have high risks for continued bleeding or rebleeding after endoscopic treatment. These patients may be more likely to benefit from aggressive post-hemostasis care.