重症中暑患者入院早期凝血功能指标与预后的关系

Relationship between early coagulability parameters at admission and outcome in patients with severe heatstroke

目的探讨重症中暑患者入院早期凝血功能指标与预后的关系。方法回顾分析广州军区广州总医院2002年1月1日至2013年8月31日176例重症中暑患者的临床资料，按照患者预后分为存活组（150例）和死亡组（26例）。收集患者入院24h内凝血功能指标的初始值，比较两组患者凝血酶原时间（PT）、活化部分凝血活酶时间（APTT）、血小板计数（PLT）的差异，对有统计学意义的指标进行受试者工作特征曲线（ROC曲线）分析，判断其对预后的预测作用。结果与存活组比较，死亡组PT、APTT明显延长[PT（s）：34．0（18．8，45．6）比18．4（13．8，18．0），z=-6．09，P=0．000；APTT（s）：79．7（41．0，91．2）比60．8（33．4，41．0），Z=-5．08，P=0．000]，PLT明显降低[×10^9／L：60．8（4．7，95．3）比128．4（79．8，180．8），z=-4．34，P=0．000]。PT预测重症中暑患者死亡的ROC曲线下面积（AUC）为0．874，面积的标准误为0．028，其95％可信区间（95％CI）为0．819。0．927（P=0．000），在最佳诊断界点为18．5s时，敏感度和特异度分别为76．9％和20．0％；APTT预测重症中暑患者死亡的AUC为0．812，面积的标准误为0．047，其95％CI为0．740～0．903（P=0．000），在最佳诊断界点为46．55s时，敏感度和特异度分别为69．2％和14．0％；PLT预测重症中暑患者死亡的AUC为0．767，面积的标准误为0．040，其95％CI为0．688—0．845（P=0．000），在最佳诊断界点为86．5×10^9／L时，敏感度和特异度分别为68．0％和36．8％。结论重症中暑患者早期PT、APTT延长及PLT降低提示病死率增加，对于重症中暑患者死亡具有预测作用。

Objective To discuss the relationship between early coagulability parameters at admission in patients with severe heatstroke and their outcome. Methods The data from 176 patients with severe heatstroke admitted to Guangzhou General Hospital of Guangzhou Military Command from January 1st, 2002 to August 31st, 2013 were retrospectively analyzed. The patients were divided into survival group （n = 150） and non-survival group （n =26） according to the outcome. The incipient values of coagulability function indexes within 24 hours after admission were collected, and prothrombin time （PT）, activated partial thromboplastin time （APTT） and platelet count （PLT） were compared between two groups to assess the statistically significant indexes for the analysis of the relationship between coagulability parameters and outcome with receiver operator characteristic curve （ROC curve）. Results Compared with those in survival group, PT and APTT were significantly prolonged in non-survival group [PT is）： 34.0 （18.8, 45.6） vs. 18.4 （13.8, 18.0）, Z=-6.09, P=0.000; APTT is）： 79.7 （41.0, 91.2） vs. 60.8（33.4, 41.0）, Z=-5.08, P= 0.000]. The PLT counts were significantly lower in the non-survival group than those in survival group [ × 10^9/L： 60.8 （4.7, 95.3 ） vs. 128.4 （ 79.8, 180.8）, Z=-4.34, P= 0.000 ]. ROC curve analysis showed that the area under ROC curve （AUC） for PT in predicting the death of patients with severe heatstroke was 0.874, with standard error of 0.028 and 95% confidence interval （95%CI） of 0.819-0.927 （P=0.000）. The best cut-offwas 18.5 s, with sensitivity of 76.9% and specificity of 20.0%. AUC for APTT in predicting the death of patients with severe heatstroke was 0.812, with standard error of 0.047 and 95%CI of 0.740-0.903 （P=0.000）. The best cut-off was 46.55 s, with sensitivity of 69.2% and specificity of 14.0%. AUC for PLT in predicting the death of patients with severe heatstroke was 0.767, with standard error of 0.040 and 95%CI of 0.688-0.845 （P=0.000）. The best cut-off was 86.5 × 10^9/L, with sensitivity of 68.0% and specificity of 36.8%. Conclusion Early prolonged PT and APTT and reduced PLT count are associated with increased risk of death, and it can predict a poor outcome in patients with severe heatstroke.