选择适宜导管/静脉比对预防ICU患者经外周置入中心静脉导管并发上肢深静脉血栓的价值

The value of selection of appropriate catheter to vein ratio to prevent development of complication of upper extremity deep vein thrombosis related to peripherally inserted central venous catheter in patients at intensive care unit

目的 分析重症加强治疗病房（ICU）经外周置入中心静脉导管（PICC）患者导管/静脉比与PICC相关上肢深静脉血栓（PICC-UEDVT）形成的关系,探讨减少PICC-UEDVT的最佳导管/静脉比.方法 采用回顾性研究方法,选择2013年8月至2016年12月南昌大学第一附属医院重症医学科收治的资料完整且年龄〉18岁、导管留置时间＆gt;1周的69例PICC患者,收集患者的基本情况、疾病相关实验室检查数据、置管情况.依据PICC-UEDVT发生情况将患者分为PICC-UEDVT组与非PICC-UEDVT组;绘制导管/静脉比对PICC-UEDVT发生的受试者工作特征曲线（ROC曲线）,探讨减少PICC-UEDVT的最佳导管/静脉比.结果 69例患者中,PICC-UEDVT组7例,非PICC-UEDVT组62例,PICC-UEDVT发生率为10.14%.置入4 Fr导管者43例,5 Fr者23例,6 Fr者3例,导管/静脉比20%~67%.PICC-UEDVT组既往DVT发生率 〔42.9%（3/7）比6.5%（4/62）〕、升压药物应用率〔57.14%（4/7）比17.74%（11/62）〕、D-二聚体水平〔mg/L：9.0（3.0,12.3）比1.8（1.0,3.6）〕、5Fr导管使用率〔71.4%（5/7）比29.0%（18/62）〕及45%~67%导管/静脉比患者比例〔57.14%（4/7）比17.74%（11/62）〕均明显高于非PICC-UEDVT组,差异均有统计学意义（均P〈0.05）.ROC曲线分析显示：44%的导管/静脉比是最佳临界点,该点的ROC曲线下面积（AUC）=0.755,95%可信区间（95%CI）=0.554~0.955,敏感度=71.4%,特异度=79.0%.使用45%~67%导管/静脉比的患者发生PICC-UEDVT的危险性为20%~44%者的6.182倍〔优势比（OR）=6.182,95%CI=1.208~31.634,P=0.036〕;而0%~32%的PICC-UEDVT发生率与33%~44%比较差异无统计学意义（P=1.000）.结论 44%的导管/静脉比是减少PICC-UEDVT的最佳临界点,具有较高的特异度和敏感度;导管/静脉比〈44%可以降低ICU患者发生PICC-UEDVT的危险性.

Objective To analyze the relationship between the catheter to vein ratio and the formation of peripheral insertion of central venous catheter （PICC） related upper extremity deep venous thrombosis （PICC-UEDVT） in cases having undergone PICC in patients at intensive care unit （ICU） and further identify the best optimal ratio cut-off point to reduce the incidence of PICC-UEDVT.Methods A retrospective study was conducted, including 69 patients having undergone PICC with complete clinical data admitted to the Department of Critical Care Medicine of the First Affiliated Hospital of Nanchang University from August 2013 to December 2016; their ages were 〉 18 years old and catheter indwelling times were 〉 1 week; the patients＇ basic information, disease related laboratory parameters and catheter insertion situation were collected. According to the occurrence of PICC-UEDVT, they were divided into PICC-UEDVT group and non PICC-UEDVT group; the receiver operating characteristic （ROC） curve of the catheter to vein ratio versus the incidence ofPICC-UEDVT was plotted to assess the optimal ratio to reduce the incidence of PICC-UEDVT.Results In the 69 patients, there were 7 patients in the PICC-UEDVT group and 62 patients in the non PICC-UEDVT group, the incidence of PICC-UEDVT being 10.14%. Four, 5 and 6 French （Fr） catheters were indwelled in 43, 23 and 3 cases respectively, and the range of catheter to vein ratio was 20% - 67%. The comparisons between PICC-UEDVT group and non PICC-UEDVT group in various aspects were as follows： the incidence of DVT in the PICC-UEDVT group was significantly higher than that in non PICC-UEDVT group [42.9% （3/7） vs. 6.5% （4/62）], the rate of using vasopressor drugs [57.14% （4/7） vs. 17.74% （11/62）], D-dimer level [mg/L： 9.0 （3.0, 12.3） vs. 1.8 （1.0, 3.6）], patients of indwelling 5Fr catheter [71.4% （5/7） vs. 29.0% （18/62）] and the percentage of patientsapplying catheter to vein ratio 45%-67% [57.14% （4/7） vs. 17.74% （11/62）] in PICC-UEDVT group were all higher than those in the non PICC-UEDVT group, the differences being statistically significant （allP 〈 0.05）. ROC analysis showed that the catheter to vein ratio 44% was the optimal cut off or critical point, the area under the ROC curve （AUC） at that point was 0.755, 95% confidence interval （95%CI） = 0.554-0.955, sensitivity = 71.4% and specificity = 79.0%; compared with the patients using 45%-67% catheter to vein ratio, the incidence of PICC-UEDVT was 6.182 times higher than those using the ratio 20%-44% [odds ratio （OR） = 6.182, 95%CI = 1.208-31.634,P = 0.036]; however, there was no significant difference in incidence of PICC-UEDVT between 20%-32% and 33%-44% （P = 1.000）.Conclusion It is found that the 44% catheter to vein ratio was the optimal critical point to reduce the incidence of PICC-UEDVT, possessing relatively high sensitivity and specificity; applying 〈44% catheter to vein ratio can decrease the risk of PICC-UEDVT occurrence in patients at ICU.