肌红蛋白和D-二聚体对重症中暑的诊断意义:附38例重症中暑患者的临床资料分析

Predictive value of myoglobin and D-dimer on severe heat stroke:a clinical analysis of 38 patients with severe heat stroke

目的探讨重症中暑患者的临床特征及热射病的早期敏感指标,以期对重症中暑患者病情发展进行早期预测。方法选择2018年7月30日至8月5日北京市大兴区人民医院急诊科收治的38例重症中暑患者为研究对象,其中热射病患者30例,包括劳力型热射病(EHS)18例、经典型热射病(CHS)12例;热痉挛与热衰竭患者8例,作为对照组。记录患者的性别、年龄、发病时间,入院时的体温、心率(HR)、血乳酸(Lac)、血小板计数(PLT)、丙氨酸转氨酶(ALT)、天冬氨酸转氨酶(AST)、尿素氮(BUN)、血肌酐(SCr)、Na+等理化指标,以及肌红蛋白(MYO)和D-二聚体阳性率(MYO阳性阈值为107μg/L,D-二聚体阳性阈值为600μg/L),并比较各组指标的差异。绘制受试者工作特征曲线(ROC),分析MYO和D-二聚体对热射病的早期诊断价值。随访所有患者的转归,比较EHS与CHS患者的28 d病死率,探讨EHS患者经积极降温治疗4 h后的体温(T4 h)是否降到38 ℃以下与28 d病死率的关系。结果重症中暑以男性患者居多,特别是EHS患者,且EHS患者年龄较CHS患者更小,发病时间更短,各组间比较差异有统计学意义。EHS组及CHS组患者入院时体温和HR均明显高于对照组〔体温(℃):41.34±0.67、40.39±0.58比37.80±1.39,HR(次/min):139.78±15.63、113.08±17.70比92.00±15.89,均P<0.05〕,PLT均明显低于对照组(×10^9/L:164.94±73.80、165.78±53.49比249.50±84.22,均P<0.05),MYO和D-二聚体阳性率亦均明显高于对照组〔MYO阳性率:100.0%(18/18)、100.0%(12/12)比50.0%(4/8),D-二聚体阳性率:77.8%(14/18)、100.0%(12/12)比12.5%(1/8),均P<0.05〕。ROC曲线分析显示,患者入院时MYO和D-二聚体阳性对热射病均有一定诊断价值,ROC曲线下面积(AUC)分别为0.750、0.871,敏感度分别为50.0%、87.5%,特异度分别为100%、86.7%。EHS组患者28 d病死率明显高于CHS组〔44.4%(8/18)比8.3%(1/12),P<0.05〕;且EHS组中T4 h≥38℃患者28 d病死率明显高于T4 h<38℃者〔70.0%(7/10)比12.5%(1/8),P<0.05〕。结论热射病患者发病早期PLT降低、D-二聚体增高,提示凝血机制损害表现突出;EHS患者具有起病急、病情重、病情进展快、预后差的特点,28 d病死率较CHS患者明显增高;MYO和D-二聚体是热射病的早期敏感指标,可作为热射病早期诊断的参考依据。

Objective To explore the clinical characteristics and early sensitive indicators of severe heat stroke patients in order to predict the development of severe heat stroke in the early stage.Methods Thirty-eight patients with severe heat stroke admitted to emergency department of Beijing Daxing District People's Hospital from July 30th to August 5th in 2018 were enrolled.There were 18 patients suffered from exertional heat stroke(EHS),and 12 patients suffered from classical heat stroke(CHS),and 8 patients with heat spasm and heat exhaustion were selected as control group.The gender,age,onset time,body temperature,heart rate(HR),lactic acid(Lac),platelet(PLT),alanine aminotransferase(ALT),alanine aminotransferase(AST),blood urea nitrogen(BUN),serum creatinine(SCr),serum sodium at admission of hospital,as well as positive rate of myoglobin(MYO)and D-dimer(the positive threshold of MYO and D-dimer was 107μg/L and 600μg/L respectively)were recorded and compared among the groups.Receiver operating characteristic(ROC)curve was plotted to analyze the prognostic value of MYO and D-dimer on heat stroke.The outcome of all patients was followed up,and the 28-day mortality between EHS and CHS patients was compared.The patient's body temperature was measured again after 4 hours of active cooling treatment(T4 h),and the relationship between T4 h and 28-day mortality was discussed.Results The majority of severe heat stroke patients were male,especially in EHS patients.EHS patients were younger than CHS ones,and had shorter onset time,with significant differences among the groups.The body temperature and HR at admission in the EHS group and the CHS group were significantly higher than those in the control group[body temperature(℃):41.34±0.67,40.39±0.58 vs.37.80±1.39;HR(bpm):139.78±15.63,113.08±17.70 vs.92.00±15.89,all P<0.05],PLT was significantly lowered(×10^9/L:164.94±73.80,165.78±53.49 vs.249.50±84.22,both P<0.05),and the positive rates of MYO and D-dimer were also significantly increased[MYO positive rate:100.0%(18/18),100.0%(12/12)vs.50.0%(4/8);D-dimer positive rate:77.8%(14/18),100.0%(12/12)vs.12.5%(1/8),all P<0.05].ROC curve analysis showed that positive MYO and D-dimer at admission had certain diagnostic value for heat stroke,the area under ROC curve(AUC)was 0.750 and 0.871,the sensitivity was 50.0%and 87.5%,and the specificity was 100%and 86.7%,respectively.The 28-day mortality of the EHS group was significantly higher than that of the CHS group[44.4%(8/18)vs.8.3%(1/12),P<0.05].Furthermore,the 28-day mortality of the patients with T4 h≥38℃in the EHS group was significantly higher than those with T4 h<38℃[70.0%(7/10)vs.12.5%(1/8),P<0.05].Conclusions The decreased PLT and the increased D-dimer in the early stage of heat stroke indicate that the damage of coagulation mechanism is prominent in patients with heat stroke.EHS patients have the characteristics of acute onset,severe condition,rapid progression and poor prognosis,and the 28-day mortality is significantly higher than that of CHS patients.MYO and D-dimer are sensitive indicators in early stage of heat stroke patients,which can be used as reference for early diagnosis of heat stroke.