骨科手术病人不同类型急性肺栓塞的临床分析

Clinical analysis of different types of acute pulmonary embolism in orthopedic surgery patients

目的探讨骨科手术病人不同类型急性肺栓塞的临床特点、相关因素及意义。方法回顾性分析我院骨科2015年1月至2019年1月经CT肺动脉成像(computed tomographic pulmonary angiography, CTPA)确诊为急性肺栓塞的40例病人的临床资料。按照栓塞部位将其分为中央型和周围型两组,其中中央型18例,周围型22例,分别记录并比较两组的临床特点(包括性别、年龄、高危因素、危险分层及手术类型等),实验室检查[包括D-二聚体(D-dimer)、肌钙蛋白、N末端B型钠尿肽前体(NTproBNP)、血气等],心电图以及心脏超声等。结果中央型高、中、低危病人分别为3例、10例、5例,周围型高、中、低危病人分别为0例、9例、13例,中央型中高危病人比例高于周围型,危险分层在两组间的差异有统计学意义(χ^2=3.922,P=0.048)。在临床治疗方式的选择上,中央型与周围型选择溶栓治疗的病人分别为3例和0例。其余如性别、年龄、高危因素等临床特点差异均无统计学意义(P均>0.05)。中央型肌钙蛋白较周围型升高,差异有统计学意义(χ^2=5.992,P=0.025);其余两组间如D-dimer等实验室检查的差异无统计学意义(P均>0.05)。中央型心脏超声异常较周围型更常见,差异有统计学意义(χ^2=5.527,P=0.033)。结论骨科手术病人发生中央型急性肺栓塞危险程度更高,及时完善相关检查能够提供早期诊断价值,可以指导治疗,进一步降低骨科手术肺栓塞病人死亡率、改善其预后。

Objective To investigate the clinical related factors and features of different types of acute pulmonary embolism in orthopedic patients. Methods A retrospective analysis was done on 40 patients with acute pulmonary embolism diagnosed by computed tomographic pulmonary angiography(CTPA) from January2015 to January 2019 in Department of Orthopedics, Tongji Hospital. The patients were divided into central type and peripheral type groups according to the location of the embolism. The clinical characteristics(including gender, age, comorbidity and type of operation), laboratory examinations(including D-dimer,troponin, NT-proBNP, blood gas, etc.), ECG and echocardiography of the two groups were recorded and compared. Results Of 40 patients with acute pulmonary embolism, there were 18 cases of central type and 22 cases of peripheral type. There were 3, 10 and 5 patients with high, middle and low risk of central type, and 0, 9 and 13 patients with peripheral type, respectively. The proportion of patients with middle and high risk of central type was higher than that of peripheral type. Risk stratification was statistically significant between the two groups(χ^2=3.922, P=0.048). In the choice of clinical treatment methods, the number of central and peripheral thrombolytic therapy cases was 3 and 0 respectively. The other clinical characteristics such as gender, age and comorbidity had no significant difference(P>0.05). There was significant difference in Troponin elevation between two groups(χ^2=5.992, P=0.025), and the rest laboratory tests such as D-dimer had no significant difference between the two groups(P>0.05). Echocardiographic abnormalities in the central type group were more common than in the peripheral type group, and the difference was statistically significant(χ^2=5.527, P=0.033). Conclusion The risk of central type of acute pulmonary embolism is higher in patients undergoing orthopedic surgery. Timely and selective examination can provide early diagnosis, and more effective treatment can further reduce the mortality rate and improve prognosis in patients with pulmonary embolism after orthopedic surgery.