早期纠正凝血功能障碍降低大面积烧伤成年患者28d病死率

Early correction of coagulopathy reduces the 28-day mortality in adult patients with large-area burns

目的:大面积烧伤导致的凝血功能障碍是成年患者28 d病死率的独立危险因素,然而早期(入院48 h)纠正凝血功能障碍能否降低大面积烧伤成年患者28 d病死率未见阐明。本研究旨在探讨早期纠正凝血功能障碍对大面积烧伤成年患者28 d病死率的影响。方法:检索2014年4月至2019年7月在南昌大学第一附属医院烧伤科住院治疗的烧伤输血患者的病历资料,经筛选后纳入573名大面积烧伤成年患者作为研究对象。将患者分为实验组(早期凝血功能障碍纠正者,n=290)和对照组(早期凝血功能障碍未纠正者,n=283),比较2组患者临床基本资料及预后和转归指标,采用logistic单因素回归分析筛选大面积烧伤成年患者28 d病死率的影响因素,并进一步对影响因素进行logistic多因素回归分析以得出独立危险因素和独立保护因素,采用Kaplan-Meier法绘制2组患者的生存曲线并运用logrank检验进行分析。结果:2组患者烧伤面积/总体表面积(total body surface area,TBSA)、Ⅲ°烧伤面积、入院24 h尿量及补液量、入院48 h新鲜冰冻血浆输注量及入院48 h活化部分凝血活酶时间(activated partial thromboplastin time,APTT)的差异均有统计学意义(均P<0.05)。实验组机械通气时间短于对照组,且28 d病死率亦明显低于对照组(10%vs 24%),差异均有统计学意义(均P<0.05)。Logistic单因素回归分析结果显示:烧伤面积/TBSA、Ⅲ°烧伤面积、伴吸入性损伤、住院时间、机械通气时间、入院48 h冰冻血浆输注量和入院48 h凝血功能障碍是否纠正均为入院时伴凝血功能障碍大面积烧伤成年患者28 d病死率的影响因素(均P<0.05)。Logistic多因素回归分析结果显示:烧伤面积/TBSA(OR=1.058,95%CI:0.921~1.214,P=0.022)、Ⅲ°烧伤面积(OR=1.085,95%CI:1.009~1.168,P=0.027)均是大面积烧伤成年患者28 d病死率的独立危险因素,入院48 h冰冻血浆输注量(OR=0.098,95%CI:0.012~0.789,P=0.029)及入院48 h凝血功能障碍得到纠正(OR=0.103,95%CI:0.015~0.679,P=0.018)是其独立保护因素。KaplanMeier生存曲线分析显示实验组和对照组患者28 d病死率分别为90%和76%,差异有统计学意义(χ^(2)=14.270,P<0.001)。结论:烧伤面积/TBSA、Ⅲ°烧伤面积是大面积烧伤成年患者28 d病死率的独立危险因素,而入院48 h冰冻血浆输注量及入院48 h凝血功能障碍得到纠正是其独立保护因素,早期纠正凝血功能障碍可降低患者28 d病死率。

Objective:Coagulation dysfunction caused by large-area burns is an independent risk factor for the 28-day mortality of adult patients.However,whether early(48 hours after admission)correction of coagulopathy can reduce the 28-day mortality of adult patients with large-area burns has not been clarified.The purpose of this study was to investigate the effect of early correction of coagulopathy on the 28-day mortality in the adult patients with large-area burns.Methods:Medical records of burn patients with blood transfusion who were hospitalized in the Department of Burn,First Affiliated Hospital of Nanchang University from April 2014 to July 2019 were retrieved.Among them,573 adult patients with large-area burns were selected as the research subjects.The patients were divided into an experimental group(patients had early rectification of coagulation dysfunction,n=290)and a control group(patients without early rectification of coagulation dysfunction,n=283).The basic clinical data and prognostic indicators of the 2 groups were compared.Logistic univariate regression analysis was used to screen the influential factors of 28-day mortality in adult patients with large-area burns,and further logistic multivariate regression analysis was carried out to obtain independent risk factors and protective factors.Kaplan-Meier method was used to draw the survival curve for the 2 groups of patients,and log-rank test was used.Results:The differences of the burn area/the total body surface area(TBSA),Ⅲ°burn area,24-hour urine volume and rehydration volume,48-hour fresh frozen plasma transfusion volume,and 48-hour activated partial thromboplastin time(APTT)between the 2 groups were statistically significant(all P<0.05).The duration of mechanical ventilation in the experimental group was shorter than that in the control group,and the 28-day mortality in the experimental group was significantly lower than that in the control group(10%vs 24%,both P<0.05).The results of logistic univariate regression analysis showed that burn area/TBSA,Ⅲ°burn area,inhalation injury,length of hospital stay,mechanical ventilation time,48-hour frozen plasma infusion,and 48-hour coagulation dysfunction correction were the influential factors of 28-day mortality of adult patients with large-area burns and coagulation dysfunction at admission(all P<0.05).Logistic multivariate regression analysis showed that the burn area/TBSA(OR=1.058,95%CI 0.921 to 1.214,P=0.022)andⅢ°burn area(OR=1.085,95%CI 1.009 to 1.168,P=0.027)were independent risk factors for 28-day mortality of adult patients with large-area burns,while 48-hour frozen plasma transfusion volume(OR=0.098,95%CI 0.012 to 0.789,P=0.029)and 48-hour coagulation dysfunction correction(OR=0.103,95%CI 0.015 to 0.679,P=0.018)were independent protective factors.Kaplan-Meier survival curve analysis showed that 28-day survival rates of the experimental group and the control group were 90%and 76%,respectively.The difference between them was statistically significant(χ^(2)=14.270,P<0.001).Conclusion:The burn area/TBSA andⅢ°burn area are independent risk factors for 28-day mortality in adult patients with large-area burns.The 48-hour frozen plasma transfusion volume and 48-hour correction of coagulopathy are independent protective factors.Early correction of coagulation dysfunction is beneficial to reducing the 28-day mortality for the adult patients with large-area burns.