肋骨骨折后引发血胸的危险因素分析

Risk factors of hemothorax after rib fracture

目的探讨肋骨骨折后引发血胸的危险因素,并评估其对血胸的预测价值。方法采用回顾性病例对照研究分析2018年1月至2019年11月南京医科大学附属江苏盛泽医院收治的449例肋骨骨折患者的临床资料,其中男308例,女141例;年龄19~97岁[(57.4±14.0)岁]。将入院时或入院后1周内胸部CT或X线片检查存在胸腔积液的情况定义为血胸,其中330例为血胸组,119例为非血胸组。比较两组性别、年龄、职业、体重、身高、基础疾病[糖尿病、慢性阻塞性肺病(COPD)、高血压和高血脂]、致伤原因、影像学结果[肋骨骨折数、连枷胸、双侧肋骨骨折、肋骨骨折部位及胸内合并伤(气胸、肺挫伤、纵隔气肿和心肌挫伤)]、胸腔置管、受伤至入院时间、入院时生命体征(血压、心率)、血常规[白细胞、血红蛋白(Hb)、血小板、红细胞压积(Hct)]、血型、尿常规(尿隐血、尿蛋白和尿酮体)、生化检查[总胆固醇(TCHO)、甘油三酯(TG)、高密度脂蛋白(HDL-C)、低密度脂蛋白(LDL-C)、白蛋白(ALB)、总胆红素(TBIL)、谷草转氨酶(AST)、谷丙转氨酶(ALT)、尿素氮(BUN)、肌酐(CRE)和糖化血红蛋白(HbA1C)]、凝血指标[凝血酶原时间(PT)、纤维蛋白原(FIB)、D-二聚体(D-D)和凝血酶时间(TT)]、创伤评分[胸壁损伤评分(CIS)、损伤严重度评分(ISS)、新损伤严重度评分(NISS)]及住院时间。单因素分析观察各因素与肋骨骨折后引发血胸的相关性,筛查显著相关因素。再通过多因素Logistic回归分析,明确肋骨骨折后引发血胸的独立危险因素。采用受试者工作特征(ROC)曲线分析独立危险因素中连续变量预测血胸的价值,并计算最佳阈值。结果两组性别、职业、体重、身高、糖尿病、COPD、高血脂、受伤至入院时间、血压、心率、血小板、尿蛋白、尿酮体、TCHO、HDL-C、TBIL、ALT、CRE、HbA1C、PT等方面差异均无统计学意义(P>0.05);血胸组Hb、Hct、TG、LDL-C、TT值较非血胸组显著降低,而年龄、肋骨骨折数、白细胞、AST、FIB、D-D、创伤评分及住院时间均显著高于非血胸组(P<0.05)。血胸组高血压、致伤原因、连枷胸、双侧肋骨骨折、肋骨骨折部位、尿隐血与非血胸组比较,差异有统计学意义(P<0.05)。单因素分析结果显示,年龄、高血压、肋骨骨折数、连枷胸、双侧肋骨骨折、肋骨骨折部位(上胸部前外侧段、中胸部前外侧段、中胸部后外侧段、中胸部近脊柱侧段、下胸部后外侧段及下胸部近脊柱侧段)、气胸、肺挫伤、心肌挫伤、胸腔置管、白细胞、尿隐血、BUN、FIB、创伤评分(CIS、ISS和NISS)及住院时间与肋骨骨折后引发血胸相关(P<0.05)。多因素Logistic回归分析结果显示,肋骨骨折部位(中胸部后外侧段、中胸部近脊柱侧段、下胸部后外侧段及下胸部近脊柱侧段)、肺挫伤、胸腔置管、BUN及创伤评分(CIS、ISS和NISS)与肋骨骨折后引发血胸显著相关(P<0.05)。独立危险因素中连续变量的ROC曲线显示,BUN、CIS、ISS和NISS曲线下面积(AUC)分别为0.587(95%CI 0.529~0.645)、0.824(95%CI 0.779~0.870)、0.789(95%CI 0.739~0.840)和0.876(95%CI 0.835~0.917)(P<0.05),最佳阈值分别为5.0 mmol/L、2.5分、15分和21.5分。结论肋骨骨折部位(包括中胸部后外侧段、中胸部近脊柱侧段、下胸部后外侧段和下胸部近脊柱侧段)、肺挫伤、胸腔置管、BUN及创伤评分(CIS、ISS和NISS)是肋骨骨折后引发血胸的独立危险因素。BUN>5.0 mmol/L和创伤评分(CIS>2.5分、ISS>15分和NISS>21.5分)具有显著的预测肋骨骨折后引发血胸的价值。

Objective To explore the risk factors of hemothorax after rib fracture and evaluate its predictive value for hemothorax.Methods A retrospective case control study was made on the data of 449 patients with rib fracture admitted to Jiangsu Shengze Hospital affiliated to Nanjing Medical University from January 2018 to November 2019.There were 308 males and 141 females,with the age range of 19-97 years[(57.4±14.0)years].The hemothorax was defined as pleural effusion on chest CT or X examination on admission or within one week after admission.There were 330 patients in hemothorax group and 119 patients in non-hemothorax group.Indices were compared between the two groups,including gender,age,occupation,weight,height,underlying diseases[diabetes,chronic obstructive pulmonary disease(COPD),hypertension,hyperlipidemia],causes of injury,imaging findings[number of rib fracture,flail chest,bilateral rib fractures,locations of rib fracture and intramural injuries(pneumothorax,pulmonary contusion,mediastinal emphysema and myocardial contusion)],thoracic cavity drainage,injury to admission time,vital signs(blood pressure and heart rate),routine blood[white blood cell,hemoglobin(Hb),platelet,hematocrit(Hct)],blood type,urine routine(urinary occult blood,urinary protein,urinary ketone body),biochemical examination[total cholesterol(TCHO),triglyceride(TG),high density lipoprotein(HDL-C),low-density lipoprotein(LDL-C),albumin(ALB),total bilirubin(TBIL),glutamic oxalacetic transaminase(AST),alanine transaminase(ALT),urea nitrogen(BUN),creatinine(CRE),glycosylated hemoglobin(HbA1C)],coagulation tests[prothrombin time(PT),fibrinogen(FIB),plasma D-dimer(D-D),thrombin time(TT)]after admission,trauma score[chest wall injury score(CIS),injury severity score(ISS),new injury severity score(NISS)]and length of hospital stay.The univariate analysis was used to observe the correlation between each factor and hemothorax after rib fracture and to screen the significant correlation factors,followed by multivariate logistic regression analysis to further identify the independent risk factors.The receiver operating characteristic(ROC)curve was used to analyze the predictive value of continuous variables in independent risk factors and to calcuate the optimal threshold.Results The two groups showed no significant differences in gender,occupation,weight,height,diabetes,COPD,hyperlipidemia,injury to admission time,blood pressure,heart rate,platelet,urine protein,urine ketone body,TCHO,HDL-C,TBIL,ALT,CRE,HbA1C or PT(P>0.05).The hemothorax group showed significantly decreased Hb,Hct,TG,LDL-C and TT and significantly increased age,number of rib fracture,white blood cell count,AST,FIB,D-D,trauma score(CIS,ISS,NISS)and length of hospital stay when compared to non-hemothorax group(P<0.05).There were significant differences in hypertension,causes of injury,flail chest,bilateral rib fractures and locations of rib fracture and urinary occult blood between the two groups(P<0.05).The univariate analysis showed that age,hypertension,number of rib fractures,flail chest,bilateral rib fractures,locations of rib fracture(upper chest anterolateral segment,middle chest anterolateral segment,middle chest posterolateral segment,middle chest proximal spinal segment,lower chest posterolateral segment,lower chest proximal spinal segment),pneumothorax,pulmonary contusion,myocardial contusion,thoracic cavity drainage,white blood cell count,urinary occult blood,BUN,FIB,trauma score(CIS,ISS,NISS)and length of hospital stay were significantly associated with hemothorax(P<0.05).The multivariate Logistic regression analysis showed that locations of rib fracture(including middle chest posterolateral segment,middle chest proximal spinal segment,lower chest posterolateral segment and lower chest proximal spinal segment),pulmonary contusion,thoracic cavity drainage,BUN and trauma score(CIS,ISS,NISS)were significantly associated with hemothorax after rib fracture(P<0.05).The ROC curve analysis of continous variables in independent risk factors showed BUN area under the curve(AUC)of 0.587(95%CI 0.529-0.645),CIS AUC of 0.824(95%CI 0.779-0.870),ISS AUC of 0.789(95%CI 0.739-0.840)and NISS AUC of 0.876(95%CI 0.835-0.917)(P<0.05),and the optimal thresholds for the above variables were 5.0 mmol/L,2.5 points,15 points and 21.5 points,respectively.Conclusion Locations of rib fracture(including the middle chest posterolateral segment,middle chest proximal spinal segment,lower chest posterolateral segment,lower chest proximal spinal segment),pulmonary contusion,thoracic cavity drainage,BUN,trauma score(CIS,ISS,NISS)are independent risk factors for hemothorax after rib fracture.BUN>5.0 mmol/L and trauma score(CIS>2.5 points,ISS>15 points,NISS>21.5 points)have significant values in predicting hemothorax.