低钙血症在老年创伤性凝血病早期诊断中的效价研究

Value of hypocalcaemia for predicting trauma-induced coagulopathy in elderly trauma patients

目的探讨低钙血症在老年创伤性凝血病(trauma-induced coagulopathy,TIC)早期诊断中的预警价值。方法回顾性分析2015年1月至2020年9月浙江大学医学院附属第二医院急诊ICU中老年创伤患者临床资料,包括年龄、性别、损伤部位、创伤严重度评分(injury severity score,ISS)、格拉斯哥昏迷评分、入院24 h内首次动脉血气分析(Ca^(2+)、K^(+))、静脉血生化电解质(Ca^(2+)、K^(+)、Na^(+))、凝血谱[国际标准化比值、活化部分凝血活酶时间(activated partial thromboplastin time,APTT)、凝血酶原时间(prothrombin time,PT)、纤维蛋白原水平(fibrinogen,FIB)]、血制品使用、临床预后、ICU住院时间、总住院时间、总费用。采用多因素Logistic回归分析和ROC曲线评价血钙水平等相关风险因素在老年TIC早期诊断中效能。结果371例老年创伤患者年龄(72.5±6.8)岁,其中男性248例(66.8%)。TIC组ISS评分高于非TIC组[25(20,34)分vs.21(16,29)分];TIC组中胸部损伤、腹部损伤和四肢损伤发生率均高于非TIC组,而头颈部损伤发生率低于非TIC组;差异均具有统计学意义(均P<0.05)。TIC组静脉血生化血钙水平低于非TIC组[(1.97±0.19)mmol/L vs.(2.15±0.16)mmol/L,P<0.001],而动脉血气分析中钙离子水平差异无统计学意义。TIC组凝血谱中APTT值[(47.6±21.8)s vs.(33.8±4.1)s]、PT值[(18.0±3.9)s vs.(13.7±0.8)s]明显高于非TIC组,FIB值则明显低于非TIC组[(1.7±0.8)g/L vs.(2.8±0.9)g/L];差异均具有统计学意义(均P<0.01)。TIC组血制品使用率、总费用高于非TIC组,而预后好转率低于非TIC组(69.8%vs.86.4%,P<0.001)。多因素logistics回归分析显示低钙血症是老年创伤TIC的独立危险因素(OR=5.830,95%CI:3.295~10.314)。生化血钙与老年创伤TIC相关性的ROC曲线下面积为0.779(95%CI:0.728~0.831),最佳截断值为2.06 mmol/L。结论老年严重创伤早期生化血钙水平降低是发生TIC的独立危险因素。积极纠正老年TIC有助于不断改善临床预后。

Objective To investigate the value of hypocalcaemia for predicting trauma-induced coagulopathy(TIC)in elderly trauma patients.Methods The clinical data of elderly trauma patients in emergency ICU of the Second Affiliated Hospital of Zhejiang University School of Medicine from January 2015 to September 2020 were retrospectively analyzed,including age,sex,site of injury,injury severity score(ISS),Glasgow coma scale(GCS),admission arterial blood gas analysis(Ca^(2+),K^(+)),venous blood biochemical electrolyte(Ca^(2+),K^(+),Na^(+));international normalized ratio(INR),activated partial thromboplastin time(APTT),prothrombin time(PT),fibrinogen(FIB),use of blood products,length of stay,length of stay in ICU,total cost,and clinical prognosis.Receiver operating characteristic(ROC)curves and multivariate logistic regression analysis were performed to estimate the contribution of hypocalcaemia to triggering TIC in elderly trauma patients.Results Totally 371 elderly trauma patients were included with a mean age of(72.5±6.8)years,and 248(66.8%)were male.ISS score of the TIC group was higher than that of the non-TIC group[25(20,34)vs.21(16,29)].Compared with the non-TIC group,the incidence of chest injury,abdominal injury and limb injury were significantly higher,while the incidence of head and neck injury were significantly lower in the TIC group(all P<0.05).The biochemical blood calcium in the TIC group was significantly lower than that in the non-TIC group[(1.97±0.19)mmol/L vs.(2.15±0.16)mmol/L,P<0.001],but there was no significant difference in blood gas calcium between the two groups.The APTT value of the TIC group[(47.6±21.8)s vs.(33.8±4.1)s],PT value[(18.0±3.9)s vs.(13.7±0.8)s]were significantly higher than that of the non-TIC group,and FIB level was significantly lower than that of the non-TIC group[(1.7±0.8)g/L vs.(2.8±0.9)g/L](all P<0.01).The utilization rate of blood products and the total cost in the TIC group were higher than that in the non-TIC group,while the recovery rate in the TIC group was lower than that in the non-TIC group(69.8%vs.86.4%,P<0.001).Multivariate logistic regression analysis showed that hypocalcaemia was an independent risk factor for TIC in elderly trauma patients(OR=5.830,95%CI:3.295-10.314).The area under ROC curve of correlation between biochemical calcium and TIC was 0.779(95%CI:0.728-0.831).The optimal diagnostic cut-off value was 2.06 mmol/L.Conclusions The decrease of biochemical serum calcium level is an independent risk factor for TIC in elderly trauma patients.Positive correction of TIC in elderly trauma patients contributes to continuous improvement of clinical prognosis.