急性创伤患者围手术期隐性失血量与创伤后应激障碍发病关系的研究

Study on the correlation between perioperative hidden blood loss and post-traumatic stress disorder in patients with acute trauma

目的探讨急性创伤患者围手术期隐性失血量与创伤后应激障碍(posttraumatic stress disorder,PTSD)发病的关系。方法以2018年1月至2021年8月因急性创伤就诊于徐州医科大学附属医院急诊医学科的109例患者为研究对象。入院时收集患者人口统计学资料,采用休克指数(shock index,SI)、创伤严重程度评分(Injury Severity Score,ISS)、急性生理学和慢性健康状况评价Ⅱ(Acute Physiology and Chronic Health EvaluationⅡ,APACHEⅡ)评分、脓毒症相关序贯器官衰竭评分(Sequential Organ Failure Assessment,SOFA)评估伤情严重程度;记录患者入院时、术前、术后的Hct、Hb(并判断是否贫血)、WBC计数、血小板计数、凝血功能及Cr等,术前、术后是否使用止血药、抗凝药、镇痛药及术后镇痛泵使用情况;于入院时、术前7 d、术后24 h、术后7 d、术后14 d进行日常生活活动量表(Activity of Daily Living Scale,ADL)评分,入院时和术后当天采用数字分级评分法(Numerical Rating Scale,NRS)进行疼痛评分;记录是否为急诊手术、手术时长、术中是否输血及引流量,观察计算围手术期失血情况。根据患者创伤后1个月的创伤后应激障碍筛查量表-5(the Posttraumatic Stress Disorder Checklist for DSM-5,PCL-5)评分将患者分为PTSD组(26例)与非PTSD组(83例)。比较两组患者围手术期失血量的差异,对围手术期相关指标与伤后1个月PCL-5评分行Spearman相关性分析,进一步通过多因素Logistic回归分析围手术期失血量与PTSD发病之间的关系,并绘制受试者工作特征(receiver operating characteristic,ROC)曲线研究围手术期失血量对PTSD的预测价值。结果PTSD组患者APACHEⅡ评分、入院贫血发生率、隐性失血量、总失血量以及术后贫血发生率明显高于非PTSD组(P<0.05),入院时和术后Hct、Hb及术前和术后24 h ADL评分明显低于非PTSD组(P<0.05)。其他指标差异无统计学意义(P>0.05)。PCL-5评分与APACHEⅡ评分、隐性失血量呈正相关(r=0.256,P=0.007;r=0.203,P=0.035),与术后24 h ADL评分、术后Hct呈负相关(r=-0.271,P=0.004;r=-0.194,P=0.044)。单因素回归分析结果表明,入院贫血及隐性失血量是PTSD发生的危险因素,多因素回归分析结果再次验证,隐性失血量是影响PTSD发生的独立危险因素[比值比(odds ratio,OR)1.001,95%CI 1.000~1.002]。ROC曲线分析结果表明,隐性失血量>1157.8 ml时,发生PTSD的可能性大(P=0.028)。结论围手术期隐性失血量是急性创伤患者PTSD发生的独立危险因素,应采取有效措施减少隐性失血量以降低PTSD发生的风险。

Objective To investigate the correlation between perioperative hidden blood loss and posttraumatic stress disorder(PTSD)in trauma patients.Methods A total of 109 patients who visited the Department of Emergency Medicine of the Affiliated Hospital of Xuzhou Medical University for acute trauma from January 2018 to August 2021 were recruited as the object of study.Patient demographics were collected on admission.Scales such as shock index(SI),Injury Severity Score(ISS),Acute Physiology and Chronic Health EvaluationⅡ(APACHEⅡ),and Sequential Organ Failure Assessment(SOFA)were used to evaluate injury severity.The patients'hematocrit(Hct),hemoglobin(Hb)(and determine whether or not anemia),white blood cell(WBC)count,platelet count,coagulation function indexes,creatinine(Cr),and other indexes were recorded at admission,before and after surgery.The use of hemostatic drugs,anticoagulants,analgesics,and postoperative analgesic pumps were recorded before and after surgery.The Activity of Daily Living Scale(ADL)was scored at admission,before surgery,24 h,7 d,and 14 d after surgery.The Numerical Rating Scale(NRS)was used to evaluate pain at admission and on the day after surgery.The emergency operation,operation duration,intraoperative blood transfusion,and drainage volume were recorded,and perioperative blood loss was observed and calculated.Patients were divided into a PTSD group(n=26)and a non-PTSD group(n=87)according to the score of the Posttraumatic Stress Disorder Checklist for DSM-5(PCL-5)1 month after injury.We investigate the difference in perioperative blood loss between the two groups and use Spearman's correlation to analyze perioperative blood loss and PCL-51 month after injury.The relationship between perioperative blood loss and the incidence of PTSD was further analyzed by multivariate logistic regression analysis.And the receiver operating characteristic(ROC)curve was drawn to study the predictive value of perioperative blood loss on PTSD.Results The APACHEⅡscore,the incidence of anemia on admission,hidden blood loss,total blood loss,and the incidence of postoperative anemia in the PTSD group were significantly higher than those in the non-PTSD group(P<0.05).Hct and Hb on admission and after a operation,and ADL scores before and 24 h after operation were significantly lower than those in the non-PTSD group(P<0.05).There was no significant difference in other indicators(P>0.05).PCL-5 score was positively correlated with APACHEⅡand hidden blood loss(r=0.256,P=0.007;r=0.203,P=0.035),and negatively correlated with ADL score at 24 h after operation and postoperative Hct(r=-0.271,P=0.004;r=-0.194,P=0.044).Univariate regression analysis showed that anemia on admission and hidden blood loss were risk factors for PTSD.The multivariate logistic regression analysis results confirmed that hidden blood loss was still a risk factor for PTSD[odds ratio(OR)1.001(95%CI 1.000,1.002)].ROC curve analysis showed that patients had a significantly higher proportion of experiencing PTSD when the hidden blood loss was more than 1157.8 ml(P=0.028).Conclusions Perioperative hidden blood loss is an independent risk factor for PTSD.Effective measures should be taken to reduce hidden blood loss and the risk of PTSD.