颅脑损伤急诊处理多因素与预后相关性分析

Analysis on correlation between multiple factors and prognosis in emergency management of traumatic brain injury

目的研究影响颅脑损伤(TBI)患者预后的临床因素,为改善TBI患者预后提供参考。方法回顾性分析2018年1月—2022年12月徐州医科大学附属连云港医院神经外科收治的220例TBI手术患者的临床资料,根据格拉斯哥预后分级(GOS)评分定义预后良好组(GOS≥4分)和预后不良组(GOS≤3分);采用单因素和多因素Logistic回归分析TBI手术患者预后不良的危险因素,采用R软件构建列线图模型预测颅脑损伤手术患者预后不良的风险,采用校准曲线和决策分析曲线验证模型的预测效能。结果单因素分析显示年龄、格拉斯哥昏迷评分(GCS)、院前时间、手术时间窗、血糖浓度、D-二聚体浓度、中线移位距离和出血部位与不良预后存在显著相关性(P<0.05);多因素分析结果显示患者年龄≥60岁(OR=2.048,P=0.037)、GCS评分≤8分(OR=2.240,P=0.037)、手术时间窗(OR=1.239,P=0.006)、血糖浓度≥8.8 mmol/L(OR=2.165,P=0.027)、D-二聚体浓度(OR=1.636,P=0.002)、中线移位>1 cm(OR=5,467,P<0.001)和硬膜下出血(OR=3.031,P=0.003)是TBI手术患者不良预后的独立危险因素;模型的曲线下面积为0.838(95%CI=0.785~0.891);校准曲线与理想曲线基本重合。结论患者年龄≥60岁、GCS评分≤8分、手术时间窗≥6.9 h、血糖浓度≥8.8 mmol/L、D-二聚体浓度≥11590 ng/mL、中线移位≥1 cm和硬膜下出血是TBI手术患者不良预后的影响因素;TBI患者损伤后3.8 h内送达医院,6.9 h内进行开颅手术,预后不良的发生率低;基于以上危险因素构建的列线图模型有一定的预测性能,对TBI手术患者的预后评估有临床应用价值。

Objective To study the clinical factors that affect the prognosis of patients with traumatic brain injury(TBI)and provide reference for improving the prognosis of TBI patients.Methods The clinical data of 220 TBI patients underwent surgery from January 2018 to December 2022 in Department of Neurosurgery,the Affiliated Lianyungang Hospital of Xuzhou Medical University were analyzed retrospectively.According to the Glasgow outcome score(GOS),they were divided into a good prognosis group(GOS≥4 points)and a poor prognosis group(GOS≤3 points).Univariate and multivariate logistic regression analysis were used to analyze the risk factors of poor prognosis in patients with TBI surgery.R software was used to construct a column chart model to predict the risk of poor prognosis in patients underwent craniocerebral injury surgery,and the calibration curve and decision analysis curve were used to verify the predictive performance of the model.Results Univariate analysis showed a significant correlation between age,GCS score,time from injury to emergency room,surgery time window,blood glucose concentration,D-dimer concentration,midline shift distance and bleeding site(P<0.05-0.001).The results of multivariate analysis showed that age≥60 years(OR=2.048,P=0.037),GCS score≤8 points(OR=2.240,P=0.037),surgery time window(OR=1.239,P=0.006),blood glucose concentration≥8.8 mmol/L(OR=2.165,P=0.027),D-dimer concentration(OR=1.636,P=0.002),midline shift distance>1 cm(OR=5,467,P<0.001)and subdural hemorrhage(OR=3.031,P=0.003)were independent risk factors in patients undergoing TBI surgery.Building a column chart model based on the above risk factors,the area under the curve of the model was 0.838(95%CI=0.785-0.891).The calibration curve basically coincided with the ideal curve.Conclusions Age≥60 years old,GCS score≤8 points,surgery time window≥6.9 hours,blood glucose concentration≥8.8 mmol/L,D-dimer concentration≥11590 ng/mL,midline shift distance>1 cm and subdural hemorrhage are influencing factors for poor prognosis in TBI surgery patients.TBI patients are transported to the hospital within 3.8 hours after injury and undergo craniotomy within 6.9 hours,resulting in a low incidence of poor prognosis.The column chart model constructed based on the above risk factors has certain predictive performance and clinical application value for the prognosis evaluation of TBI patients.