创伤出血性休克患者急性肝功能不全的预测模型构建与验证

Construction and verification of prediction model of traumatic hemorrhagic shock complicated by acute hepatic insufficiency

目的探讨创伤失血性休克患者发生急性肝功能不全的危险因素,并构建模型进行验证。方法回顾性研究北京大学人民医院2013年1月至2023年5月的417例创伤失血性休克患者,记录患者住院期间的各项临床指标,根据创伤失血性休克后3 d内是否发生急性肝功能不全分为急性肝功能不全组(n=125)和非急性肝功能不全组(n=292),通过Logistic回归模型明确急性肝功能不全的危险因素,构建列线图模型并采用内部数据验证该模型的性能。使用受试者工作特征(ROC)曲线评估该列线图模型的诊断效能,采用临床决策曲线分析(DCA)其临床适用性。结果创伤失血性休克患者的急性肝功能不全发生率为30.0%,Logistic回归分析发现创伤失血性休克患者发生急性肝功能不全的独立危险因素包括骨盆出血(OR=2.311,95%CI 1.109~4.814,P=0.025)、腹部出血(OR=2.529,95%CI 1.104~5.794,P=0.028)、心率快(OR=1.020,95%CI 1.006~1.035,P=0.005)、凝血酶原时间延长(OR=1.112,95%CI 1.003~1.233,P=0.044)和急性心肌损伤(OR=2.002,95%CI 1.113~3.600,P=0.020)。基于以上独立危险因素构建列线图预测模型,ROC曲线分析其预测急性肝功能不全发生的曲线下面积(AUC)为0.840,95%CI为0.794~0.886,提示该模型具有较好的区分度。Hosmer-Lemeshow拟合优度检验显示该模型具有较好的拟合度(P>0.05),DCA提示该模型具有较好的临床适用性。结论急性肝功能不全在创伤失血性休克患者中发生率较高,基于骨盆出血、腹部出血、心率、凝血酶原时间和急性心肌损伤构建的列线图模型预测创伤失血性休克患者发生急性肝功能不全的风险具有可靠的临床价值,尽早及时监测和处理这几项指标有利于患者早期识别和治疗。

Objective To explore the risk factors of traumatic hemorrhagic shock complicated by acute hepatic insufficiency and to construct a prediction model for verification.Methods This study retrospectively studied 417 patients with traumatic hemorrhagic shock from January 2013 to May 2023.Various clinical indicators of patients during hospitalization were recorded,and the patients were divided into the acute hepatic insufficiency group(n=125)and the non-acute hepatic insufficiency group(n=292)according to whether acute hepatic insufficiency occurred within 3 d after traumatic hemorrhagic shock.Risk factors for acute hepatic insufficiency were identified by the Logistic regression model,then a nomogram prediction model was constructed and its performance was verified with internal data.Receiver operating characteristic(ROC)curve was used to evaluate the diagnostic effectiveness of the nomogram prediction model,and the clinical applicability of this model was evaluated by clinical decision curve analysis(DCA).Results The incidence of acute hepatic insufficiency after traumatic hemorrhagic shock was 30.0%.The Logistic regression model found that independent risk factors for acute hepatic insufficiency in the patients with traumatic hemorrhagic shock included pelvic bleeding(OR=2.311,95%CI 1.109-4.814,P=0.025),abdominal bleeding(OR=2.529,95%CI 1.104-5.794,P=0.028),fast heart rate(OR=1.020,95%CI 1.006-1.035,P=0.005),prolonged prothrombin time(OR=1.112,95%CI 1.003-1.233,P=0.044)and acute myocardial injury(OR=2.002,95%CI 1.113-3.600,P=0.020).The above independent risk factors were used to build a nomogram prediction model,and the area under ROC curve(AUC)of nomogram prediction model for predicting acute hepatic insufficiency were 0.840 with 95%CI 0.794-0.886,suggesting that the model had good discrimination.The Hosmer-Lemeshow goodness-of-fit test showed a good calibration with P>0.05.At the same time,DCA showed that the nomogram prediction model had good clinical applicability.Conclusions The incidence of acute hepatic insufficiency is high in the patients with traumatic hemorrhagic shock.The nomogram prediction model based on pelvic bleeding,abdominal bleeding,heart rate,prothrombin time and acute myocardial injury has good clinical significance for the risk prediction of acute hepatic insufficiency in the patients with traumatic hemorrhagic shock.Early and timely monitoring and management of these indicators is conducive to early identification and treatment of traumatic hemorrhagic shock combined with acute hepatic insufficiency.