严重多发伤合并急性呼吸窘迫综合征和多器官功能障碍综合征诊断标准参数的判别

Discrimination of diagnostic parameters for severe multiple trauma complicated by acute respiratory distress syndrome and multiple organ dysfunction syndrome

目的 探讨高海拔地区多发伤后急性呼吸窘迫综合征 (ARDS)和多器官功能障碍综合征 (MODS)诊断指标参数的适用界值。 方法 将 180例以颅脑伤为主的严重多发伤合并ARDS/MODS患者 ,根据海拔高度分为西宁玉门组 (2 2 61～ 2 40 0m ,简称西玉组 ) 3 1例、兰州组 56例 (1517m )和西安组 93例 (43 0m)。三组患者分别用王今达等、Marshall等和笔者等三个标准绘制受检者运行特征曲线 (receiveroperatingcharacteristiccurve ,ROC) ,并参照急性生理学和长期健康评估 (APACHE)Ⅱ、Ⅲ对结局作综合评估 ,比较不同海拔高度不同标准预测结局的差异。结果在西安组用王今达等标准与Marshall等标准预测结局的准确率、敏感度、特异度分别为 0 .82 3 ,0 .83 3 ,0 .73 1和 0 .815,0 .767,0 .762 ;在西玉组用王今达等、Marshall等和笔者等三个标准分别是0 .788,0 .80 0 ,0 .650和 0 .869,1.0 0 0 ,0 .616及 0 .873 ,0 .80 0 ,0 .847。三个标准用于平原患者以王今达等标准准确率最高 ,用于高海拔区以笔者等试验标准最高。动态观察三组氧合指数(PaO2 /FiO2 )预测结局的最佳界值 ,西玉组、兰州组、西安组分别是 97.58,13 1.50 ,198.3 2mmHg。三组的死亡率分别是 16% (5/ 3 1)、2 3 % (13 / 56)、3 2 % (3 0 / 93 )。 结论

Objective To study the application range of the diagnos ti c parameters for acute respiratory distress syndrome (ARDS) and multiple organ d ysfunction syndrome (MODS) at high altitude after multiple trauma. Met hods A total of 180 cases with severe multiple trauma complicated by A RDS/MODS were divided into three groups according to their originating altitude: Xining-Yumen group (Xi-Yu group, 31 cases, at altitude of 2 261-2 400 m), La nzhou group (56 cases, at altitude of 1 517 m) and Xi'an group (93 cases, at alt itude of 430 m). The receiver operating characteristic curves (ROC curves) of th ree groups were drafted for a comprehensive evaluation of the results according to the diagnostic criteria of WANG Jin-da et al, Marshall et al and ours in con junction with the acute physiology and chronic health evaluation (APACHE-Ⅱ,Ⅲ) . Results In the Xi'an group, accuracy, sensitivity and spec ificity of criteria of WANG Jin-da et al in predicting the outcome were 0.823, 0.833 and 0.731 respectively and those of Marshall et al 0.815, 0.767 and 0.762, respectively. In the Xi-Yu group, however, accuracy, sensitivit y and specifi city of the same criteria of WANG Jin-da et al were 0.788, 0.800 and 0.650 resp ectively, those of Marshall et al 0.869, 1.000 and 0.616 respect ively and those of ours 0.873 , 0.800 and 0.847 respectively. The accuracy of critria of WANG Jin-da et al was the highest in the plain areas but that of ou rs ranked the highest in the high altitude areas. The optimum cutoff points of P aO 2/FiO 2 were 97.6 mm Hg, 131.5 mm Hg and 198.3 mm Hg respectively and the mortalities of severe trauma in Xi-Yu, Lanzhou and Xi'an groups were 16%, 23% a nd 32% respectively. Conclusions ⑴ The difference of diagn ostic parameters for ARDS between plain and high altitude areas has been confirm ed. However, the diagnostic parameters for MODS vary considerably, which needs m ore investigations to ascertain the exact organ from which the differences origi nate. ⑵ In three groups, the cases of cranial trauma with similar scores of APA CHE-Ⅱ, Ⅲ, the death rates of ARDS/MODS decrease with elevation of altitude, a s reveals that the plain criteria can not reflect the clinical practice at high altitude and that criteria for the highland need improvement.