CAJ | 학술논문

目的探讨重症监护病房(ICU)中创伤性凝血病的影响因素及对严重创伤患者预后的影响.方法回顾性收集2008年6月至2009年9月伤后24h内收住浙江大学医学院附属第二医院院急诊ICU的223例严重创伤患者的资料,记录损伤严重程度评分(ISS)、急性生理和慢性健康评分(APACHEⅡ)、收住时的凝血功能、血常规、生化常规和血气分析等指标.以需要血管活性药物维持血压、碱缺失(BD) ≥6和休克指数(SI)≥1作为存在组织低灌注的标准.根据凝血功能结果将患者分为凝血病组和无凝血病组(对照组).比较两组间创伤严重程度、APACHEⅡ值、低体温及低灌注发生率等指标,分析创伤性凝血病的影响因素,并建立多因素回归方程.比较死亡与存活患者凝血功能指标及创伤性凝血病的发生率.结果 52例(23.3％)符合创伤性凝血病的诊断,病死率明显高于对照组(36.5％ vs 9.4％,P＜ 0.01).两组间的年龄、性别构成、创伤原因和受伤时间具有可比性,凝血病组的损伤严重程度评分、低体温和组织低灌注发生率、合并严重脑损伤的比例明显高于对照组(P＜0.01),GCS评分、血红蛋白浓度(Hb)、红细胞压积(Hct)和血小板(Plt)计数均明显低于对照组(P＜0.01).多因素logistic回归分析显示BD≥6、GCS≤8和Pl计数是创伤患者入ICU时发生凝血病的独立预测因素.与存活患者相比,死亡患者的凝血功能指标明显延长.结论伤后24h内收住ICU的创伤患者有较高的创伤性凝血病发生率；创伤性凝血病与全身损伤严重程度、合并重型颅脑损伤、休克及低体温有关,并对不良预后有重要影响.
목적 탐토중증감호병방(ICU)중창상성응혈병적영향인소급대엄중창상환자예후적영향.방법 회고성수집2008년6월지2009년9월상후24h내수주절강대학의학원부속제이의원원급진ICU적223례엄중창상환자적자료,기록손상엄중정도평분(ISS)、급성생리화만성건강평분(APACHEⅡ)、수주시적응혈공능、혈상규、생화상규화혈기분석등지표.이수요혈관활성약물유지혈압、감결실(BD) ≥6화휴극지수(SI)≥1작위존재조직저관주적표준.근거응혈공능결과장환자분위응혈병조화무응혈병조(대조조).비교량조간창상엄중정도、APACHEⅡ치、저체온급저관주발생솔등지표,분석창상성응혈병적영향인소,병건립다인소회귀방정.비교사망여존활환자응혈공능지표급창상성응혈병적발생솔.결과 52례(23.3％)부합창상성응혈병적진단,병사솔명현고우대조조(36.5％ vs 9.4％,P＜ 0.01).량조간적년령、성별구성、창상원인화수상시간구유가비성,응혈병조적손상엄중정도평분、저체온화조직저관주발생솔、합병엄중뇌손상적비례명현고우대조조(P＜0.01),GCS평분、혈홍단백농도(Hb)、홍세포압적(Hct)화혈소판(Plt)계수균명현저우대조조(P＜0.01).다인소logistic회귀분석현시BD≥6、GCS≤8화Pl계수시창상환자입ICU시발생응혈병적독립예측인소.여존활환자상비,사망환자적응혈공능지표명현연장.결론 상후24h내수주ICU적창상환자유교고적창상성응혈병발생솔；창상성응혈병여전신손상엄중정도、합병중형로뇌손상、휴극급저체온유관,병대불량예후유중요영향.
Objective To investigate the risk factors of trauma induced coagulopathy and its effect on the outcome of ICU patients with severe trauma.Methods Totally 223 severe trauma patients admitted to emergency ICU within 24h after injuring between June,2008 and September,2009 were retrospectively analyzed.Injury severity score (ISS),APACHE Ⅱ score,coagulation function,routine blood test,biochemical test,and blood gas assay were completed for each patient. Hypoperfusion was defined as vasoactive agents usage,or base deficit (BD) ≥ 6 or shock index ≥ 1. Patients were divided into coagulopathy group and non-coagulopathy (control) group according to coagulation function.ISS,APACHE Ⅱ score,the occurrence of hypothermia and hypoperfusion were compared between the two groups.The risk factors of trauma induced coagulopathy were analyzed,and the multivariate logistic regression equation was formulated.Coagulation function and incidence of trauma induced coagulopathy were compared between nonsurvival and survival group.Results Fifty-two of 223 (23.3 ％ ) patients met the criteria of trauma induced coagulopathy.Mortality rate in this group was significantly higher than that in non-coagulopathy group (36.5％ vs 9.4％, P ＜ 0.01 ). Patients in both groups had the comparability in age,sex, injury mechanism and time after trauma.ISS,the incidence of hypothermia,hypoperfusion and severe traumatic brain injury in coagulopathy group were higher than those in non-coagulopathy group ( P ＜ 0.01 ).GCS,hemoglobin,hematocrit,and platelet counts in coagulopathy group were significantly lower than that in noncoagulopathy group (P＜ 0.01).Base deficit ≥6,GCS ≤ 8,and platelet counts were considered as the independent risk factors involved in trauma- induced coagulopathy according to logistic regression in this study.Coagulation function of non-survivors also remarkably attenuated when compared with survival group.Conclusions The incidence rate of trauma induced coagulopathy is high in severe trauma patients admitted to ICU within 24h. Trauma induced coagulopathy correlates well with ISS core,severe traumatic brain injury,shock and hypothermia,and results in high mortality.