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凝血指标对于颅脑创伤患者住院病死率的预测价值

Prognostic value of coagulation tests for in-hospital mortality of patients with traumatic brain injury

摘要:

目的 探讨颅脑创伤(TBI)后凝血功能障碍的发生率以及评估凝血指标对TBI患者住院病死率的预测价值.方法 回顾性纳入2004年12月至2015年6月复旦大学附属华山医院神经外科收治2 319例TBI患者的临床资料与凝血指标.根据是否纳入凝血指标分别建立两种住院病死率的预测模型:模型A涵盖基本预测因子,包括年龄、格拉斯哥昏迷评分(GCS)、瞳孔反应、损伤类型、血红蛋白及血糖水平等;模型B在模型A的基础上,加入凝血功能检测的相关结果.对两种预测模型进行内部与外部验证.通过ROC曲线下面积评估预测模型的区分度,通过Hosmer-Lemeshow(H-L)检验评估预测模型的校准度.结果 本研究共纳入2 319例TBI患者,其中432例(18.63%)患者出现凝血功能障碍.TBI后凝血功能异常的发生与患者颅脑损伤的严重程度密切相关.影响TBI患者颅脑损伤严重程度的相关因素包括:血小板计数偏低(<100×109/L)、国际标准化比值(INR)> 1.25、凝血酶原时间(PT)> 14 s、活化部分凝血活酶时间(APTT) >36 s、D-二.聚体>5 mg/L和纤维蛋白原<1.5 g/L(均P<0.05).年龄、瞳孔对光反应、GCS评分、是否合并硬膜外血肿、血糖水平、INR> 1.25以及APTT >36 s是影响TBI患者住院病死率的独立危险因素(均P<0.05).模型外部验证结果显示,模型A和B均有良好的区分度(A:c=0.868;B:c=0.875).但模型B的校准度(H-L检验,P=0.152)较模型A更好(H-L检验,P=0.046).结论 凝血指标是TBI患者住院死亡的独立危险因素,纳入凝血指标对患者住院死亡风险进行预测能增加预测的校准度,提高预测的准确性.

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abstracts:

Objective To evaluate the prognostic value of coagulation tests for in-hospital mortality of patients with traumatic brain injury (TBI).Methods We retrospectively analyzed the data of TBI patients who were admitted to Neurosurgery Department of Huashan Hospital,Fudan University,from December 2004 to June 2015.Two models were developed based on the admission characteristics.Model A included predictors such as age,Glasgow Coma Scale (GCS) score,pupil reactivity,type of injury,hemoglobin and glucose levels.Model B included the predictors in model A as well as coagulation test results.Performance of the models was assessed according to discrimination by means of the c statistic (equivalent to the area under the receiver operator characteristic curve) and calibration using the HosmerLemeshow (H-L) goodness-of-fit test.Results A total of 2,319 patients were enrolled into this study.Among them,432 (18.63%) patients developed coagulopathy after TBI.The prevalence of acute traumatic coagulopathy was associated with the severity of brain injury.The percentage of platelet count < 100 × 109/L,international normalized ratio (INR) > 1.25,prothrombin time (PT) > 14 sec,activated partial thromboplastin time (APTT) > 36 sec,D-dimer > 5 mg/L and fibrinogen (FIB) < 1.5 g/L were also closely related to the severity of brain injury (All P < 0.05).Age,pupillary reactivity,GCS score,epidural hematoma (EDH),and glucose levels were independent prognostic factors for in-hospital mortality in model A.Age,pupillary reactivity,GCS score,EDH,glucose levels,INR > 1.25 and ApTT > 36 sec exhibited strong prognostic values in model B (P < 0.05).Discrimination and calibration were good for the development group in both prediction models.However,the external validation test showed that calibration was better in model B than in model A for patients from the validation population (Hosmer-Lemeshow test,P =0.152 vs.P =0.046,respectively).Conclusions The coagulation function could serve as independent prognostic factor for in-hospital mortality of patients with traumatic brain injury.Incorporating the coagulation tests might improve the predictive power in relevant model.

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作者: 赵剑斓 [1] 袁强 [1] 吴惺 [1] 虞剑 [1] 杜倬婴 [1] 孙一睿 [1] 吴雪海 [1] 胡锦 [1]
期刊: 《中华神经外科杂志》2018年34卷2期 134-138页 ISTICPKUCSCD
栏目名称: 神经重症
DOI: 10.3760/cma.j.issn.1001-2346.2018.02.006
发布时间: 2018-03-21
基金项目:
国家自然科学基金(81471241,81271375,81171133)National Natural Science Foundation of China
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