本文選題：創(chuàng)傷 + 血流動力學��； 參考：《第三軍醫(yī)大學》2013年博士論文

【摘要】：背景與目的：創(chuàng)傷在全球范圍內(nèi)正日益成為現(xiàn)代社會的第一大公害。據(jù)有關統(tǒng)計數(shù)據(jù)顯示,全球每年死于創(chuàng)傷的人數(shù)高達500萬,占全球總死亡人數(shù)的9%,平均每分鐘就有9.5人因意外創(chuàng)傷死亡。在我國,每年的創(chuàng)傷死亡人數(shù)高達70萬,是第五位死亡原因。創(chuàng)傷尤其是嚴重創(chuàng)傷的救治一直是當今醫(yī)學界所面臨的一個重要難題。嚴重創(chuàng)傷患者病情復雜、危重,快速對患者做出準確的傷情評估是嚴重創(chuàng)傷救治的關鍵。CT在全身各部位損傷檢查中具有不可比擬的優(yōu)勢,在嚴重創(chuàng)傷患者的傷情評估中具有重大的作用。然而,CT檢查必須將危重癥患者轉移至放射科而有潛在風險,常常出現(xiàn)患者在檢查過程中或檢查完后不久血流動力學狀態(tài)突然惡化的情況。組織器官灌注不足是休克發(fā)生的核心環(huán)節(jié)。當創(chuàng)傷患者因失血而導致循環(huán)血量不足時,早期機體會激活交感神經(jīng)系統(tǒng)和腎素-血管緊張素系統(tǒng)來減少諸如胃腸道、腎臟、皮膚等器官的血供以保證心、腦的血供。腹部臟器在休克早期是最先被犧牲血供的部位之一,而腹部臟器血供的減少在增強CT上將表現(xiàn)為乏血供狀態(tài)。當血容量進一步減少以至不足以支撐大循環(huán)后,將會出現(xiàn)主動脈、下腔靜脈等大血管的塌陷征象�；谝陨蠈π菘瞬±砩韺W的改變及低血容量休克患者中的一些CT征象認識,將多層螺旋CT對創(chuàng)傷患者血流動力學的評估應用于嚴重創(chuàng)傷患者的早期救治中將會是一條全新的思路。在嚴重創(chuàng)傷患者早期救治中廣泛應用多層螺旋CT檢查,不僅可以有效地縮短從入院到給予確定性治療的時間,同時可以為更為全面的了解各臟器的血液灌流情況及對復蘇終點時機的把握提供依據(jù)。據(jù)此,本研究希望通過分析嚴重創(chuàng)傷患者傷后的CT影像學資料,量化個腹部血管及實質(zhì)臟器CT數(shù)據(jù),以創(chuàng)傷患者是否發(fā)生休克事件為分組依據(jù),將入院研究創(chuàng)傷患者分為穩(wěn)定組和休克組。比較兩組患者CT數(shù)據(jù)的差異,探討可用于評估創(chuàng)傷患者血流動力學狀態(tài)的CT影像學征象,為多層螺旋CT應用于嚴重創(chuàng)傷患者血流動力學的評估提供具體數(shù)據(jù)支持。研究對象與方法：選取第三軍醫(yī)大學大坪醫(yī)院野戰(zhàn)外科研究所全軍戰(zhàn)創(chuàng)傷中心2008年1月—2011年12月收治的嚴重創(chuàng)傷患者的病歷及影像學資料。根據(jù)患者的入院及病程記錄資料,將63例患者按CT檢查后24h內(nèi)是否發(fā)生休克事件分為穩(wěn)定組與休克組。通過影像診斷工作站調(diào)閱患者CT影像學資料,利用CT影像診斷工具中的長度測量尺測量血管直徑、長度等,利用CT值測量工具測定血管及組織器官各期掃描的CT值。利用統(tǒng)計學方法比較兩組患者間存在差異性的指標。然后以休克分組作為狀態(tài)標量,對組間具有統(tǒng)計學差異的指標進行ROC曲線分析,得出最佳診斷切點,計算診斷指標的SEN、SPE、PPV、NPV及AUC,以評價各診斷指標的診斷價值。最后將通過Logistic回歸將各CT診斷指標整合,建立聯(lián)合CT診斷模型,得出模型方程,并采用歸一變換法得到CT聯(lián)合診斷新指標——CTSI (CT Shock Index, CT休克指數(shù)),代入創(chuàng)傷患者數(shù)據(jù)計算出CTSI后,以其結果作為新的預測指標繪制ROC曲線,以評估最終預測模型的診斷效能。結果：1.休克組(34人)與穩(wěn)定組(29人)在性別組成、年齡、受傷至入院時間、受傷至行CT檢查時間、平均住院天數(shù)和平均ICU天數(shù)等方面差異均無統(tǒng)計學意義(P0.05)。休克組死亡率顯著高于穩(wěn)定組(P0.001),并且休克組創(chuàng)傷患者平均輸血量也顯著大于穩(wěn)定組(5986±6510ml vs 1083±2068ml, P0.001).休克組入院時HR、SBP, Hgb及Hct與穩(wěn)定組比較差異無統(tǒng)計學意義(P0.05),但ISS及SI顯著大于穩(wěn)定組(30±8 vs 22±6, P0.001;1.17±0.37 vs 0.96±0.33, P=0.019)。血氣分析指標方面,休克組血pH與穩(wěn)定組之間無統(tǒng)計學差異(7.37±0.05 vs 7.35±0.05,P=0.019),而Lac顯著高于穩(wěn)定組(3.27±0.69 mmol/L vs 2.56±0.89 mmol/L, P=0.021), BE則顯著低于穩(wěn)定組(-3.67±2.66mmol/L vs 1.34±2.72mmol/L,P0.001);2.休克組患者IVC較穩(wěn)定組比較有明顯塌陷趨勢,休克組IVC塌陷指數(shù)(T/AP)在4個層面上均顯著大于穩(wěn)定組(P0.05),其中休克組T/AP在IVC2最大(4.08±1.79),在IVC4層面最小(2.18±0.93)；休克組AO、SMA及SMV在其測量層面上所測得直徑與穩(wěn)定組相比差異均無統(tǒng)計學意義(P0.05)；3.CT增強掃描早期,休克組SMA的CT值顯著低于穩(wěn)定組(133.2±32.4HU vs 186.3±23.3HU, P=0.021),休克組AO及SMA的CT值與穩(wěn)定組比較,差異均無統(tǒng)計學意義(P0.05)。而休克組IVC只在IVC1平面CT值顯著高于穩(wěn)定組(133.4±20.3HU vs 112.0±21.9HU, P=0.018)。在CT增強掃面延遲期,兩組之間各腹部血管CT值之間差異均無統(tǒng)計學意義(P0.05)；4.CT增強掃描早期,休克組脾臟CT值顯著低于穩(wěn)定組(93±16HU vs 112±24HU, P=0.001),腎上腺CT值顯著高于穩(wěn)定組(153±35HU vs 131±24HU,P=0.007),而肝臟、胰腺、腎臟皮質(zhì)、腎臟髓質(zhì)與穩(wěn)定組比較差異無統(tǒng)計學意義(P0.05)。增強掃描延遲期,休克組只有腎臟髓質(zhì)CT值顯著低于穩(wěn)定組(193±57HU vs 228±53HU,P=0.014),而其他臟器CT值與穩(wěn)定組比較差異無統(tǒng)計學意義(P0.05)；5.ROC曲線分析顯示,在常規(guī)傷情評估及休克指標中,SI、ISS、Lac、BE的最佳診斷臨界值分別為1.19、19.5分.2.75mmol/L及.2.88mmol/L,其中BE的AUC最大(0.866),其在最佳診斷臨界值的SEN及SPE分別為88.2%和80.3%。而SI的AUC最小為0.688,其在最佳診斷臨界值的SPE及SPE分別僅為55.9%和86.2%。在CT指標中,IVC塌陷指數(shù)(T/AP)、增強早期SMA、IVC、脾臟、腎上腺及延遲期腎髓質(zhì)CT值的最佳診斷臨界值分別為3.02.166HU.121HU.115HU、150HU、184HU。其中IVC塌陷指數(shù)(T/AP)的AUC最大為0.833,其在最佳診斷臨界值的診斷SEN及SPE分別為73.5%和86.2%,而延遲期腎髓質(zhì)CT值的AUC最小為0.677,其在最佳診斷臨界值的SEN及SPE分別為47.1%和82.8%。6.整合六個CT指標得出CTSI方程表達式：CTSI=X1-0.040X2+0.254X3-0.331X4+0.455X5-0.196X6(其中X1代表IVC塌陷指數(shù)(T/AP),X2代表增強早期SMA的CT值,X3代表增強早期IVC的CT值,X4代表增強早期脾臟CT值,X5代表增強早期腎上腺CT值,X6代表增強延遲期腎臟髓質(zhì)CT值)。通過ROC曲線分析,求得CTSI的最佳診斷臨界值為21.235,AUC為0.9038,其SEN和SPE分別為92.1%和90.3%,總體預測準確度為91.7%。結論：1.休克組患者在入院時HR、SBP、Hgb及Hct與穩(wěn)定組比較差異無統(tǒng)計學意義,而休克組患者具有比穩(wěn)定組更高的ISS、SI、Lac及更低的BE；2.通過量化和比較穩(wěn)定組與休克組患者的CT影像學數(shù)據(jù),發(fā)現(xiàn)下腔靜脈塌陷、增強早期下腔靜脈強化早現(xiàn)、腸系膜上動脈及脾臟低灌注、腎上腺過度強化以及延遲期腎臟髓質(zhì)強化減弱等CT征象對預測嚴重創(chuàng)傷患者早期低血容量性休克的發(fā)生具有一定價值；3.通過數(shù)學統(tǒng)計方法科學整合多個CT影像學指標,創(chuàng)新性提出"CT休克指數(shù)”(CTSI)的新概念,其在最佳診斷臨界值21.235時的預測敏感度和特異度分別為92.1%和90.3%,預測準確度達到91.7%,具有潛在的臨床應用價值；4.本研究證實了某些腹部CT征象可以作為預測嚴重創(chuàng)傷患者休克發(fā)生的指標,為CT影像學技術應用于嚴重創(chuàng)傷患者早期血流動力學的評估提供了前期具體數(shù)據(jù)支持,為后續(xù)開展大規(guī)模的臨床前瞻性試驗奠定了基礎。
[Abstract]:Background and purpose: trauma is becoming the first public hazard in the modern world. According to statistics, the number of people who die of trauma in the world is as high as 5 million every year, accounting for 9% of the total number of deaths in the world. On average, 9.5 people die by accidental trauma per minute. In China, the number of traumatic deaths per year is as high as 700 thousand, and fifth in China. The cause of death. The treatment of trauma, especially severe trauma, has been an important problem in the medical field today. The patients with severe trauma are complicated, critical and quick to make accurate assessment of the patient's injury. The key.CT of severe trauma treatment has an unparalleled advantage in all parts of the whole body, in severe trauma. However, the CT examination must transfer critically ill patients to the radiology department and have a potential risk. The sudden deterioration in the hemodynamic state of the patient during or shortly after examination is the key link in the occurrence of Hugh. When the circulation blood is insufficient, the early experience activates the sympathetic nervous system and the renin angiotensin system to reduce the blood supply such as the gastrointestinal, kidney, skin and other organs to ensure the heart and the blood supply of the brain. The abdominal organs are one of the first to be sacrificed in the early stage of the shock, while the decrease in the blood supply of the abdominal organs will be enhanced on the CT. There will be signs of collapse of the aorta and the inferior vena cava when the blood volume is further reduced or not enough to support the large circulation. Based on the above changes in the shock pathophysiology and some CT signs in patients with hypovolumetric shock, the multislice spiral CT is used for the hemodynamics of the trauma patients. The assessment of early treatment for severe trauma patients will be a new idea. The extensive use of multislice spiral CT in early treatment of severe trauma patients can not only effectively shorten the time from admission to deterministic treatment, but also provide a more comprehensive understanding of the blood perfusion and recovery of the organs. On the basis of this, we hope to quantify the CT data of the abdominal vessels and the parenchymal viscera CT data by analyzing the data of the abdominal vessels and the parenchymal viscera after the injury of the patients with severe trauma, and divide the patients into the stable group and the shock group on the basis of the shock events of the trauma patients. Compare the CT data of the two groups. CT imaging findings can be used to assess the hemodynamic status of traumatic patients and provide specific data support for the assessment of the hemodynamic evaluation of patients with severe trauma with multi-slice spiral CT. Research objects and methods: select the whole army war trauma center of the Department of field surgery, Daping Hospital, Third Military Medical University, January 2008 - 2011 1 Medical records and imaging data of patients with severe trauma in February were divided into stable and shock groups according to the patient's admission and course records of 63 patients in 24h after CT examination. Through the imaging diagnosis workstation, the patient's CT imaging data were read and the length measuring ruler in the CT imaging tool was used to measure the length measurement ruler. Blood vessel diameter, length and so on, using the CT value measuring tool to measure the CT value of the blood vessels and tissues and organs in each phase. Compare the differences between the two groups of patients by statistical method. Then the shock group is used as the state scalar, and the ROC curve analysis is used to analyze the statistical difference between the groups. The best diagnosis point is obtained and the diagnosis is calculated. SEN, SPE, PPV, NPV and AUC are used to evaluate the diagnostic value of each diagnostic index. Finally, the diagnostic indexes of CT are integrated by Logistic regression, a joint CT diagnostic model is established, the model equation is obtained, and a new CT joint diagnostic index, CTSI (CT Shock, shock index), will be obtained by the method of normalization transformation into the data meter of the trauma patients. After calculating CTSI, the ROC curve was drawn as a new predictor to evaluate the diagnostic efficiency of the final prediction model. Results: there was no significant difference in the gender composition, age, injury to admission time, injury to CT examination time, average days of hospitalization and the average number of ICU days in the 1. shock group (34 people) and the stable group (29 people). (P0.05) the mortality of the shock group was significantly higher than that in the stable group (P0.001), and the average blood transfusion in the shock group was also significantly greater than that in the stable group (5986 + 6510ml vs 1083 + 2068ml, P0.001). The shock group had no statistically significant difference (P0.05) with the group of HR, SBP, Hgb and Hct compared with the stable group (30 + 8 22 + 6). 01, 1.17 + 0.37 vs 0.96 + 0.33, P=0.019). There was no statistical difference between the blood pH and the stable group (7.37 + 0.05 vs 7.35 + 0.05, P=0.019), while Lac was significantly higher than that in the stable group (3.27 + 0.69 mmol/L vs 2.56 + 0.89 mmol/L, P=0.021), BE was significantly lower than that of the stable group (-3.67 + 0.33 + + 7.37). In the 2. shock group, there was a significant collapse trend in the IVC group than the stable group. The IVC collapse index (T/AP) in the shock group was significantly greater than that in the stable group (P0.05) in the shock group (P0.05). The shock group was the largest (4.08 + 1.79) in the shock group (4.08 + 1.79) and the smallest (2.18 + 0.93) in the IVC4 level. The diameter of the shock group AO, SMA and SMV in the shock group was different from the stable group. The CT value of SMA in shock group was significantly lower than that of stable group (133.2 + 32.4HU vs 186.3 + 23.3HU, P=0.021) at the early stage of enhanced scan in shock group. The CT value of AO and SMA in shock group was not statistically significant compared with that of the stable group (P0.05), but the value of shock group was significantly higher than that of the stable group (133.4 + 112 + 2) in shock group (133.4 + 112 + 2) 1.9HU, P=0.018). There was no significant difference between the CT values of the abdominal vessels between the two groups (P0.05). The spleen CT value of the shock group was significantly lower than that of the stable group (93 + 16HU vs 112 + 24HU, P=0.001) at the early stage of 4.CT enhanced scan, and the adrenal CT value was significantly higher than that of the stable group (153 + 131 + 131), and the liver and pancreas There was no significant difference between the renal cortex and the renal medulla in the stable group (P0.05). Only the renal medulla CT value in the shock group was significantly lower than that in the stable group (193 + 57HU vs 228 + 53HU, P=0.014) in the shock group, while the CT value of other organs was not statistically significant (P0.05) compared with the stable group (P0.05), and the 5.ROC curve analysis showed that in the routine injury evaluation. The best critical diagnostic values for SI, ISS, Lac, and BE were 1.19,19.5.2.75mmol/L and.2.88mmol/L, respectively, of which BE AUC was the largest (0.866), and the minimum critical value of SEN and SPE were 88.2% and 0.688 respectively. In the IVC collapse index (T/AP), the optimal critical value for the diagnosis of CT in the early SMA, IVC, spleen, adrenal and delayed renal medulla was 3.02.166HU.121HU.115HU, 150HU, 184HU., and IVC collapse index (T/AP) was 0.833, respectively, which was 73.5% and 86.2% at the best diagnostic critical value, respectively. The minimum of AUC is 0.677. The expression of CTSI equation is derived from the SEN and SPE of the best diagnostic critical value and the integration of six CT indexes of 47.1% and 82.8%.6., respectively. CTSI=X1-0.040X2+0.254X3-0.331X4+0.455X5-0.196X6 (X1 represents IVC collapse index (T/AP), X2 represents the enhancement of the early SMA value. The CT value of the spleen, X5 represents the early adrenal CT value, and X6 represents the CT value of the renal medulla in the delayed stage. Through the ROC curve analysis, the optimal critical value for the diagnosis of CTSI is 21.235, AUC is 0.9038, and SEN and SPE are 92.1% and 90.3% respectively. The overall prediction accuracy is 91.7%. junction. 1. shock group patients are in hospital when they are hospitalized. There was no statistical difference in the group, but the patients in the shock group had higher ISS, SI, Lac and lower BE than the stable group. 2. by quantifying and comparing the CT imaging data of the stable group and the shock group, it was found that the inferior vena cava collapsed, the early inferior vena cava was enhanced early, the upper intestinal artery and the spleen were low perfusion, and the adrenal adrenalation was overstrengthened. CT signs, such as renal medullary enhancement and weakening in the delayed stage, have a certain value in predicting early hypovolemic shock in patients with severe trauma; 3. a new concept of "CT shock index" (CTSI) is innovatively proposed by mathematical statistics and a new concept of "CTSI", which is sensitive to the best diagnostic critical value of 21.235. The degree and specificity are 92.1% and 90.3%, respectively, and the prediction accuracy is 91.7%, which has potential clinical value. 4. this study confirms that some abdominal CT signs can be used as an indicator for predicting shock occurrence in severe trauma patients, and provide early concrete for the application of CT imaging techniques to the assessment of early hemodynamics in patients with severe trauma. Data support laid the foundation for the follow-up of large-scale clinical prospective trials.
【學位授予單位】：第三軍醫(yī)大學
【學位級別】：博士
【學位授予年份】：2013
【分類號】：R641

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