【作者】 赵明；

【导师】 赵立；

【作者基本信息】 中国医科大学 ， 呼吸内科（专业学位）， 2021， 硕士

【摘要】 研究目的:明确医院获得性静脉血栓栓塞症(HA-VTE)的临床特征,筛选出住院患者发生静脉血栓栓塞症的高危因素以指导临床医师决策。研究方法:回顾性检索电子病历系统,对2011年1月至2019年11月中国医科大学附属盛京医院所有科室收治的静脉血栓栓塞(VTE)患者2177例进行病历筛选,最终纳入274例医院获得性静脉血栓栓塞患者作为病例组(VTE组),选择同时期(±30d)、同科室非静脉血栓栓塞患者共399例作为对照组(非VTE组)。对两组间一般情况、合并疾病、治疗方式以及实验室指标等可能危险因素进行单因素统计分析,利用多因素Logistic回归模型确定HA-VTE的独立危险因素,在此基础上制定HA-VTE的评分简表,应用受试者工作特征曲线(ROC曲线)对简易评分表预测效能进行验证。并对手术患者进行亚组分析,进一步明确手术方式、时长、部位、级别、麻醉方式对VTE的影响。结果:1)危险因素单因素分析结果:住院患者卧床时间>72h(P<0.05)、转入ICU(P<0.05)、住院时间延长(P<0.05)、进行大手术(P<0.05)、合并骨折(P=0.010)、高血压(P<0.05)、贫血(P<0.05)、低白蛋白血症(P<0.05)、肠梗阻(P=0.004)、胆结石(P=0.012)更容易发生静脉血栓栓塞。VTE组较非VTE组有较高的WBC、D-Dimer、ALP、GGT、TC、TG、LDL、CRP、BNP、cTnI、ASO、TSH水平,而Hb、PTA、APTT、TP、ALB、BA、UA、FT3、TGAb、TPOAb、ESR、Pa CO2、PO2、AB、BE、Sa O2、Hb A1c的值下降。2)多因素分析结果显示住院期间进行大手术(OR=3.116,95%CI 1.577～6.158,P=0.001)、合并贫血(OR=2.859,95%CI 1.331～6.138,P=0.007)、合并低白蛋白血症(OR=2.991,95%CI 1.294～6.915,P=0.010)、住院时间延长(OR=1.011,95%CI1.003～1.020,P=0.009)、抗链球菌溶血素O升高(OR=1.062,95%CI 1.026～1.099,P<0.05)、总胆固醇升高(OR=4.594,95%CI 2.159～9.774,P<0.05)、促甲状腺激素升高(OR=1.850,95%CI 1.235～2.771,P=0.003)是医院获得性静脉血栓栓塞症的独立危险因素。3)手术患者亚组分析结果显示:VTE组较非VTE组手术时间延长(t=2.888,P=0.004),不同手术方式、部位、级别、麻醉方式对VTE影响不同,开放手术(OR=2.848,95%CI 1.921～4.224,P<0.05)、四级手术(OR=4.280,95%CI 2.391～7.660,P<0.05)、术中采用全身麻醉(OR=3.889,95%CI 2.599～5.817,P<0.05)VTE发生风险最高,肠道手术及子宫附件手术分别使VTE风险增加7.314倍(95%CI 1.536～34.822,P=0.012)和3.021倍(95%CI 1.744～5.234,P=0.001)。4)根据多因素Logistic回归分析结果对独立危险因素建立简易评分模型,利用受试者工作特征曲线评估模型的预测效能,结果显示曲线下面积AUC为0.866(95%CI0.837～0.894,P<0.05)。结论:进行大手术、合并贫血、低白蛋白血症、ASO升高、TC升高、TSH升高、住院时间延长是住院患者发生静脉血栓栓塞症的独立危险因素。手术时间延长、手术级别高,开放手术以及应用全身麻醉影响着静脉血栓栓塞的发生。本研究构建的HA-VTE简易评分模型有较好的预测效果,提示医护人员在诊疗过程中及时、充分评估患者血栓风险并采取个体化预防措施以降低院内获得性静脉血栓栓塞症的发生。更多还原

【Abstract】 Objective:To determine the clinical characteristics and related risk factors of hospital-acquired venous thromboembolism.Methods:A retrospective search of the electronic medical record system was conducted to screen the medical records of 2177 patients with venous thromboembolism(VTE)admitted to all departments of Shengjing Hospital,China Medical University from January2011 to November 2019.Finally,274 patients with nosocomial acquired VTE were included as the case group(VTE group),and the same departments were selected over the same period(±30 days)A total of 399 non-VTE patients were used as control group(non-VTE group).The differences between the two groups in general conditions,co-existing diseases,treatment methods and laboratory indicators were compared.The independent risk factors for HA-VTE were determined by multi-factor Logistic regression model,and a simple scoring scale for HA-VTE was developed.The predictive efficiency of the simple rating scale was verified by receiver operating characteristic curve(ROC curve).Subgroup analysis was conducted on the patients undergoing surgery to further clarify the effects of operation method,duration,location,level and anesthesia method on VTE.Results:1)The results of univariate analysis of risk factors:There were significant differences in bedridden(x~2=14.281,P<0.05),transferred to ICU(x~2=22.196,P<0.05),length of hospital stay(t=6.752,P<0.05),major surgery(x~2=22.173,P<0.05),fracture(x~2=6.648,P=0.010),hypertension(x~2=14.586,P<0.05),anemia hypoalbuminemia(x~2=105.010,P<0.05),intestinal obstruction(x~2=8.248,P=0.004)and gallstones(x~2=6.323,P=0.012).The levels of WBC,D-Dimer,ALP,GGT,TC,TG,LDL,CRP,BNP,c Tn I,ASO and TSH in the case group were higher than those in the control group.The levels of BNP,c Tn I,ASO and TSH in the case group were higher than those in the control group.The levels of Hb,PTA,APTT,TP,ALB,BA,FT3,TGAb,TPOAb,ESR,Pa CO2,PO2,AB,BE,Sa O2 and Hb A1c decreased.2)Multivariate analysis:major surgery(O R=3.1 1 6,9 5%C I 1.5 7 7-6.1 5 8),a n e m i a(O R=2.8 5 9,9 5%C I 1.3 3 1-6.1 3 8),hypoproteinemia(OR=2.991,95%CI 1.294-6.915-0.010),hospital stay(OR=1.011,95%CI1.003-1.020),antistreptococcal hemolysin O(OR=1.062,95%CI 1.026-1.099),total cholesterol(OR=4.594,95%CI 2.159-9.774).The increase of OR=1.850,95%CI 1.235 to2.771 was the independent risk factor of hospital acquired venous thromboembolism.3)The results of subgroup analysis showed that the operation time in VTE group was longer than that in non-VTE group.Different surgical methods,sites,grades and anesthetic methods had different effects on VTE.Open surgery(OR=2.848,95%CI 1.921 to 4.224,O R=4.2 8 0,9 5%C I 2.3 9 1 t o 7.6 6 0,a n d i n t r a o p e r a t i v e g e n e r a l a n e s t h e s i a(OR=3.889,95%CI 2.599 to 5.817,P<0.05)had the highest risk of VTE.Intestinal surgery and uterine adnexal surgery increased the risk of VTE by 7.314 times(95%CI1.536 to 34.822,respectively.0.012)and 3.021 times(95%CI 1.744 5.234).4)A simple scoring model was established for independent risk factors according to the results of multivariate Logistic regression analysis,and the predictive efficiency of the model was evaluated by receiver operating characteristic curve.The results showed that the area under the curve was 0.866(95%CI 0.837～0.894,P<0.05).Conclusion:This study confirmed that major surgery,anemia,hypoalbuminemia,elevated ASO,TC,TSH and prolonged hospitalization were independent risk factors for venous thromboembolism in inpatients.Prolonged operation,high grade of operation,open surgery and application of general anesthesia affect the occurrence of venous thromboembolism.It is suggested that in the process of diagnosis and treatment,medical staff should timely and fully assess the risk of thrombosis and take individual preventive measures to reduce the incidence of nosocomial acquired venous thromboembolism.更多还原