肝移植术后二次气管插管的危险因素及预测模型的建立

doi:10.3877/cma.j.issn.1674-0793.2023.05.009

目的

探讨肝移植术后二次气管插管的危险因素，建立并验证预测模型。

方法

回顾性分析2016年1月至2021年12月在中山大学附属第一医院接受肝移植术的500例患者的临床资料，分为二次气管插管组（R组，21例）和对照组（C组，479例）。比较两组患者围手术期临床资料，分析肝移植术后二次气管插管的危险因素及预后情况。建立列线图预测模型，并运用受试者工作特征（ROC）曲线和拟合优度检验进行评价。

结果

500例接受肝移植术的患者术后二次气管插管发生率为4.2%（21/500）。多因素Logistic回归分析结果显示，术前终末期肝病模型（MELD）评分高、术后48 h血肌酐（Scr）升高、术后丙氨酸氨基转移酶（ALT）峰值是术后二次气管插管的独立危险因素。将上述危险因素绘制ROC曲线，曲线下面积为0.790（95% CI：0.677~0.903，P<0.001）。制作肝移植术后二次气管插管的列线图预测模型，根据得分实现对肝移植术后二次气管插管的初步预测。

结论

接受肝移植术的患者，术前MELD评分高、术后48 h Scr升高、术后ALT峰值是术后二次气管插管的独立危险因素。

关键词: 肝移植, 二次气管插管, 术后, 危险因素, 回顾性, 预测模型

Objective

To explore the risk factors of reintubation after liver transplantation, establish and validate prediction model, so as to provide reference for clinical practice.

Methods

A retrospective study was conducted in 500 patients who underwent liver transplantation in the First Affiliated Hospital of Sun Yat-sen University from January 2016 to December 2021. The selected patients were divided into reintubation group (Group R, 21 cases) and control group (Group C, 479 cases). The perioperative clinical data of the two groups were compared, and the risk factors and prognosis of reintubation after liver transplantation were analyzed.

Results

The incidence of reintubation in patients undergoing liver transplantation was 4.2% (21/500). Multivariate logistic regression analysis showed that high MELD score, elevated serum creatinine (Scr) 48 hours after operation, and alanine aminotransferase (ALT) peak value after operation were independent risk factors for reintubation after operation. The ROC curve was drawn for the above risk factors, and the area under the curve was 0.790 (95% CI: 0.677-0.903, P<0.001). The Nomogram prediction model of reintubation after liver transplantation was made, and the preliminary prediction of reintubation after liver transplantation was realized according to the score.

Conclusion

For patients undergoing liver transplantation, high MELD score before operation, increased Scr at 48 hours after operation, and peak ALT after operation are independent risk factors for reintubation after operation.

Key words: Liver transplantation, Reintubation, Postoperative, Risk factors, Retrospective, Predictive model

表1 二次气管插管组与对照组肝移植患者术前一般资料的比较

项目	C组	R组	统计值	P值
例数	479	21
年龄(岁)	52.12±10.87	50.76±10.91	0.558	0.577
性别^a			1.759	0.259
男	431(90.0)	17(81.0)
女	48(10.0)	4(19.0)
体质指数(kg/m²)	23.27±3.56	21.82±3.31	1.837	0.067
ASA分级^a			2.337	0.498
Ⅱ	43(9.0)	3(14.3)
Ⅲ	301(62.8)	10(47.6)
Ⅳ	135(28.2)	8(138.1)
MELD评分(分)	24.01±7.46	30.11±11.15	-3.582	0.022
MELD-Na评分(分)	24.31±7.56	29.95±11.29	-3.267	0.034
术前合并症^a
高血压病	69(14.4)	2(9.5)	0.393	0.753
糖尿病	69(14.4)	1(4.8)	1.554	0.336
肝硬化	345(72.0)	15(71.4)	0.004	0.952
肝衰竭	73(15.2)	9(42.9)	11.192	0.003
术前实验室检查
Hb(g/L)	114.97±29.03	105.05±32.02	1.526	0.128
PLT(×10⁹/L)^b	85.5(49,144)	83(56,182)	0.696	0.486
ALB(g/L)	36.89±5.46	36.67±6.08	0.180	0.857
TBIL(μmol/L)^b	29.2(17.1,102.4)	343.3(99.1,483.8)	2.310	0.021
ALT(U/L)^b	29.0(19.0，46.0)	52.0(45.0,104.0)	1.734	0.083
AST(U/L)^b	43.0(32.0,70.0)	142.0(65.0,222.0)	3.079	0.002
GGT(U/L)^b	66.5（36.0,122.5)	85.0(46.0,250.0)	0.864	0.387
LDH(U/L)^b	215.0(183.0,259.0)	270.0(209.0,286.0)	1.497	0.134

表1 二次气管插管组与对照组肝移植患者术前一般资料的比较

项目	C组	R组	统计值	P值
例数	479	21
年龄(岁)	52.12±10.87	50.76±10.91	0.558	0.577
性别^a			1.759	0.259
男	431(90.0)	17(81.0)
女	48(10.0)	4(19.0)
体质指数(kg/m²)	23.27±3.56	21.82±3.31	1.837	0.067
ASA分级^a			2.337	0.498
Ⅱ	43(9.0)	3(14.3)
Ⅲ	301(62.8)	10(47.6)
Ⅳ	135(28.2)	8(138.1)
MELD评分(分)	24.01±7.46	30.11±11.15	-3.582	0.022
MELD-Na评分(分)	24.31±7.56	29.95±11.29	-3.267	0.034
术前合并症^a
高血压病	69(14.4)	2(9.5)	0.393	0.753
糖尿病	69(14.4)	1(4.8)	1.554	0.336
肝硬化	345(72.0)	15(71.4)	0.004	0.952
肝衰竭	73(15.2)	9(42.9)	11.192	0.003
术前实验室检查
Hb(g/L)	114.97±29.03	105.05±32.02	1.526	0.128
PLT(×10⁹/L)^b	85.5(49,144)	83(56,182)	0.696	0.486
ALB(g/L)	36.89±5.46	36.67±6.08	0.180	0.857
TBIL(μmol/L)^b	29.2(17.1,102.4)	343.3(99.1,483.8)	2.310	0.021
ALT(U/L)^b	29.0(19.0，46.0)	52.0(45.0,104.0)	1.734	0.083
AST(U/L)^b	43.0(32.0,70.0)	142.0(65.0,222.0)	3.079	0.002
GGT(U/L)^b	66.5（36.0,122.5)	85.0(46.0,250.0)	0.864	0.387
LDH(U/L)^b	215.0(183.0,259.0)	270.0(209.0,286.0)	1.497	0.134

表2 二次气管插管组与对照组肝移植患者术中情况的比较

项目	C组	R组	统计值	P值
例数	479	21
手术时间(min)^a	451(394,520)	427(377,485)	0.590	0.555
阻断肝门时间(min)^a	54.0(44.5,65.0)	52.0(43.0,57.0)	0.360	0.719
阻断下腔时间(min)^a	49.0(40.0,57.0)	47.0(41.0,58.0)	0.057	0.954
术中出血量(ml)^a	1 500(800,2 500)	2 000(1 200,3 600)	2.107	0.035
输红细胞量(ml)^a	920(400,1 600)	1 550(600,3 600)	2.269	0.023
输血浆量(ml)^a	1 400(1 000,2 000)	1 600(1 000,2 800)	1.930	0.054
输冷沉淀(U)	5.71±7.84	6.29±8.11	-0.330	0.741
输血小板(U)	0.81±2.49	0.33±0.48	0.866	0.387

表2 二次气管插管组与对照组肝移植患者术中情况的比较

项目	C组	R组	统计值	P值
例数	479	21
手术时间(min)^a	451(394,520)	427(377,485)	0.590	0.555
阻断肝门时间(min)^a	54.0(44.5,65.0)	52.0(43.0,57.0)	0.360	0.719
阻断下腔时间(min)^a	49.0(40.0,57.0)	47.0(41.0,58.0)	0.057	0.954
术中出血量(ml)^a	1 500(800,2 500)	2 000(1 200,3 600)	2.107	0.035
输红细胞量(ml)^a	920(400,1 600)	1 550(600,3 600)	2.269	0.023
输血浆量(ml)^a	1 400(1 000,2 000)	1 600(1 000,2 800)	1.930	0.054
输冷沉淀(U)	5.71±7.84	6.29±8.11	-0.330	0.741
输血小板(U)	0.81±2.49	0.33±0.48	0.866	0.387

表3 二次气管插管组与对照组肝移植患者术后情况的比较[M（P25，P75）]

项目	C组	R组	Z值	P值
例数	479	21
术后48 h Scr (μmol/L)	79.0(64.0,99.5)	99.0(74.0,167.0)	-2.631	0.009
术后24 h PT (s)	17.2(15.4,20.1)	19.9(17.4,21.7)	-2.599	0.009
术后24 h INR	1.47(1.31,1.74)	1.78(1.55,1.91)	-2.688	0.007
术后24 h APTT (s)	50.1(41.0,61.8)	62.1(55.0,73.0)	-3.814	<0.001
术后24 h FIB(g/L)	1.69(1.35,2.07)	1.35(1.25,1.63)	-3.014	0.003
术后24 h血氨(μmol/L)	32.0(21.0，47.0)	49.0(33.0,60.0)	-2.507	0.012
术后ALT峰值(U/L)	623(327,976)	782(452,1183)	-2.227	0.026
术后AST峰值(U/L)	1243(737,2223)	1850(1356,2778)	-3.141	0.002

表3 二次气管插管组与对照组肝移植患者术后情况的比较[M（P25，P75）]

项目	C组	R组	Z值	P值
例数	479	21
术后48 h Scr (μmol/L)	79.0(64.0,99.5)	99.0(74.0,167.0)	-2.631	0.009
术后24 h PT (s)	17.2(15.4,20.1)	19.9(17.4,21.7)	-2.599	0.009
术后24 h INR	1.47(1.31,1.74)	1.78(1.55,1.91)	-2.688	0.007
术后24 h APTT (s)	50.1(41.0,61.8)	62.1(55.0,73.0)	-3.814	<0.001
术后24 h FIB(g/L)	1.69(1.35,2.07)	1.35(1.25,1.63)	-3.014	0.003
术后24 h血氨(μmol/L)	32.0(21.0，47.0)	49.0(33.0,60.0)	-2.507	0.012
术后ALT峰值(U/L)	623(327,976)	782(452,1183)	-2.227	0.026
术后AST峰值(U/L)	1243(737,2223)	1850(1356,2778)	-3.141	0.002

表4 肝移植患者术后二次气管插管危险因素的多因素Logistic回归分析

危险因素	B	SE	Wald	df	P值	OR	95% CI
术前MELD评分	0.082	0.027	9.481	1	0.002	1.086	1.030~1.144
术后48 h Scr	0.008	0.003	8.100	1	0.004	1.008	1.003~1.014
术后24 h APTT	0.008	0.009	0.873	1	0.350	1.009	0.991~1.027
术后ALT峰值	<0.001	<0.001	5.299	1	0.021	1.001	1.000~1.001

表4 肝移植患者术后二次气管插管危险因素的多因素Logistic回归分析

危险因素	B	SE	Wald	df	P值	OR	95% CI
术前MELD评分	0.082	0.027	9.481	1	0.002	1.086	1.030~1.144
术后48 h Scr	0.008	0.003	8.100	1	0.004	1.008	1.003~1.014
术后24 h APTT	0.008	0.009	0.873	1	0.350	1.009	0.991~1.027
术后ALT峰值	<0.001	<0.001	5.299	1	0.021	1.001	1.000~1.001

图1 肝移植术后二次气管插管的列线图预测模型

图2 肝移植术后二次气管插管发生概率　A为ROC曲线；B为H-L校正曲线

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Risk factors and prediction model of reintubation after liver transplantation

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Risk factors and prediction model of reintubation after liver transplantation