Blocksom Jason M, Tyburski James G, Sohn Richard L, Williams Mallory, Harvey E, Steffes Christopher P, Carlin Arthur M, Wilson Robert F
Department of Surgery, Detroit Receiving Hospital, Wayne State University, Michigan 48201, USA.
Am Surg. 2004 Mar;70(3):248-55; discussion 255.
A retrospective review of 222 consecutive patients with duodenal injuries admitted to an urban Level 1 Trauma Center who subsequently underwent laparotomy during the period July 1980 to April 2002 was performed in an effort to elucidate factors associated with mortality, infectious morbidity, and length of stay in these patients. Predictably, the patients were predominantly male (92.7%) and young (mean age, 31.6 years). The overall mortality rate was 22.5 per cent, with a mortality rate of 18 per cent seen in the first 48 hours. Penetrating trauma was suffered by 88.3 per cent of the patients. Multivariate analysis revealed the performance of a thoracotomy, initial emergency department (ED) systolic blood pressure (SBP) <90 mm Hg, final operating room (OR) core body temperature less than 35 degrees C, and presence of a splenic injury to be the most important predictors of mortality (all P < 0.05). Mortality in the patients undergoing a resuscitative thoracotomy was 88.9 per cent versus 13.3 per cent in those patients not requiring thoracotomy. An initial SBP in the ED <90 was associated with a 46 per cent mortality rate, as compared with 4 per cent in those patients not in shock. A final OR core body temperature of less than 35 degrees C led to a 60 per cent mortality rate versus 8.3 per cent for warmer patients. Patients with a concomitant splenic injury were noted to have a 62.5 per cent mortality rate; those without had a 19.4 per cent mortality rate. The mean length of stay among survivors greater than 48 hours was 16.0 +/- 24.7 days. Univariate analyses revealed lowest OR core body temperature below 35 degrees C, initial OR SBP <90, presence of infection, >5 transfusions, initial ED SBP <90, final OR core temperature <35 degrees C, colon injury, spleen injury, and an injury severity score (ISS) >25 all to be significantly associated with increased length of stay. Multivariate analysis revealed an initial operating room blood pressure of less than 90 mm Hg systolic, the presence of an infection, and greater than 5 blood transfusions to be the factors most significantly correlated with increased length of stay (all P < 0.02). Of 182 patients surviving 48 hours, 98 (54%) developed an infection. Fifty-seven (31%) patients were noted to have wound-related infections, 92 (51%) patients had nosocomial infections, and 50 (27%) patients had both types. The presence of an abdominal arterial injury, an ISS >25, pancreatic injury, and lowest OR core body temperature <35 degrees C were the factors identified on multivariate analysis most significantly correlated with infectious morbidity (all P < 0.05). This data suggests that early efforts to prevent shock and rapidly control bleeding are the most likely efforts to reduce mortality rates in these patients. Those patients with duodenal injury presenting in shock or requiring a thoracotomy for resuscitation did poorly. Splenic injury was the associated injury found on multivariate analysis to be most closely associated with increased mortality. Early control of bleeding and the prevention of infection provide the most significant opportunity for decreasing length of stay. Infections are common with duodenal injuries, and aggressive surveillance should especially be performed in those patients with an abdominal arterial injury, an ISS >25, pancreatic injury, or lowest OR core body temperature <35 degrees C.
对1980年7月至2002年4月期间在一家城市一级创伤中心连续收治的222例十二指肠损伤患者进行了回顾性研究，这些患者随后接受了剖腹手术，旨在阐明与这些患者的死亡率、感染性发病率和住院时间相关的因素。不出所料，患者以男性为主（92.7%）且较为年轻（平均年龄31.6岁）。总体死亡率为22.5%，在前48小时内的死亡率为18%。88.3%的患者遭受穿透性创伤。多因素分析显示，开胸手术、急诊科（ED）初始收缩压（SBP）<90 mmHg、手术室（OR）最终核心体温低于35℃以及存在脾损伤是死亡率的最重要预测因素（所有P<0.05）。接受复苏性开胸手术的患者死亡率为88.9%，而不需要开胸手术的患者死亡率为13.3%。急诊科初始SBP<90与46%的死亡率相关，而未休克患者的死亡率为4%。手术室最终核心体温低于35℃导致死亡率为60%，体温较高的患者死亡率为8.3%。伴有脾损伤的患者死亡率为62.5%；无脾损伤的患者死亡率为19.4%。存活超过48小时的患者平均住院时间为16.0±24.7天。单因素分析显示，手术室最低核心体温低于35℃、手术室初始SBP<90、存在感染、输血>5次、急诊科初始SBP<90、手术室最终核心体温<35℃、结肠损伤、脾损伤以及损伤严重程度评分（ISS）>25均与住院时间延长显著相关。多因素分析显示，手术室初始收缩压低于90 mmHg、存在感染以及输血超过5次是与住院时间延长最显著相关的因素（所有P<0.02）。在182例存活48小时的患者中，98例（54%）发生了感染。57例（31%）患者有伤口相关感染，92例（51%）患者有医院感染，50例（27%）患者两种感染都有。多因素分析确定，存在腹主动脉损伤、ISS >25、胰腺损伤以及手术室最低核心体温<35℃是与感染性发病率最显著相关的因素（所有P<0.05）。该数据表明，早期预防休克和迅速控制出血是降低这些患者死亡率最有可能采取的措施。那些因休克就诊或需要开胸手术进行复苏治疗十二指肠损伤的患者预后较差。多因素分析发现，脾损伤是与死亡率增加最密切相关的合并伤。早期控制出血和预防感染为缩短住院时间提供了最重要的机会。十二指肠损伤患者感染很常见，对于那些存在腹主动脉损伤、ISS >25、胰腺损伤或手术室最低核心体温<35℃的患者，应尤其进行积极监测。
