Scarcello Edoardo, Ferrari Mauro, Rossi Giuseppe, Berchiolli Raffaella, Adami Daniele, Romagnani Francesco, Mosca Franco
Unit of Vascular Surgery of the Department of Oncology, Transplantation and New Technologies in Medicine, University of Pisa, Pisa, Italy.
Ann Vasc Surg. 2010 Apr;24(3):315-20. doi: 10.1016/j.avsg.2009.07.011. Epub 2009 Nov 8.
In patients with ruptured abdominal aortic aneurysm (RAAA) and shock, the time lag between the onset of the symptoms due to RAAA and the presence of a full developed shock syndrome was evaluated to assess its prognostic meaning. This time lag was called time before shock (TBS).
Ninety-four patients operated on between 2002 and 2007 have been retrospectively analyzed regarding TBS and the following parameters: presence of shock, severity of bleeding, age, comorbidities, and gender. According to TBS, on a 10-hour cutoff value, three groups of patients were distinguished: patients with TBS of 10 or less (short TBS), patients with TBS greater than 10 (long TBS), and patients without shock. The relationship of these variables with intraoperative and 30-day mortality was analyzed by both univariate and multivariate analyses.
In the univariate analysis, patients with short TBS presented with four-fold mortality compared to patients without shock (p=0.000), whereas the increase in mortality of the patients with long TBS was nonsignificant (p=0.448). The mortality in patients with shock (presence of shock) was 3.7 times higher than in patients without shock (p=0.001). The mortality related to massive bleeding was 3.7 times higher than that associated with moderate bleeding (p=0.001). An increased mortality with borderline significance level was observed in patients older than 75 years (p=0.052). The relationship of mortality to the presence of comorbidities and gender was not significant. In the multivariate analysis, the mortality among the patients with short TBS was clearly highest, after either massive or moderate bleeding. In the logistic model with TBS, the Wald test showed as significant both short TBS (p=0.001) and severity of bleeding (p=0.033) but not age (p=0.103) and long TBS (p=0.0401). The model with TBS presented a better performance than that with shock, showing higher sensitivity, higher values of Youden's J, and a greater proportion of the total variation in mortality. Through the model with TBS, two groups of patients (those 75 years or younger with massive bleeding and those older than 75 years with moderate bleeding), both with short TBS, presented with a high risk of death not predicted by the model with shock.
TBS seems to complete the information given by the parameter "presence of shock," and its evaluation allows a more effective judgment of the risk of death, at emergency admission of patients with RAAA.
在腹主动脉瘤破裂（RAAA）并伴有休克的患者中，评估RAAA症状出现至完全性休克综合征出现之间的时间间隔，以评估其预后意义。这个时间间隔被称为休克前时间（TBS）。
回顾性分析了2002年至2007年间接受手术的94例患者的TBS以及以下参数：休克的存在、出血严重程度、年龄、合并症和性别。根据TBS，以10小时为界值，将患者分为三组：TBS为10小时或更短的患者（短TBS）、TBS大于10小时的患者（长TBS）以及无休克的患者。通过单因素和多因素分析来分析这些变量与术中及30天死亡率的关系。
在单因素分析中，短TBS患者的死亡率是无休克患者的4倍（p = 0.000），而长TBS患者死亡率的增加不显著（p = 0.448）。休克患者（存在休克）的死亡率比无休克患者高3.7倍（p = 0.001）。与大量出血相关的死亡率比中度出血高3.7倍（p = 0.001）。75岁以上患者的死亡率有临界显著性增加（p = 0.052）。死亡率与合并症的存在及性别的关系不显著。在多因素分析中，短TBS患者的死亡率在大量或中度出血后明显最高。在包含TBS的逻辑模型中，Wald检验显示短TBS（p = 0.001）和出血严重程度（p = 0.033）具有显著性，但年龄（p = 0.103）和长TBS（p = 0.0401）不具有显著性。包含TBS的模型比包含休克的模型表现更好，显示出更高的敏感性、更高的约登指数值以及死亡率总变异中更大的比例。通过包含TBS的模型，两组患者（75岁及以下大量出血患者和75岁以上中度出血患者），均为短TBS，呈现出休克模型未预测到的高死亡风险。
TBS似乎完善了“存在休克”这一参数所提供的信息，对其进行评估能在RAAA患者急诊入院时更有效地判断死亡风险。
