Department of Intensive Care, Hedi Chaker, University Hospital Sfax, Tunisia.
Ann Thorac Med. 2011 Oct;6(4):199-206. doi: 10.4103/1817-1737.84773.
To determine the predictive factors, clinical manifestations, and the outcome of patients with post-traumatic pulmonary embolism (PE) admitted in the intensive care unit (ICU).
During a four-year prospective study, a medical committee of six ICU physicians prospectively examined all available data for each trauma patient in order to classify patients according to the level of clinical suspicion of pulmonary thromboembolism. During the study period, all trauma patients admitted to our ICU were classified into two groups. The first group included all patients with confirmed PE; the second group included patients without clinical manifestations of PE. The diagnosis of PE was confirmed either by a high-probability ventilation/perfusion (V/Q) scan or by a spiral computed tomography (CT) scan showing one or more filling defects in the pulmonary artery or its branches.
During the study period, 1067 trauma patients were admitted in our ICU. The diagnosis of PE was confirmed in 34 patients (3.2%). The mean delay of development of PE was 11.3 ± 9.3 days. Eight patients (24%) developed this complication within five days of ICU admission. On the day of PE diagnosis, the clinical examination showed that 13 patients (38.2%) were hypotensive, 23 (67.7%) had systemic inflammatory response syndrome (SIRS), three (8.8%) had clinical manifestations of deep venous thrombosis (DVT), and 32 (94%) had respiratory distress requiring mechanical ventilation. In our study, intravenous unfractionated heparin was used in 32 cases (94%) and low molecular weight heparin was used in two cases (4%). The mean ICU stay was 31.6 ± 35.7 days and the mean hospital stay was 32.7 ± 35.3 days. The mortality rate in the ICU was 38.2% and the in-hospital mortality rate was 41%. The multivariate analysis showed that factors associated with poor prognosis in the ICU were the presence of circulatory failure (Shock) (Odds ratio (OR) = 9.96) and thrombocytopenia (OR = 32.5).Moreover, comparison between patients with and without PE showed that the predictive factors of PE were: Age > 40 years, a SAPS II score > 25, hypoxemia with PaO(2)/FiO(2) < 200 mmHg, the presence of spine fracture, and the presence of meningeal hemorrhage.
Despite the high frequency of DVT in post-traumatic critically ill patients, symptomatic PE remains, although not frequently observed, because systematic screening is not performed. Factors associated with poor prognosis in the ICU are the presence of circulatory failure (shock) and thrombocytopenia. Predictive factors of PE are: Age > 40 years, a SAPS II score > 25, hypoxemia with PaO(2)/FiO(2) < 200, the presence of a spine fracture, and the presence of meningeal hemorrhage. Prevention is highly warranted.
确定入住重症监护病房（ICU）的创伤后肺栓塞（PE）患者的预测因素、临床表现和转归。
在一项为期四年的前瞻性研究中，一个由六名 ICU 医生组成的医学委员会前瞻性地检查了每位创伤患者的所有可用数据，以便根据肺血栓栓塞症的临床疑似程度对患者进行分类。在研究期间，我们 ICU 收治的所有创伤患者均分为两组。第一组包括所有确诊为 PE 的患者；第二组包括无 PE 临床表现的患者。PE 的诊断通过高概率通气/灌注（V/Q）扫描或螺旋 CT 扫描证实，后者显示肺动脉或其分支存在一个或多个充盈缺损。
在研究期间，我们 ICU 收治了 1067 名创伤患者。34 名患者（3.2%）确诊为 PE。PE 的平均发病时间为 11.3±9.3 天。8 名患者（24%）在 ICU 入院后 5 天内发生此并发症。在 PE 诊断当天，临床检查显示 13 名患者（38.2%）血压低，23 名患者（67.7%）存在全身炎症反应综合征（SIRS），3 名患者（8.8%）存在深静脉血栓形成（DVT）的临床表现，32 名患者（94%）存在需要机械通气的呼吸窘迫。在我们的研究中，32 例（94%）患者使用了普通肝素静脉注射，2 例（4%）患者使用了低分子肝素。ICU 住院时间平均为 31.6±35.7 天，住院时间平均为 32.7±35.3 天。ICU 死亡率为 38.2%，院内死亡率为 41%。多因素分析显示，ICU 预后不良的相关因素为循环衰竭（休克）（优势比（OR）=9.96）和血小板减少症（OR=32.5）。此外，比较有和无 PE 的患者发现，PE 的预测因素为：年龄>40 岁，SAPS II 评分>25，PaO(2)/FiO(2)<200mmHg 的低氧血症，脊柱骨折，脑膜下出血。
尽管创伤后危重症患者深静脉血栓形成的频率较高，但由于未进行系统筛查，仍存在有症状的 PE，尽管并不常见。ICU 预后不良的相关因素为循环衰竭（休克）和血小板减少症。PE 的预测因素为：年龄>40 岁，SAPS II 评分>25，PaO(2)/FiO(2)<200，存在脊柱骨折，脑膜下出血。高度需要预防。
