肠壁积气预测评估研究：美国创伤外科协会的一项多中心流行病学研究。
Pneumatosis Intestinalis Predictive Evaluation Study: A multicenter epidemiologic study of the American Association for the Surgery of Trauma.
作者信息
Ferrada Paula, Callcut Rachael, Bauza Graciela, O'Bosky Karen R, Luo-Owen Xian, Mansfield Nicky J, Inaba Kenji, Pasley Jason, Bugaev Nikolay, Pereira Bruno, Moore Forrest O, Han Jinfeng, Pasley Amelia, DuBose Joseph
机构信息
From the Virginia Commonwealth University, Richmond, Virginia (P.F., J.H.); University of California, San Francisco (R.C.); University of Pittsburg Medical Center, Pittsburg, Pennsylvania (G.B.); Loma Linda University and Medical Center, Loma Linda, California (K.R.O., X.L-O.); Keck School of Medicine at the University of Southern California, Los Angeles, California (N.J.M., K.I.); University of Maryland Medical Center, Baltimore, Maryland (J.P., A.P.); Tuffs University, Medford, Massachusetts (N.B.); University of Campinas, Campinas, São Paulo, Brazil (B.P.); Chandler Regional Medical Center, Chandler, Arizona (F.O.M.); and University of California, Davis, California (J.D.).
出版信息
J Trauma Acute Care Surg. 2017 Mar;82(3):451-460. doi: 10.1097/TA.0000000000001360.
BACKGROUND
Our group has previously published a retrospective review defining variables predictive of transmural bowel ischemia in the setting of pneumatosis intestinalis (PI). We hypothesize this prospective study will confirm the findings of the retrospective review, enhancing legitimacy to the predictive factors for pathologic PI previously highlighted.
METHODS
Data were collected using the Research Electronic Data Capture. Forward logistic regression was utilized to identify independent predictors for pathologic PI. Statistical significance was defined as p ≤ 0.05.
RESULTS
During the 3-year study period, 127 patients with PI were identified. Of these, 79 had benign disease, and 49 pathologic PI defined by the presence of transmural ischemia during surgical exploration or autopsy. Laboratory values such as elevated international normalized ratio (INR), decreased hemoglobin, and a lactate value of greater than 2.0 mmol/L were predictive of pathologic PI, as well as clinical factors including adynamic ileus, peritoneal signs on physical examination, sepsis, and hypotension. The location was also a significant factor, as patients with small bowel PI had a higher incidence of transmural ischemia than colonic PI. On multiple logistic regression, lactate value of greater than 2.0 mmol/L (odds ratio, 5.1, 1.3-19.5; p = 0.018), elevated INR (odds ratio, 3.2, 1.1-9.6; p = 0.031), peritonitis (15.0, 2.9-78; p = 0.001), and decreased hemoglobin (0.70, 0.50-0.97, 0.031) remained significant predictors of transmural ischemia (area under the curve, 0.90; 0.83-0.97). A lactate value of 2.0 mmol/L or greater and peritonitis are common factors between the retrospective review and this prospective study.
CONCLUSIONS
We recommend surgical exploration to be strongly considered for those PI patients presenting also with a lactate greater than 2 mmol/L and/or peritonitis. We suggest strong suspicion for necrosis in those patient with PI and small bowel involvement, ascites on computed tomography scan, adynamic ileus, anemia, and a high INR.
LEVEL OF EVIDENCE
Prognostic study, level II; therapeutic study, level II.
背景
我们团队之前发表了一项回顾性研究，确定了在肠壁积气（PI）情况下预测透壁性肠缺血的变量。我们假设这项前瞻性研究将证实回顾性研究的结果，增强之前所强调的病理性PI预测因素的可信度。
方法
使用研究电子数据采集系统收集数据。采用向前逻辑回归来确定病理性PI的独立预测因素。统计学显著性定义为p≤0.05。
结果
在3年的研究期间，共确定了127例PI患者。其中，79例为良性疾病，49例为病理性PI，通过手术探查或尸检时存在透壁性缺血来定义。实验室检查值如国际标准化比值（INR）升高、血红蛋白降低以及乳酸值大于2.0 mmol/L可预测病理性PI，临床因素包括麻痹性肠梗阻、体格检查时有腹膜刺激征、脓毒症和低血压也可预测。部位也是一个重要因素，因为小肠PI患者透壁性缺血的发生率高于结肠PI患者。在多因素逻辑回归分析中，乳酸值大于2.0 mmol/L（比值比，5.1，1.3 - 19.5；p = 0.018）、INR升高（比值比，3.2，1.1 - 9.6；p = 0.031）、腹膜炎（15.0，2.9 - 78；p = 0.001）以及血红蛋白降低（0.70，0.50 - 0.97，0.031）仍然是透壁性缺血的显著预测因素（曲线下面积，0.90；0.83 - 0.97）。乳酸值2.0 mmol/L或更高以及腹膜炎是回顾性研究和这项前瞻性研究中的共同因素。
结论
对于同时伴有乳酸值大于2 mmol/L和/或腹膜炎的PI患者，我们建议强烈考虑进行手术探查。对于伴有PI且有小肠受累、计算机断层扫描显示有腹水、麻痹性肠梗阻、贫血和高INR的患者，我们建议高度怀疑有坏死。
证据级别
预后研究，二级；治疗研究，二级。
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