Zhang P, Yuan L L, Luo J, Song H P, Xiang F, Luo G X, Huang Y S
State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burn Research, the First Affiliated Hospital of Army Medical University (the Third Military Medical University), Chongqing 400038, China.
Zhonghua Shao Shang Za Zhi. 2021 Mar 20;37(3):243-249. doi: 10.3760/cma.j.cn501120-20201127-00503.
To investigate the influencing factors and their predictive value of skin graft survival after Meek grafting in severe burn patients. A retrospective case-control study was conducted in 115 severe burn patients (95 males, 20 females, aged 1-74 years) who met the inclusion criteria and received Meek grafting in the First Affiliated Hospital of Army Medical University (the Third Military Medical University) from January 2013 to December 2019. The patients were divided into good skin graft survival group with skin graft survival rate≥70% (68 cases) and poor skin graft survival group with skin graft survival rate<70% (47 cases). The statistics of patients in the two groups were recorded during their first Meek grafting after admission including the gender, age, body mass index, full-thickness burn area, burn index, complication of inhalation injury, time from injury to operation, preoperative cystatin C level, preoperative albumin level, preoperative neutrophil, preoperative hemoglobin level, preoperative platelet count, and platelet count on the first, third, and fifth day after operation. The above indicators were statistically analyzed between the two groups with independent sample test, Mann-Whitney test, and chi-square test. A 1∶1 propensity score matching (PSM) of the gender, age, body mass index, full-thickness burn area, burn index, complication of inhalation injury, time from injury to operation of patients in the two groups were performed to eliminate the differences in baseline data, and then the above indicators of the remaining patients in the two groups were recorded and analyzed again. The indicators with statistically significant differences between the two groups after 1∶1 PSM were selected for multivariate logistic regression analysis to screen the independent risk factors affecting the skin graft survival after Meek grafting in severe burn patients. The receiver operating characteristic (ROC) curve of independent risk factors for predicting poor skin graft survival after Meek grafting in severe burn patients after 1∶1 PSM was drawn, and the area under the curve, the cut-off value, and the sensitivity and specificity under the cut-off value were calculated. The patients after 1∶1 PSM were divided into independent risk factor>the cut-off value group and independent risk factor≤the cut-off value group with the incidence of poor skin graft survival after Meek grafting compared using the chi-square test, and the relative risk of poor skin graft survival after Meek grafting was calculated. Before 1∶1 PSM, there were no statistically significant differences in gender, age, body mass index, complication of inhalation injury, time from injury to operation, preoperative cystatin C level, preoperative albumin level, preoperative neutrophil, preoperative hemoglobin level of patients between the two groups (>0.05); the full-thickness burn area and burn index of patients in poor skin graft survival group were significantly higher than those in good skin graft survival group (=-2.672, -2.882, <0.01); the preoperative platelet count and the platelet count on the first, third, and fifth day after operation of patients in poor skin graft survival group were significantly lower than those in good skin graft survival group (-3.411, -3.050, -2.748, -2.686<0.01). After 1∶1 PSM, 46 cases were remained in each group. There were no statistically significant differences in gender, age, body mass index, full-thickness burn area, burn index, complication of inhalation injury, time from injury to operation, preoperative cystatin C level, preoperative albumin level, preoperative neutrophil, preoperative hemoglobin level of remaining patients between the two groups (>0.05); the preoperative platelet count and the platelet count on the first, third, and fifth day after operation of patients in poor skin graft survival group were significantly lower than those in good skin graft survival group (=-3.428, -2.940, =-2.427, -2.316, <0.05 or <0.01). Multivariate logistic regression analysis showed that the preoperative platelet count was the only independent risk factor affecting the skin graft survival after Meek grafting in severe burn patients (odds ratio=0.994, 95% confidence interval=0.989-0.998, <0.01). The area under the ROC curve of preoperative platelet count predicting poor skin graft survival after Meek grafting in 92 patients was 0.707 (95% confidence interval=0.603-0.798, <0.01), and the cut-off value of preoperative platelet count was 98×10/L, with sensitivity of 54.3% and specificity of 78.3% under the cut-off value. The incidence of poor skin survival after Meek grafting of patients in preoperative platelet count≤98×10/L group was 71.4% (25/35), which was obviously higher than 36.8% (21/57) in preoperative platelet count>98×10/L group (=10.376, <0.01). Compared with that in preoperative platelet count>98×10/L group, patients in preoperative platelet count≤98×10/L group had a relative risk of poor skin graft survival after Meek grafting of 2.211 (95% confidence interval=1.263-3.870). Preoperative platelet count is an independent risk factor affecting the skin graft survival after Meek grafting in severe burn patients and has a good predictive value. Meek grafting should be performed with caution when the preoperative platelet count of patients is≤98×10/L.
探讨严重烧伤患者微粒皮移植术后皮片存活的影响因素及其预测价值。对陆军军医大学第一附属医院（第三军医大学）2013年1月至2019年12月收治的115例符合纳入标准并接受微粒皮移植的严重烧伤患者（男95例，女20例，年龄1 - 74岁）进行回顾性病例对照研究。将患者分为皮片存活率≥70%的皮片存活良好组（68例）和皮片存活率<70%的皮片存活不良组（47例）。记录两组患者入院后首次微粒皮移植时的性别、年龄、体重指数、全层烧伤面积、烧伤指数、吸入性损伤并发症、伤后至手术时间、术前胱抑素C水平、术前白蛋白水平、术前中性粒细胞、术前血红蛋白水平、术前血小板计数以及术后第1、3、5天的血小板计数。采用独立样本t检验、Mann - Whitney检验和卡方检验对上述指标在两组间进行统计学分析。对两组患者的性别、年龄、体重指数、全层烧伤面积、烧伤指数、吸入性损伤并发症、伤后至手术时间进行1∶1倾向评分匹配（PSM）以消除基线数据差异，然后再次记录并分析两组剩余患者的上述指标。选取1∶1 PSM后两组间差异有统计学意义的指标进行多因素logistic回归分析，筛选影响严重烧伤患者微粒皮移植术后皮片存活的独立危险因素。绘制1∶1 PSM后严重烧伤患者微粒皮移植术后预测皮片存活不良的独立危险因素的受试者工作特征（ROC）曲线，并计算曲线下面积、截断值以及截断值下的敏感度和特异度。将1∶1 PSM后的患者按独立危险因素>截断值组和独立危险因素≤截断值组分组，采用卡方检验比较两组微粒皮移植术后皮片存活不良的发生率，并计算微粒皮移植术后皮片存活不良的相对危险度。1∶1 PSM前，两组患者的性别、年龄、体重指数、吸入性损伤并发症、伤后至手术时间、术前胱抑素C水平、术前白蛋白水平、术前中性粒细胞、术前血红蛋白水平差异无统计学意义（>0.05）；皮片存活不良组患者的全层烧伤面积和烧伤指数显著高于皮片存活良好组（=-2.672，-2.882，<0.01）；皮片存活不良组患者术前血小板计数及术后第1、3、5天的血小板计数显著低于皮片存活良好组（-3.411，-3.050，-2.748，-2.686<0.01）。1∶1 PSM后，每组各余46例。两组剩余患者的性别、年龄、体重指数、全层烧伤面积、烧伤指数、吸入性损伤并发症、伤后至手术时间、术前胱抑素C水平、术前白蛋白水平、术前中性粒细胞、术前血红蛋白水平差异无统计学意义（>0.05）；皮片存活不良组患者术前血小板计数及术后第1、3、5天的血小板计数显著低于皮片存活良好组（=-3.428，-2.940，=-2.427，-2.316，<0.05或<0.01）。多因素logistic回归分析显示，术前血小板计数是影响严重烧伤患者微粒皮移植术后皮片存活的唯一独立危险因素（比值比=0.994，95%置信区间=0.989 - 0.998，<0.01）。92例患者术前血小板计数预测微粒皮移植术后皮片存活不良的ROC曲线下面积为0.707（95%置信区间=0.603 - 0.798，<0.01）,术前血小板计数截断值为98×10⁹/L，截断值下敏感度为54.3%，特异度为78.3%。术前血小板计数≤98×10⁹/L组患者微粒皮移植术后皮片存活不良发生率为71.4%（25/35），明显高于术前血小板计数>98×10⁹/L组的36.8%（21/57）（=10.376，<0.01）。与术前血小板计数>98×10⁹/L组相比，术前血小板计数≤98×10⁹/L组患者微粒皮移植术后皮片存活不良的相对危险度为2.211（95%置信区间=1.263 - 3.870）。术前血小板计数是影响严重烧伤患者微粒皮移植术后皮片存活的独立危险因素，具有良好的预测价值。患者术前血小板计数≤98×10⁹/L时，应谨慎进行微粒皮移植。
