成人钝性脾损伤非手术治疗失败的危险因素研究

目的：探讨成人钝性脾损伤非手术治疗（ NOM ）失败的原因和危险因素。方法回顾性分析2011年11月～2014年3月间收治的110例钝性脾损伤成人患者，其中58例最初接受了非手术治疗，其中男性36例，女性22例；年龄17～89岁，平均（43.4±15.1）岁。根据治疗后期是否剖腹手术分为非手术治疗失败组和非手术治疗成功组，采用单因素分析和多因素Logistic回归法分析影响脾损伤非手术治疗结果的相关因素，确定脾损伤非手术治疗失败的独立危险因素。结果非手术治疗应用率为52.7％（58／110），其中失败率为24.14％（14／58），没有死亡发生。非手术治疗失败的主要原因：早期为活动性出血、早期再出血和脾损伤分级的误判，晚期为迟发性脾脏包膜下血肿破裂。单因素分析显示成人钝性脾损伤非手术治疗失败的相关因素有休克指数、腹腔积血程度、美国创伤外科协会（ AAST ）脾损伤分级、损伤严重程度评分（ISS）、新的损伤严重程度评分（NISS）、输注红细胞（RBC）量、住院时间（P＜0.05）。多因素Logistic回归分析发现AAST脾损伤分级≥3、中量或大量腹腔积血、输注RBC＞4U为NOM失败的独立危险因素。结论中量或大量腹腔积血，脾损伤≥3级和输注RBC＞4U为NOM失败的高危因素。

Risk factors for failures of non-operative management in adults with blunt splenic injury

Objective To explore the causes and risk factors of non-operative management ( NOM) fail-ure in adults with blunt splenic injury.Methods A total of 110 adults cases admitted from Nov.2011 to Mar.2014 with blunt splenic injury ( BSI) were reviewed retrospectively,among whom 58 patients received NOM initially.A-mong these patients,36 were male and 22 were female.The average age was (43.4 ±15.1) years(17-89 years). The patients were then divided into success group and failure group based on whether they were performed laparoto-my.Univariate and multivariate logistic analyses were performed to investigate correlative factors affecting the out-come of NOM in adults with BSI and to identify independent risk factors of NOM failure.Results The rate of NOM was 52.7%(58/110).The rate of NOM failure was 24.14%(14/58) and no death occurred.The main causes of failure were active bleeding,early rebleeding and incorrect classification of splenic injuries in the early stage and de-layed subcapsular hematoma in the late stage.Univariate analysis revealed that factors associated with NOM failure in patients with BSI were shock index, degree of hemoperitoneum, grade of splenic injury, injury severity score ( ISS) ,new injury severity score( NISS) ,amount of transfused RBCs as well as hospitalization period( length of hos-pital stay),(P<0.05).Multivariate logistic regression analysis showed that the presence of moderate or large hae-moperitoneum,higher-grade splenic injury(AAST grade 3-5)and transfusion of more than 4U of RBCs were inde-pendent predictors of NOM failure.Conclusion Moderate or large haemoperitoneum,higher-grade splenic injury and transfusion of more than 4U of RBCs are high risk factors for NOM failure in adults with blunt splenic injury.