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| 老年患者股骨粗隆间骨折术中低血压动态列线图预测模型 |
| Dynamic nomogram of intraoperative hypotension in elderly patients with intertrochanteric femur fractures |
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| DOI：10.12089/jca.2024.12.007 |
| 中文关键词: 老年 股骨粗隆间骨折 术中低血压 预测 动态列线图 |
| 英文关键词: Aged Intertrochanteric femur fractures Intraoperative hypotension Prediction Dynamic nomogram |
| 基金项目:安徽省高校自然科研重点项目（2022AH053047） |
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| 摘要点击次数: 555 |
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| 中文摘要: |
目的：构建老年患者股骨粗隆间骨折（ITFF）闭合复位髓内针内固定术患者术中低血压（IH）风险的动态列线图。
方法：选择ITFF行闭合复位髓内针内固定术治疗老年患者211例，男69例，女142例，年龄65～85 岁，BMI 18.5～28.0 kg/m 2，ASA Ⅱ或Ⅲ级。根据是否发生IH将患者分为两组：IH组和对照组（CO组）。记录基础疾病、血管活性药物使用情况、骨折部位、改良5项衰弱指数（mFI-5）评分，临床实验室检查指标包括血红蛋白（Hb）、血小板（PLT）、白细胞（WBC）、白蛋白（ALB）、C反应蛋白（CRP）、血尿素氮（BUN）、血清肌酐（SCr）和空腹血糖（FBG）。记录基线血压、麻醉诱导前、麻醉诱导后15、45和75 min的SBP和DBP，术中平均体温、术中失血量、麻醉时间和手术时间。采用多因素Logistic回归分析探讨ITFF患者IH危险因素，通过R语言构建IH风险的列线图并验证，进一步使用DynNom包开发动态列线图。
结果：老年患者ITFF中IH发生率为40.3%。与CO组比较，IH组女性、年龄、mFI-5、CRP、BUN、FBG、术中失血量明显升高，Hb和ALB明显降低，麻醉时间和手术时间明显延长（P＜0.05）。多因素Logistic回归分析显示女性（OR=1.672，95%CI 1.168～2.654，P=0.017）、年龄增加（OR=2.039，95%CI 1.268～4.685，P＜0.001）、mFI-5升高（OR=2.150，95%CI 1.532～3.068，P＜0.001）、ALB降低（OR=0.739，95%CI 0.634～0.987，P=0.021）、FBG升高（OR=1.712，95%CI 0.971～2.135，P＜0.001）和麻醉时间延长（OR=1.068，95%CI 0.965～1.864，P=0.019）是发生IH的独立危险因素。基于上述变量构建IH风险列线图，其校正曲线显示，一致性指数为0.972，具有较高预测准确性。决策曲线分析结果显示列线图风险阈值大于0.032，能提供明显意义的临床净收益。将列线图可视化为IH风险动态列线图（https://mldynamic.shinyapps.io/DynNomapp/）。
结论：本研究基于性别、年龄、mFI-5、ALB、FBG和麻醉时间构建老年ITFF患者中IH风险的动态列线图，有助于制定更为积极的诊疗决策，为IH管理提供参考。 |
| 英文摘要: |
Objective: To construct a dynamic nomogram of intraoperative hypotension (IH) in patients undergoing closed reduction intramedullary pin internal fixation in elderly patients with intertrochanteric femur fracture (ITFF).
Methods: Two hundred and eleven patients, 69 males and 142 females, aged 65-85 years, with BMI 18.5-28.0 kg/m 2 and ASA physical status Ⅱ or Ⅲ, were selected to be treated with closed reduction intramedullary pin internal fixation for ITFF in the elderly patients. Patients were divided into two groups according to whether IH occurred intraoperatively: group IH and the control group (group CO). Underlying diseases, vasoactive drug use, fracture site, modified 5-item frailty index (mFI-5) score, and clinical laboratory tests including hemoglobin (Hb), platelets (PLT), white blood cells (WBC), albumin (ALB), C-reactive protein (CRP), blood urea nitrogen (BUN), serum creatinine (SCr), and fasting blood glucose (FBG) were recorded. Baseline blood pressure, SBP and DBP before induction of anesthesia, 15, 45, and 75 minutes after induction of anesthesia, mean intraoperative temperature, intraoperative blood loss, anesthesia time and operation time were recorded. Multifactorial logistic regression analysis was used to explore the risk factors of IH in ITFF patients, and a nomogram of IH risk was constructed and validated by R programing larguage. Dynamic nomogram were further developed using the DynNom package.
Results: The incidence of IH in elderly ITFF patients was 40.3%. Compared with group CO, patients in group IH had significantly higher females, age, mFI-5, CRP, BUN, FBG, intraoperative blood loss, and significantly lower Hb and ALB, longer anaesthesia time and operation time(P < 0.05). Multifactorial logistic regression analysis showed that females (OR = 1.672, 95% CI 1.168-2.654, P = 0.017), increased age (OR = 2.039, 95% CI 1.268-4.685, P < 0.001), elevated mFI-5 (OR = 2.150.95% CI 1.532-3.068, P < 0.001), decreased ALB (OR = 0.739, 95% CI 0.634-0.987, P = 0.021), increased FBG (OR = 1.712, 95% CI 0.971-2.135, P < 0.001) and prolonged anesthesia (OR=1.068, 95% CI 0.965-1.864, P = 0.019) were independent risk factors for developing IH. A nomogram of IH risk was constructed based on the above variables, and its calibration curve showed a consistency index of 0.972 with high predictive accuracy. The results of decision curve analysis showed that the nomogram risk threshold was greater than 0.032, providing a clearly meaningful net clinical benefit. The nomogram was visualized as a dynamic nomogram of IH risk (https://mldynamic.shinyapps.io/DynNomapp/).
Conclusion: This study constructed a dynamic nomogram of IH risk among elderly ITFF patients based on gender, age, mFI-5, ALB, FBG, and anesthesia time, which can help to make more aggressive treatment decisions and provide a reference for IH management. |
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