颈脊髓损伤患者气管切开前病情评估动态预警方案的构建

Construction of a dynamic early warning protocol for pre-tracheostomy condition assessment in patients with cervical spinal cord injury

中文关键词:  颈脊髓损伤  气管切开  影响因素  国家早期预警评分（NEWS）  病情评估

英文关键词:Cervical spinal cord injury  Tracheotomy  Influencing factors  National Early Warning Score  Condition assessment

中文摘要:

  【摘要】 目的：构建颈脊髓损伤（cervical spinal cord injury，CSCI）患者气管切开前病情评估动态预警方案，为CSCI患者气管切开前病情观察提供参考。方法：系统检索中国知网（China National Knowledge Infrastructure，CNKI）、万方、维普、中国生物医学文献数据库（China Biology Medicine，CBM）、PubMed、Embase、Web of Science、Cochrane Library及Scopus数据库（建库~2022年6月）公开发表的CSCI患者气管切开相关文献，通过Meta分析明确气管切开影响因素，并据此构建风险评估表。选取贵州省人民医院2014年1月1日~2022年9月30日入院的CSCI患者，采用倾向性评分匹配（propensity matching score，PSM）按1∶2为气管切开患者（病例组）匹配非切开患者（对照组），以CSCI患者气管切开风险评分、气管切开前不同时刻国家早期预警评分（National Early Warning Score，NEWS）为检验变量绘制受试者工作特征（receiver operating characteristic，ROC）曲线，计算曲线下面积（area under curve，AUC）、95%置信区间（conficence interval，CI）评价区分能力，基于最大约登指数确定气管切开前风险评估表和NEWS得分临界值，并经课题组讨论形成CSCI患者气管切开前病情评估动态预警方案初稿。进一步选取两所三甲医院专家共14名，通过专家会议讨论修订初稿，最终确立正式预警方案。结果：病例组110例，对照组220例。两组气管切开风险评分差异有统计学意义（P<0.05），其AUC最大为0.946（95%CI：0.923~0.968），最佳临界值34.5分。两组气管切开前0.5h、4h、8h的NEWS评分差异有统计学意义（P<0.05），12h差异无统计学意义（P>0.05）。病例组NEWS评分在切开前0.5h时AUC最大；最佳临界值7.5分。最终方案由评估指标与临床响应措施两部分构成，评估指标包括CSCI患者气管切开风险评估表和NEWS评分共18项指标，临床响应措施根据评估指标得分由低至高分为5级进行响应。结论：本研究所构建的预警方案根据气管切开风险评分及NEWS评分结果设置不同的预警级别，制定相应的临床响应措施；可应用于CSCI患者气管切开前病情的动态评估，为临床护理CSCI患者提供相应的建议。

英文摘要:

  【Abstract】 Objectives: To develop a dynamic early warning protocol for pre-tracheostomy condition assessment in patients with cervical spinal cord injur(CSCI), providing a reference for clinical monitoring before tracheostomy. Methods: A systematic search were conducted in databases including China National Knowledge Infrastructure(CNKI), Wanfang, VIP, China Biology Medicine(CBM), PubMed, Embase, Web of Science, Cochrane Library and Scopus(from inception to June 2022) to identify published literature on tracheostomy in CSCI patients. Meta-analysis was used to identify influencing factors for tracheostomy, based on which a risk assessment scale was constructed. CSCI patients admitted to Guizhou Provincial People′s Hospital between January 1, 2014 and September 30, 2022 were selected. Propensity Score Matching(PSM) was applied in a 1∶2 ratio to match tracheostomy patients(case group) with non-tracheostomy patients(control group). The receiver operating characteristics(ROC) curve was plotted with the tracheotomy risk score and the National Early Warning Score(NEWS) at different times before tracheotomy as test variables. The area under the curve(AUC) and the 95% confidence interval(CI) were used to evaluate the discriminatory ability. The optimal cutoff values of the pre-tracheotomy risk assessment table and the NEWS score were determined based on the maximum Youden index. A preliminary draft of the dynamic early warning protocol was developed through research group discussions. Further, 14 medical experts from two 3A hospitals were invited to revise the draft via expert panel discussions, finalizing the formal protocol. Results: There were 110 cases in the case group, while 220 in the control group. The risk assessment scores between the two groups showed statistically significant differences(P<0.05), with the maximum AUC being 0.946(95%CI: 0.923-0.968) and an optimal cutoff value of 34.5 points. Significant differences in NEWS scores were observed at 0.5h, 4h, and 8h before tracheostomy(P<0.05), but not at 12h(P>0.05). In the case group, the NEWS score at 0.5h before tracheostomy yielded the largest AUC with an optimal cutoff value of 7.5 points. The final protocol consists of two parts: assessment indicators and clinical response measures. The assessment indicators include 18 items from the CSCI tracheostomy risk assessment scale and NEWS. Clinical responses were stratified into five levels based on the total score. Conclusions: The dynamic warning protocol developed in this study sets up different warning levels and corresponding clinical response measures based on tracheostomy risk scores and NEWS results, it can be applied for dynamic assessment of CSCI patients before tracheostomy and offer practical recommendations for clinical nursing care.