Impacts of early cumulative fluid balance and serum electrolyte level on the short-term prognosis of patients with severe traumatic brain injury
Objective To observe the changes of early cumulative fluid balance and serum electrolyte level in patients with severe traumatic brain injury(sTBI),and to explore their impacts on the short-term prognosis of sTBI patients.Methods Totally 121 patients with sTBI were treated in the First Affiliated Hospital of Zhengzhou University from January,2022 to December,2023,and were divided into survival group(n=83)and death group(n=38)based on the prognosis within 28 d after admission.The acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ)scores on admission,fluid intake and outflow in 72 h after admission(total fluid intake and outflow in the first,second and third 24 h,cumulative fluid balance in 48 and 72 h,fluid accumulation index in 48 and 72 h),arterial blood gas electrolyte levels in 72 h after admission(blood sodium and chlorine levels on admission and in 48 and 72 h after admission,and changes in blood sodium and chlorine levels in 48 and 72 h after admission)were compared between two groups.Multivariate logistic regression analysis was done to identify the influencing factors of poor prognosis in sTBI patients within 28 d after admission.ROC curves were plotted to evaluate the efficiencies of influencing factors in 48 and 72 h after admission and corresponding regression models on predicting poor prognosis of sTBI patients within 28 d after admission.The Hosmer-Lemeshow goodness of fit test was done to evaluate the calibration ability of the model.Results The mortality rate within 28 d in 121 patients with sTBI was 31.4％.The APACHEⅡ score was higher in death group[23.50(22.00,28.00)]than that in survival group[16.00(14.00,19.00)](Z=7.378,P＜0.001).The volumes of total fluid intake in the first,second and third 24 h,the cumulative fluid balance in 48 and 72 h,the fluid accumulation indexes in 48 and 72 h,the blood sodium and chlorine levels on admission and in 48 and 72 h after admission,and the changes in blood sodium and chlorine levels in 48 and 72 h after admission were higher in death group than those in survival group(P＜0.05),and there were no significant differences in the volumes of total fluid output in the first,second and third 24 h between two groups(P＞0.05).Using the influencing factor in 48 h after admission as the independent variable,the APACHEⅡ score(OR=1.370,95％CI:1.099-1.707,P=0.005),48-h fluid accumulation index(OR=2.463,95％CI:1.336-4.541,P=0.004),and 48-h blood sodium change value(OR=1.235,95％CI:1.045-1.461,P=0.013)were the influencing factors of poor prognosis within 28 d after admission in sTBI patients.The formula for regression model 1 was ln(p/1-p)=-9.275+0.314x1+0.902x2+0.211x3(x1-x3represents APACHEⅡscore,48-h fluid accumulation index,and 48-h blood sodium change value on admission,respectively).When the optimal cut-off values of APACHEⅡ score,48-h fluid accumulation index,blood sodium change in 48 h after admission,and regression model 1 were 21.00,0.104,5.5 mmol/L and 0.234,the AUCs for predicting poor prognosis of sTBI patients within 28 d after admission were 0.918(95％CI:0.870-0.966,P＜0.001),0.905(95％CI:0.841-0.968,P＜0.001),0.912(95％CI:0.846-0.977,P＜0.001),and 0.979(95％CI:0.958-1.00,P＜0.001),with the sensitivities of 84.2％,86.8％,84.2％and 97.4％,and the specificities of 81.9％,86.7％,92.8％and 90.4％,respectively.The results of the Hosmer-Lemeshow goodness of fit test showed that regression model 1 had a good fitting effect(x2=2.419,P=0.965).Using the influencing factor in 72 h after admission as the independent variable,the APACHEⅡscore(OR=1.362,95％CI:1.102-1.682,P=0.004)and 72-h fluid accumulation index(OR=1.149,95％CI:1.058-1.247,P＜0.001)were the influencing factors of poor prognosis within 28 d after admission in sTBI patients.The formula for regression model 2 was ln(p/1-p)=-8.820+0.309x1+0.139x2(x1-x2 represents APACHE Ⅱ score,and 72-h fluid accumulation index,respectively).When the optimal cut-off values of APACHEⅡ score,72-h fluid accumulation index,and regression model 2 were 21.00,0.080 and 0.424,the AUCs for predicting poor prognosis of sTBI patients within 28 d after admission were 0.918(95％CI:0.870-0.966,P＜0.001),0.942(95％CI:0.887-0.997,P＜0.001)and 0.968(95％CI:0.924-1.000,P＜0.001),with the sensitivities of 84.2％,94.7％and 94.7％,and the specificities of 81.9％,92.8％and 94.0％,respectively.The results of the Hosmer-Lemeshow goodness of fit test showed that regression model 2 had a good fitting effect(x2=6.673,P=0.572).Conclusion In sTBI patients with stable hemodynamics in the early stage,the high APACHEⅡ score,high 48-and 72-h fluid accumulation indexes,and significant increase in blood sodium in 48 h after admission increase the risk of short-term death,and the regression model based on the above indicators has a high value to the prediction of the short-term prognosis of sTBI patients.
severe traumatic brain injurycumulative fluid balanceliquid accumulation indexserum electrolyteacute physiology and chronic health evaluation Ⅱ score
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