肺癌患者化疗相关静脉炎的相关因素分析.pdf

血管与腔内血管外科杂志2023 年 8 月 第 9 卷 第 8 期Journal of Vascular and Endovascular Surgery Vol.9,No.8,Aug 2023肺癌患者化疗相关静脉炎的相关因素分析陈凯丽1，姜福胜2，张 雪1，檀学兵11 首都医科大学附属北京世纪坛医院胸外科，北京 1000382 首都医科大学附属北京世纪坛医院胸外科介入组，北京 100038摘要：目的 探讨肺癌患者化疗相关静脉炎的相关因素。方法 收集2020年3月至2022年5月于首都医科大学附属北京世纪坛医院住院接受化疗的110例肺癌患者的临床资料，根据化疗期间是否发生化疗相关静脉炎分为静脉炎组（n=38）和对照组（n=72）。观察静脉炎的发生情况，比较两组患者的临床特征，采用多因素Logistic回归模型分析肺癌患者化疗相关静脉炎发生的危险因素。结果 静脉炎组患者的年龄、化疗前C反应蛋白水平、中性粒细胞计数均高于对照组患者，体重指数低于对照组患者，差异均有统计学意义（P0.05）。静脉炎组患者的非贵要静脉穿刺率明显高于对照组患者，2次以上穿刺的比例明显高于对照组患者，差异有统计学意义（P0.01）。多因素分析结果显示，年龄65岁、体重指数22 kg/m2、化疗前C反应蛋白水平升高、非贵要静脉穿刺、穿刺次数2次均是肺癌患者化疗相关静脉炎发生的独立危险因素（P0.05）。结论 年龄、体重指数、化疗前C反应蛋白水平、非贵要静脉穿刺情况、穿刺次数均与肺癌患者化疗相关静脉炎的发生密切相关。关键词：肺癌；化疗；经外周静脉穿刺中心静脉置管；静脉炎；危险因素中图分类号：R543 文献标识码：A doi:10.19418/ki.issn2096-0646.2023.08.07Analysis of risk factors for chemotherapy-related phlebitis in patients with lung cancerChen Kaili1,Jiang Fusheng2,Zhang Xue1,Tan Xuebing11 Department of Thoracic Surgery,Beijing Shijitan Hospital,Capital Medical University,Beijing 100038,China2 Thoracic Surgery Intervention Group,Beijing Shijitan Hospital,Capital Medical University,Beijing 100038,ChinaAbstract:Objective To investigate the factors for chemotherapy-related phlebitis in patients with lung cancer.Method The clinical data of 110 patients with lung cancer who received chemotherapy in Beijing Shijitan Hospital,Capital Medical University from March 2020 to May 2022 were collected,the patients were divided into phlebitis group with 38 cases and control group with 72 cases according to whether chemotherapy-related phlebitis occurred during chemotherapy.The occurrence of phlebitis was observed,the clinical features of the two groups were compared,and multivariate Logistic regression model was built to analyze the risk factors for chemotherapy-related phlebitis in patients with lung cancer.Result The age,C-reactive protein level before chemotherapy,and neutrophil count of patients in the phlebitis group were higher than those in the control group,and their body mass index was lower than that of the control group,and the difference were statistically significant(P0.05).The non-basilic venipuncture rate in the phlebitis group was significantly higher than that in the control group,and the proportion of more than two punctures was significantly higher than that in the control group,and the difference were statistically significant(P0.01).The results of multivariate analysis showed that age65 years old,body mass index22 kg/m2,elevated C-reactive protein level 作者简介 陈凯丽，主要从事肺癌、食管癌患者静脉炎相关研究，首都医科大学附属北京世纪坛医院通信作者 姜福胜（Jiang Fusheng，corresponding author），主任医师，E-mail： 论著 928血管与腔内血管外科杂志2023 年 8 月 第 9 卷 第 8 期肺癌是目前全世界范围内危害最严重的恶性肿瘤之一，严重危害人们的身心健康，是目前各国重要的疾病负担1。根据全球癌症统计数据估计，2020年全世界肺癌的新发病例约有220.8万例，在全部恶性肿瘤中居第二位；同期因肺癌死亡的病例约有179.6万例，在全部恶性肿瘤中居第1位2。中国的情况更不乐观，据统计，2015年中国肺癌新发病例约有78.7万例，肺癌死亡病例约有63.1万例，在中国恶性肿瘤排名中发病率与病死率均居于首位3。另有研究显示，目前中国肺癌的病死率仍处于稳定的上升趋势4。不过，随着年度体检的广泛开展、高分辨率计算机断层扫描等诊断技术的普及，早中期肺癌的检出率越来越高5-6。对于中晚期肺癌患者，目前相关药物研发的进展迅速，化疗方案不断优化，对于改善患者病情、争取手术机会起到了重要作用7-9。既往当通过外周静脉输入化疗药物时，化疗药物相关静脉炎的发生率极高，导致患者对化疗的依从性受到很大影响10-11。随着经外周静脉穿刺中心静脉置管（peripherally inserted central venous catheter，PICC）的普及，化疗相关静脉炎的发生率下降，症状也相对较轻12-13，但仍有部分患者在接受PICC化疗时发生静脉炎14-16。之前的一些研究对静脉炎发生的相关因素进行了探讨，但研究结果并不一致17-19。本研究探讨了肺癌患者化疗期间发生静脉炎的危险因素，现报道如下。1 资料与方法1.1 一般资料收集2020年3月至2022年5月于首都医科大学附属北京世纪坛医院住院接受化疗的肺癌患者的临床资料。纳入标准：（1）年龄18岁；（2）明确诊断为肺癌；（3）首次接受化疗。排除标准：（1）合并其他恶性肿瘤；（2）合并风湿免疫性疾病；（3）有明确的过敏史；（4）使用可能导致皮肤过敏、静脉炎的外用药物；（5）临床资料不完整。根据纳入、排除标准，最终共纳入110例肺癌患者，根据化疗期间是否发生化疗相关静脉炎将患者分为静脉炎组（n=38）和对照组（n=72）。1.2 静脉炎的判断静脉炎的诊断依据美国静脉输液护理学会制定的静脉炎分级标准20：0级，无临床症状；l级，局部疼痛，红肿或水肿，静脉无条索状改变，未触及硬结；2级，局部疼痛，红肿或水肿，静脉条索状改变，未触及硬结；3级，局部疼痛，红肿或水肿，静脉条索状改变，可触及硬结。1.3 数据收集及观察指标收集所有患者化疗前的基本信息、肺癌专科信息。基本信息包括年龄、性别、身高、体重、合并疾病、血液检测结果；肺癌专科信息包括手术信息、化疗方案、PICC信息及化疗期间静脉炎的发生情况。观察静脉炎的发生情况，比较两组患者的临床特征，分析肺癌患者化疗期间发生静脉炎的危险因素。1.4 统计学方法应用SPSS 22.0软件对数据进行统计学分析。计数资料以n（%）表示，组间比较采用2检验或Fisher确切概率法；符合正态分布的计量资料以（xs）表示，组间比较采用两独立样本t检验。采用多因素Logistic回归模型分析肺癌患者化疗期间发生静脉炎的危险因素。P0.05为差异有统计学意义。2 结果2.1 临床特征的比较静脉炎组患者的年龄、化疗前C反应蛋白水平、中性粒细胞计数均高于对照组患者，体重指数低于对照组患者，差异均有统计学意义（P0.05）。（表1）2.2 经 PICC 化疗相关指标的比较静脉炎组患者的非贵要静脉穿刺率明显高于对照组患者，2次以上穿刺的比例明显高于对照组患者，差异均有统计学意义（P0.01）。两组患者的化疗药物使用情况比较，差异无统计学意义（P0.05）。（表2）2.3 肺癌患者化疗期间发生静脉炎影响因素的多因素分析将表1、表2中差异有统计学意义的因素作为自变量，将肺癌患者化疗期间发生静脉炎作为因变量，纳入多因素Logistic回归模型进行分析，结果显示，年龄65岁、体重指数22 kg/m2、化疗前C反应蛋白水平升高、非贵要静脉穿刺、穿刺次数2次均是肺癌患者化疗相关静脉炎发生的独立危险因素（P0.05）。（表3）before chemotherapy,non-basilic venipuncture,and puncture times2 times were all independent risk factors for the occurrence of chemotherapy-related phlebitis in patients with lung cancer(P0.05).Conclusion Age,body mass index,C-reactive protein level before chemotherapy,non-basilic venipuncture,and puncture times are all closely related to chemotherapy-related phlebitis in lung cancer patients.Key words:lung cancer;chemotherapy;peripherally inserted central catheter;phlebitis;risk factor929Journal of Vascular and Endovascular Surgery Vol.9,No.8,Aug 20233 讨论目前，临床上肺癌患者的发病率较高，很多患者由于诊断相对及时而存在治疗的机会。手术切除是根治肺癌的主要手段，而化疗、放疗等是患者获取手术机会或巩固手术效果的重要辅助治疗方法，因此，无论是外科，还是肿瘤内科，均长期有大量的肺癌患者在进行化疗21-22。化疗药物的不良反应较大，刺激性强，常导致患者输液位置发生静脉炎，甚至部分穿刺点的药物渗漏而导致组织坏死23，因此，临床上对于给药途径较为重视。PICC主要是用于危重和恶性肿瘤患者的持续给药，可以显著降低输液相关并发症的发生率，但仍有部分患者会发生静脉炎、导管相关性血栓等并发症24-25。本研究多因素分析结果显示，老年（年龄65岁）、偏瘦（体重指数22 kg/m2）、化疗前C反应蛋白水平升高（5 mg/L）、非贵要静脉穿刺、穿刺次数2次均是肺癌患者化疗相关静脉炎发生的独立危险因素。不同研究中关于PICC化疗患者静脉炎发生率的报道有所差异。本研究结果显示，110例肺癌患者PICC化疗相关静脉炎的发生率为34.5%（38/110）。陈先辉等26的研究纳入了650例采用PICC进行化疗的恶性肿瘤患者，静脉炎的发生率为28.5%（185/650），这可能与纳入的人群不一致有关，该研究纳入了多种恶性肿瘤患者，本研究仅纳入了肺癌患者。杨萌和杨方英27的研究收集了210例接受化疗的脑肿瘤患者的临床资料，结果显示，静脉炎的发生率为27.6%（58/210）。魏少美等28的研究发现，静脉炎的发生率为4.5%（2/44）。关于发生静脉炎的危险因素，不同研究的结果差异较大。有研究发现，PICC导管留置时间、插管次数、导管末端在静脉中的位置、外周静脉置管的部位均与静脉炎的发生有关26，与本研究结果类似。本研究发现，体重指数下降与肺癌患者化疗相关静脉炎的发生密切相关，可能与这些患者皮肤薄、血管脆性增加有一定的关系。虽然PICC导管头端插入较深，通常不易导致穿刺部位药物渗漏，但导管本身及药物在血液中溶解后的逆向分布情况对静脉血管的刺激仍有可能造成静脉炎，因此，魏少美等28的研究对导管进行经常性生理盐水冲洗，可能与静脉炎的发生率较低有关。综上所述，采用PICC进行化疗的肺癌患者静脉炎的发生率仍较高，年龄、体重指数、化疗前C反应蛋白水平、非贵要静脉穿刺情况、穿刺次数均与其有关。表1 两组患者临床特征的比较临床特征静脉炎组（n=38）对照组（n=72）t/2值 P值年龄（岁，xs）57.37.9 53.96.42.440 0.016性别n（%）0.243 0.622 男性23（60.5）47（65.3）女性15（39.5）25（34.7）体重指数（kg/m2，xs）21.83.2 24.12.93.816 0.01收缩压（mmHg，xs）127.613.1 129.312.5 0.667 0.506血糖（mmol/L，xs）5.91.2 6.11.10.866 0.382总胆固醇（mmol/L，xs）5.50.7 5.60.60.784 0.435甘油三酯（mmol/L，xs）2.00.5 2.10.41.142 0.256化疗前C反应蛋白（mg/L，xs）3.81.4 3.11.22.744 0.007白细胞计数（109/L，xs）7.42.5 7.12.20.648 0.518中性粒细胞计数（109/L，xs）5.91.8 4.62.03.353 0.001血红蛋白（g/L，xs）140.610.3 141.59.40.462 0.645血小板计数（109/L，xs）191.728.6 195.325.8 0.670 0.504D-二聚体（mg/L，xs）1.40.5 1.50.50.997 0.321肺癌分期n（%）3.453 0.178 14（36.8）36（50.0）10（26.3）22（30.6）+14（36.8）14（19.4）注：1 mmHg=0.133 kPa表2 两组患者经PICC化疗相关指标的比较n（%）指标静脉炎组（n=38）对照组（n=72）2值P值非贵要静脉穿刺13.3920.01 是21（55.3）15（20.8）否17（44.7）57（79.2）穿刺次数14.1600.01 118（47.4）59（81.9）220（52.6）13（18.1）化疗药物 紫杉醇脂质体12（31.6）23（31.9）0.0020.969 卡铂17（44.7）38（52.8）0.6430.422 依托泊苷11（28.9）20（27.8）0.0170.897 培美曲塞二钠13（34.2）29（40.3）0.3880.533 氟尿嘧啶19（50.0）43（59.7）0.9560.328表3 肺癌患者化疗期间发生静脉炎影响因素的多因素 分析因素SE Wald 2P值 OR95%CI年龄1.09 0.593.400.03 1.18 1.011.75化疗前C反应蛋白水平 0.87 0.483.380.03 1.16 1.011.71非贵要静脉穿刺情况0.62 0.382.600.04 1.20 1.021.94穿刺次数0.72 0.423.010.04 1.20 1.011.81体重指数0.83 0.453.450.02 1.17 1.011.80中性粒细胞计数0.34 0.242.020.13 1.08 0.901.61注：各因素赋值为年龄（5 mg/L=1）；非贵要静脉穿刺（否=0，是=1）；穿刺次数（1次=0，2次=1）；体重指数（22 kg/m2=0，6109/L=1）930血管与腔内血管外科杂志2023 年 8 月 第 9 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