The Construction Of The Early Warning Model Of Urosepsis Following Holmium Laser Lithotripsy With Flexible Ureteroscope

Research Purpose:Based on statistical analysis to identify the independent risk factors of urosepsis following Holmium laser lithotripsy with flexible ureteroscope in patients with upper urinary tract stones.Further,according to the binary logistic regression to construct an early warning model.Besides,we also set up an early warning scale based on the OR of every risk factors in this model.Meanwhile,in order to give a prospective guidance in nursing assessment and observation to clinical nurses,we’ve already made a prospective confirmation of the model and the scale.Research Methods:The overall design of our study is to utilize the retrospective data to construct the early warning model and the scale,and to make an assessment of them by the prospective data.First of all,based on the inclusion criteria and exclusion criteria,we collected the clinical data retrospectively of 200 patients with upper urinary tract stones who have accepted Holmium laser lithotripsy with flexible ureteroscope at the urology wards of a general hospital of HuZhou from January 2016 to May 2019.During this process,two students collected and checked all the data together.We put those who are complicated by urosepsis after operation in the case group and those without urosepsis in the control group.There are 100 patients in each group and the clinical data were analyzed by case control study to explore the independent risk factors.We use SPSS25.0 to make statistical analysis.Above all,we try to screen the clinical indicators according to the literature,the results of statistical analysis and our clinical experience.Secondly,statistically significant factors after using single factor analysis（P<0.1）were analyzed by multivariate logistic regression method to identity the independent risk factors（P<0.05）.Thirdly,we utilized the regression coefficientβof every independent risk factor to construct the early warning model and set up the early warning scale according to the OR of every risk factor in it at the meantime.Eventually,for the sake of giving a confirmation of the model and scale,we also collected the clinical data prospectively of patients with upper urinary tract stones who have accepted Holmium laser lithotripsy with flexible ureteroscope at the urology wards of a general hospital of HuZhou from June 2019 to January 2020.Research Results:The single logistic regression shows that age[P=0.013,OR=2.250,95%CI（1.189,4.258）];gender[P=0.000,OR=2.923,95%CI（1.598,5.346）];hypoproteinemia[P=0.002,OR=26.316,95%CI（3.464,199.928）];urinary tract infections before operation[P=0.000,OR=10.016,95%CI（4.000,25.082）];ureteral stenosi[P=0.005,OR=2.389,95%CI（1.303,4.379）];positive urine culture before operation[P=0.000,OR=10.231,95%CI（3.806,27.498）];the degrees of hydronephrosis[P=0.000],including moderate hydronephrosis[P=0.000,OR=5.194,95%CI（2.368,11.393）]and severe hydronephrosis[P=0.011,OR=4.093,95%CI（1.381,12.128）];operation time[P=0.007,OR=2.453,95%CI（1.274,4.723）];albumin before operation[P=0.000,OR=0.839,95%CI（0.788,0.893）];white blood cell before operation[P=0.044,OR=1.142,95%CI（1.003,1.300）];high-sensitivity CRP before operation[P=0.000,OR=1.129,95%CI（1.067,1.195）];the platelet count before operation[P=0.042,OR=1.004,95%CI（1.000,1.007）];white blood cell two hours after operation[P=0.001,OR=1.143,95%CI（1.055,1.237）]and the high-sensitivity CRP two hours after operation[P=0.000,OR=1.119,95%CI（1.063,1.178）]have a significant statistical correlation with the urosepsis following Holmium laser lithotripsy with flexible ureteroscope in patients with upper urinary tract stones（P<0.05）.In terms of the correlation of these indicators,age;gender;ureteral stenosi and operation time have a moderate positive correlation with the urosepsis following Holmium laser lithotripsy with flexible ureteroscope in patients with upper urinary tract stones.The degrees of hydronephrosis,both of the moderate hydronephrosis and severe hydronephrosis have a strong positive correlation with the urosepsis following Holmium laser lithotripsy with flexible ureteroscope in patients with upper urinary tract stones.Hypoproteinemia;urinary tract infections and the positive urine culture before operation have a very strong positive correlation with the urosepsis following Holmium laser lithotripsy with flexible ureteroscope in patients with upper urinary tract stones.But the albumin before operation is the factor which has a weak negative correlation with the urosepsis following Holmium laser lithotripsy with flexible ureteroscope in patients with upper urinary tract stones.Further,the white blood cell;high-sensitivity CRP;platelet count before operation;the white blood cell and high-sensitivity CRP two hours after operation have no obviously correlation with the urosepsis following Holmium laser lithotripsy with flexible ureteroscope in patients with upper urinary tract stones.The multivariate logistic regression shows that age（≥60 years）[P=0.043,OR=3.550,95%CI（1.042,12.088）];gender（female）[P=0.006,OR=4.983,95%CI（1.584,15.676）];hypoproteinemia[P=0.004,Adjusted OR=32.051,95%CI（2.961,346.873）];ureteral stenosis[P=0.043,OR=3.453,95%CI（1.038,11.489）];the degree of hydronephrosis before operation[P=0.038],including moderate hydronephrosis[P=0.011,OR=4.979,95%CI（1.447,17.138）]and severe hydronephrosis[P=0.468];positive urine culture before operation[P=0.040,OR=4.945,95%CI（1.078,22.678）];high-sensitivity CRP before operation[P=0.031,OR=1.104,95%CI（1.009,1.207）];the white blood cell 2 hours after operation[P=0.000],including the increase of the white blood cell 2 hours after operation（>10×10⁹/L）[P=0.000,OR=12.496,95%CI（3.509,44.496）]and the decrease（<4×10⁹/L）of the white blood cell 2 hours after operation[P=0.016,OR=8.850,95%CI（1.499,52.259）];and the high-sensitivity CRP two hours after operation[P=0.027,OR=1.115,95%CI（1.012,1.228）]were the independent risk factors of urosepsis following Holmium laser lithotripsy with flexible ureteroscope in patients with upper urinary tract stones（P<0.05）.The early warning model constructed by our study is:Logit P=﹣6.106+1.267X₁+1.606X₂+3.467X₃+1.239X₄+1.605X_5（1）+0.654X_5（2）+1.598X₆+0.099X₇+2.525X_8（1）+2.180X_8（2）+0.109X₉.In this model,X₁ is age;X₂ is gender;X₃ is hypoproteinemia;X₄ stands for ureteral stenosis;X₅ represents the degrees of hydronephrosis before operation,X_5（1）is moderate hydronephrosis and X_5（2）is severe hydronephrosis;X₆ is the positive urine culture before operation;X₇ is the high-sensitivity CRP before operation;X₈ is the white blood cell 2 hours after operation,X_8（1）is the increase（>10×10⁹/L）of the white blood cell 2 hours after operation and X_8（2）is the decrease（<4×10⁹/L）of the white blood cell 2 hours after operation;X₉ is the high-sensitivity CRP two hours after operation.In the prospective confirmation of this model,the AUC is 0.951,the maximal Yuden Index（YI）is 0.79,the sensitivity is 87%,the specificity is 92%,the best cutoff of the model is 60%.Meanwhile,the accuracy of the model is 88.9%.Thus,both of the sensitivity and specificity of the early warning model constructed by our study are preferable,and it also have a diagnostic value.In the forthcoming future,we hope it can be widely utilized in the forecast of urosepsis following Holmium laser lithotripsy with flexible ureteroscope in patients with upper urinary tract stones.According to the OR of age;gender;hypoproteinemia;ureteral stenosis;the degrees of hydronephrosis before operation（including moderate and severe hydronephrosis）;the positive urine culture before operation;the high-sensitivity CRP before operation;the white blood cell 2hours after operation,including the increase and decrease of the white blood cell and the high-sensitivity CRP two hours after operation,we set up an early warning scale at the meantime.The value of every risk factor is 3、3、4、3、3、3、0、4 or 3、0 point.The prospective confirmation shows that the AUC is 0.925,the maximal Yuden Index（YI）is 0.72,the sensitivity is 88%,the specificity is 84%,and the best cutoff of the scale is 6.5 points.Accordingly,When a patient’s overall points≥6.5 points,he/she will have a high risk to be affected by the urosepsis following Holmium laser lithotripsy with flexible ureteroscope in patients with upper urinary tract stones.Research Conclusion:Our study shows that age（≥60 years）;gender（female）;hypoproteinemia;ureteral stenosis;the degrees of hydronephrosis before operation,including moderate hydronephrosis and severe hydronephrosis;positive urine culture before operation;high-sensitivity CRP before operation;the white blood cell 2 hours after operation,including the increase of the white blood cell 2 hours after operation（>10×10⁹/L）and the decrease（<4×10⁹/L）of the white blood cell 2 hours after operation;and the high-sensitivity CRP two hours after operation were the independent risk factors of urosepsis following Holmium laser lithotripsy with flexible ureteroscope in patients with upper urinary tract stones.Besides,the early warning model constructed by our study has a preferable sensitivity and specificity,and its’overall accuracy is 88.9%.And the early warning scale also showed a satisfying function in the identify of high risk patients.Therefore,the model as well as the scale can give a positive guidance in nursing assessment and observation to clinical nurse to some extent.During peri-operational period,clinical nurses should pay more attention to the patients with the risk factors above so as to made an early evaluation and identify the high risk patients for the purpose of reducing the incidence of urosepsis after operation.