老年患者外周静脉留置针中重度并发症风险预测模型构建

Development of a Risk Prediction Model for Moderate-to-Severe Complications Associated With Peripheral Intravenous Catheters in Older Patients

摘要

目的 构建并验证老年患者外周静脉留置针（peripheral venous catheter, PVC）中重度并发症的风险预测模型，为临床精准防控提供依据。方法 采用前瞻性队列研究，收集2023年11月-2024年9月期间收治的750例接受PVC治疗的老年患者的临床资料。按7∶3将患者分层随机分为训练集（n=526）与测试集（n=224）。通过单因素与多因素logistic回归分析筛选PVC中重度并发症的独立影响因素，分别构建二元logistic回归（binary logistic regression, BLR）、支持向量机（support vector machine, SVM）、随机森林（random forest, RF）、朴素贝叶斯（naive Bayes, NB）四种预测模型。采用受试者工作特征曲线下面积（area under the curve, AUC）结合DeLong检验评估模型区分度，使用校准曲线评估校准度，并利用决策曲线分析（decision curve analysis, DCA）评价其临床净获益，同时通过沙普利可加性模型解释算法（Shapley additive explanations，SHAP）可视化分析阐释模型的特征重要性。结果 多因素logistic回归分析确定自理能力〔轻度依赖：比值比（odds ratio, OR）=1.361，95%置信区间（confidence interval, CI）：1.031～1.802；中度依赖：OR=1.992，95%CI：1.291～3.061；重度依赖：OR=3.060，95%CI：1.700～5.512〕、渗液（OR=8.998，95%CI：4.286～18.887）、临床科室〔胃肠外科：OR=28.396，95%CI：7.537～106.990；胰腺外科：OR=5.258，95%CI：1.177～23.499；胰腺炎中心：OR=5.974，95%CI：1.287～27.725〕、患者小学及以下文化程度（OR=2.525，95%CI：1.158～5.506）、饮酒（OR=1.970，95%CI：1.011～3.838）、敷料卷边（OR=1.458，95%CI：1.150～1.848）及合并症数量（OR=0.893，95%CI：0.821～0.972）为老年患者PVC中重度并发症的独立危险因素，16G～22G导管为独立保护因素（P<0.05）。测试集验证显示，RF模型AUC最高（0.891，95%CI：0.840～0.942），经DeLong检验，其区分度与BLR（0.808，95%CI：0.738～0.879）和SVM（0.842，95%CI：0.774～0.909）模型相比，差异有统计学意义（P<0.05）；SHAP分析提示渗液、自理能力、不同临床科室为RF模型的核心影响因素；DCA表明RF模型在0～0.8的阈值概率范围内具有显著的临床净获益。结论 本研究成功构建并验证了老年患者PVC中重度并发症的RF预测模型，该模型区分度优异、临床应用价值突出，可有效早期识别高危人群，为临床精准干预提供科学依据。

Abstract

Objective To develop and validate a risk prediction model for moderate-to-severe complications associated with peripheral venous catheters (PVC) in older patients, and to provide evidence for precision-based clinical prevention and management. Methods In this prospective cohort study, the clinical data of 750 older patients who underwent PVC placement for intravenous therapy between November 2023 and September 2024 were collected. Patients were stratified and randomly assigned to a training set (n = 526) and a test set (n = 224) at a ratio of 7∶3. Independent risk factors for moderate-to-severe PVC-related complications were identified by univariate and multivariate logistic regression analyses. A total of 4 predictive models were established-binary logistic regression (BLR), support vector machine (SVM), random forest (RF), and naive Bayes (NB). Model discrimination was assessed using the area under the receiver operating characteristic curve (AUC) and DeLong test. Model calibration was evaluated by calibration curves. Clinical net benefit was determined using decision curve analysis (DCA). Shapley additive explanations (SHAP) were used to visualize and interpret feature importance in the models. Results According to multivariate logistic regression analysis, functional status (mild dependence: odds ratio [OR] = 1.361, 95% CI: 1.031-1.802; moderate dependence: OR = 1.992, 95% CI: 1.291-3.061; severe dependence: OR = 3.060, 95% CI: 1.700-5.512), infusion extravasation (OR = 8.998, 95% CI: 4.286-18.887), the clinical department the patient was admitted to (Gastrointestinal Surgery: OR = 28.396, 95% CI: 7.537-106.990; Pancreatic Surgery: OR = 5.258, 95% CI: 1.177-23.499; Pancreatitis Center: OR = 5.974, 95% CI: 1.287-27.725), primary school or less formal education (OR = 2.525, 95% CI: 1.158-5.506), drinking history (OR = 1.970, 95% CI: 1.011-3.838), the edges of the dressing being curled up (OR = 1.458, 95% CI: 1.150-1.848), and the number of comorbidities (OR = 0.893, 95% CI: 0.821-0.972) were identified as independent risk factors for moderate-to-severe PVC-related complications in older patients, while 16G-22G catheters were identified as an independent protective factor (P < 0.05). Validation in the test set revealed that the RF model yielded the highest AUC value (0.891, 95% CI: 0.840-0.942). According to the DeLong test, the discrimination performance of the RF model was significantly superior to those of the BLR model (AUC = 0.808, 95% CI: 0.738-0.879) and the SVM model (AUC = 0.842, 95% CI: 0.774-0.909) ( P < 0.05). SHAP analysis revealed that infusion extravasation, functional status, and the clinical department into which the patient was admitted were the top 3 features of the RF model. DCA showed that the RF model provided significant net clinical benefit within the threshold probability range of 0-0.8. Conclusion In this study, an RF prediction model for moderate-to-severe PVC-related complications in older patients was successfully developed and validated. The RF prediction model demonstrates excellent discrimination and high clinical applicability, enabling early identification of high-risk patients and informing precision-based clinical interventions.

关键词

老年人 / 导管，留置 / 并发症 / 比例危险度模型

Key words

Older adults / Catheters, indwelling / Complications / Proportional hazards models

参考文献

[1] 冯园园. 人口老龄化对我国医疗卫生费用的影响研究[D]. 长春: 吉林大学, 2022: 47. DOI: 10.27162/d.cnki.gjlin.2022.007555.

[2] Feng Y Y. The study of population aging influence on medical and health expenses in China[D]. Changchun: Jilin University, 2022: 47. DOI: 10.27162/d.cnki.gjlin.2022.007555.

[3] Juhlin D, Hammarskjöld F, Mernelius S, et al. Microbiological colonization of peripheral venous catheters: a prospective observational study in a Swedish county hospital[J/OL]. Infect Prev Pract, 2021, 3(3): 100152. https://doi.org/10.1016/j.infpip.2021.100152.

[4] Ponsoye M, Espinasse F, Coutte L, et al. The use of venous catheter: Which ones to choose, how to prevent their complications?[J] Rev Med Interne, 2021, 42(6): 414-415. DOI: 10.1016/j.revmed.2020.10.385.

[5] Gras E, Jean A, Rocher V, et al. Incidence of and risk factors for local complications of peripheral venous catheters in patients older than 70 years: Empirical research quantitative[J]. J Clin Nurs, 2023, 32(15/16): 5001. DOI: 10.1111/jocn.16732.

[6] 胡美红. 住院儿童患者留置针留置时间与并发症风险的关联性研究[D]. 长沙: 湖南中医药大学, 2025: 33. DOI: 10.27138/d.cnki.ghuzc.2025.000289.

[7] Hu M H. Study on the correlation between the indwelling time of indwelling needle in hospitalized children and the risk of complications[D]. Changsha: Hunan University of Traditional Chinese Medicine, 2025: 33. DOI: 10.27138/d.cnki.ghuzc.2025.000289.

[8] Drugeon B, Guenezan J, Pichon M, et al. Incidence, complications, and costs of peripheral venous catheter-related bacteraemia: a retrospective, single-centre study[J]. J Hosp Infect, 2023, 135: 67. DOI: 10.1016/j.jhin.2023.02.012.

[9] 史可为, 吴亚飞, 方亚 等. 临床预测模型的可解释性及应用进展[J]. 现代预防医学, 2023, 50(6): 1124-1125. DOI: 10.20043/j.cnki.MPM.20220808.

[10] Shi K W, Wu Y F, Fang Y, et al. Interpretability and application of clinical prediction models[J]. Mod Prev Med, 2023, 50(6): 1124-1125. DOI: 10.20043/j.cnki.MPM.20220808.

[11] 陈王跃. 普外科手术并发症的预测: 基于经典统计回归模型和贝叶斯网络模型[D]. 北京: 北京协和医学院, 2023: 9. DOI: 10.27648/d.cnki.gzxhu.2023.000556.

[12] Chen W Y. Prediction of complications in general surgery: Based on classical statistical regression model and Bayesian network model[D]. Beijing: Peking Union Medical College, 2023: 9. DOI: 10.27648/d.cnki.gzxhu.2023.000556.

[13] 张海洪, 杨阳, 丛亚丽 . 世界医学会《赫尔辛基宣言》: 涉及人类参与者的医学研究伦理原则[J]. 医学与社会, 2025, 38(1): 141. DOI: 10.13723/j.yxysh.2025.01.020.

[14] Wynants L, Bouwmeester W, Moons K G, et al. A simulation study of sample size demonstrated the importance of the number of events per variable to develop prediction models in clustered data[J]. J Clin Epidemiol, 2015, 68(12): 1406-1407. DOI: 10.1016/j.jclinepi.2015.02.002.

[15] Nickel B, Gorski L, Kleidon T, et al. Infusion Therapy Standards of Practice, 9th Edition[J]. J Infus Nurs, 2024, 47(S1): S1. DOI: 10.1097/NAN.0000000000000532.

[16] 徐舒慧. 基于决策树的住院患儿外周静脉留置针并发症严重度风险因素研究[D]. 北京: 北京协和医学院, 2022: 6. DOI: 10.27648/d.cnki.gzxhu.2022.000673.

[17] Xu S H. Risk factors for peripheral intravenous catheter complications' severity in hospitalized children: based on decision tree[D]. Beijing: Beijing Union Medical College, 2022: 6. DOI: 10.27648/d.cnki.gzxhu.2022.000673.

[18] 王文歆, 赵艳, 徐梅, 等. 迷你中长导管与留置针用于老年患者输液的效果比较[J]. 护理学杂志, 2024, 39(21): 61. DOI: 10.3870/j.issn.1001-4152.2024.21.059.

[19] Wang W X, Zhao Y, Xu M, et al. Comparison of the effectiveness of mini-midline catheter with peripheral venous catheter in older patients[J]. J Nurs Sci, 2024, 39(21): 61. DOI: 10.3870/j.issn.1001-4152.2024.21.059.

[20] Brown C J, Redden D T, Flood K L, et al. The underrecognized epidemic of low mobility during hospitalization of older adults[J]. J Am Geriatr Soc, 2009, 57(9): 1660. DOI: 10.1111/j.1532-5415.2009.02393.x.

[21] Chen P, Wan G, Zhu B. Incidence and risk factors of symptomatic thrombosis related to peripherally inserted central catheter in patients with lung cancer[J]. J Adv Nurs, 2021, 77(3): 1284. DOI: 10.1111/jan.14666.

[22] 姜珊, 郭彩霞, 郭立华, 等. 外周静脉留置针并发症风险管理系统的开发与应用[J]. 中华护理杂志, 2025, 60(8): 909. DOI: 10.3761/j.issn.0254-1769.2025.08.002.

[23] Jiang S, Guo C X, Guo L H, et al. Development and application of a risk management system for complications of peripheral intravenous indwelling needle[J]. Chin J Nurs, 2025, 60(8): 909. DOI: 10.3761/j.issn.0254-1769.2025.08.002.

[24] 邹盼盼, 吴丹, 钱金平, 等. 成人外周静脉留置针导管失效风险列线图预测模型的构建[J]. 上海护理, 2024, 24(2): 3-4. DOI: 10.3969/j.issn.1009-8399.2024.02.001.

[25] Zou P P, Wu D, Qian J P, et al. Construction of a nomogram-based risk prediction model for peripheral indwelling venous catheter failure in adults[J]. Shanghai Nurs, 2024, 24(2): 3-4. DOI: 10.3969/j.issn.1009-8399.2024.02.001.

[26] 陈亚美. 外周静脉导管相关静脉炎风险评估模型的构建[D]. 苏州: 苏州大学, 2019: 14. DOI: 10.27351/d.cnki.gszhu.2019.002340.

[27] Chen Y M. Construction of a risk assessment model for peripheral venous catheter-related phlebitis[D]. Suzhou: Suzhou University, 2019: 14. DOI: 10.27351/d.cnki.gszhu.2019.002340.

[28] Kawaguchi Y, Murotani K, Hayashi N, et al. Associations between parenteral energy or amino acid doses and clinical outcomes in fasting patients undergoing gastroenterological cancer surgery: a nationwide cohort study using real-world data[J/OL]. Gastroenterol Rep (Oxf), 2026, 14: goag014. https://doi.org/10.1093/gastro/goag014.

[29] Xu H, Hyun A, Mihala G, et al. The effectiveness of dressings and securement devices to prevent central venous catheter-associated complications: a systematic review and meta-analysis[J/OL]. Int J Nurs Stud, 2024, 149: 104620. https://www.sciencedirect.com/science/article/pii/S0020748923001852?via%3Dihub. DOI: 10.1016/j.ijnurstu.2023.104620.

[30] Rickard C M, Marsh N, Webster J, et al. Dressings and securements for the prevention of peripheral intravenous catheter failure in adults (SAVE): a pragmatic, randomised controlled, superiority trial[J]. Lancet, 2018, 392(10145): 419. DOI: 10.1016/S0140-6736(18)31380-1.

[31] Kleidon T M, Schults J, Gibson V, et al. Securement to prevent noncuffed central venous catheter dislodgement in pediatrics: the SECURED superiority randomized clinical trial[J]. JAMA Pediatr, 2024, 178(9): 861. DOI: 10.1001/jamapediatrics.2024.2202.

[32] Martin-Loeches I, Lemiale V, Geoghegan P, et al. Influenza and associated co-infections in critically ill immunosuppressed patients[J/OL]. Crit Care, 2019, 23(1): 152. https://link.springer.com/article/10.1186/s13054-019-2425-6.

[33] Simin D, Milutinović D, Turkulov V, et al. Incidence, severity and risk factors of peripheral intravenous cannula-induced complications: an observational prospective study[J]. J Clin Nurs, 2019, 28(9/10): 1586-1587. DOI: 10.1111/jocn.14760.

[34] Hu J, Szymczak S. A review on longitudinal data analysis with random forest[J/OL]. Brief Bioinform, 2023, 24(2): bbad002. https://doi.org/10.1093/bib/bbad002.