血浆N末端B型钠尿肽前体对脓毒性休克心肌抑制患者严重程度及预后的预测价值

The predictive value of plasma N-terminal pro-B-type natriuretic peptide levels in the evaluation of prognosis and the severity of patients with septic shock induced myocardial suppression

目的探讨血浆N末端B型钠尿肽前体（NT-proBNP）对脓毒性休克心肌抑制患者病情严重程度及预后的预测价值。方法采用前瞻性研究方法，选择2009年8月至2011年8月入住北京世纪坛医院重症监护病房（ICU）的脓毒性休克患者102例，于入院1、3、5d检测血浆NT-proBNP水平，并记录当日急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分、序贯器官衰竭评分（SOFA）。根据28d生存情况分为存活组和死亡组，比较两组血浆NT-pro-BNP水平及APACHEⅡ评分、SOFA评分；根据入院24h内心排血指数（CI）分为心功能正常组（CI〉50．0ml·s-1·m-2）和心功能抑制组（CI〈50．0ml·s-1·m-2），比较两组血浆NT-proBNP水平。采用多因素logistic回归分析28d病死率的独立预测因素。结果①死亡组（45例）患者APACHEⅡ评分（分）、SOFA评分（分）及血浆NT-proBNP水平（μg/L）明显高于存活组（57例，1dAPACHEⅡ评分：23．8±0．6比14．3±0．3；1dSOFA评分：12．4±3．0比7．7±2．8；NT-proBNP1d：4．13±1．05比1．65±0．26，3d：5．32±0．93比1．87±0．29，5d：6．90±1．33比1．23±0．19，P〈0．05或P〈0．01）。②心功能抑制组（47例）患者血浆NT-proBNP水平明显高于心功能正常组（55例），且两组内死亡者NT-proBNP水平高于存活者。③多因素logistic回归分析湿示，1、3、5dAPACHEⅡ评分和NT-proBNP水平是28d病死率的独立预测因素（P〈0．05或P〈0．01）。结论动态监测血浆NT-proBNP水平的变化趋势有助于评估脓毒性休克心肌抑制患者的预后及严重程度；NT-proBNP与APACHEⅡ评分同样是预测28d生存情况的独立指标。

Objective To investigate the predictive value of plasma N-terminal pro-B-type natriuretic peptide （NT-proBNP） levels in the evaluation of prognosis and the severity of patients with septic shock induced myocardial suppression. Methods A prospective study was conducted, with enrollment of 102 patients with septic shock in intensive care unit （ICU） of Beijing Shijitan Hospital from August 2009 to August 2011. Plasma NT-pro-BNP levels were measured on the 1st, 3rd and 5th day after admission, and the acute physiology and chronic health evaluation Ⅱ （APACHEⅡ ） score, sequential organ failure assessment （SOFA） score were monitored at admission to ICU. With the 28-day mortality ＇after admission to ICU as the standard, the patients with septic shock were divided into the survivor group and non-survivor group. Dynamic changes in plasma NT-proBNP levels and score of APACHE Ⅱ and SOFA were compared between two groups. The patients were divided into non-cardiac dysfunction group [ cardiac index （CI） 〉 50.0 ml. s-1.m-2] and cardiac dysfunction group （CI〈50.0 ml.s-1.m-2） according to levels of CI after admission 24 hours. The level of plasma NT-proBNP was compared between two groups. The predictive value of plasma NT-proBNP on 28-day mortality was evaluated by multivariate logistic regression analysis. Results ①APACHE Ⅱ score, SOFA score and plasma NT-proBNP levels （μg/L） in non-survivor group （n=45） were higher than those of survivor group （n=57, 1-day APACHE Ⅱ score： 23.8 ± 0.6 vs. 14.3 ± 0.3, 1-day SOFA score： 12.4 ± 3.0 vs. 7.7 ± 2.8; NT-proBNP 1 day： 4.13 ± 1.05 vs. 1.65 ±0.26, 3 days： 5.32 ±0.93 vs. 1.87 ±0.29, 5 days： 6.90 ± 1.33 vs. 1.23 ± 0.19, P〈0.05 or P〈0.01 ）. ②Plasma NT-proBNP levels in cardiac dysfunction group （n=47） were higher than those of non-cardiac dysfunction group （n= 55 ）, and elevated obviously in non-survivors than those in survivors. ③In multivariate logistic regression analysis, NT-proBNP level and APACHEⅡ score were independent predictors of 28-day mortality （P 〈0.05 or P 〈0.01 ）. Conclusions Plasma NT-proBNP levels show obvious significance in evaluation of prognosis and the severity of patients with septic shock induced myocardial depression. Plasma NT-proBNP level and APACHE Ⅱ score are independent prognostic markers of mortality and sepsis-induced myocardial depression in septic shock.