重症心肺复苏患者早期预后的预测指标

Evaluation index in predicting the prognosis of critical patients post cardiopulmonary resuscitation

目的结合临床常用炎症指标与格拉斯哥评分（glasgow coma scale，GCS）和急性生理和慢性健康评分（acute physiology and chronic heath evaluation Ⅱ，APACHE Ⅱ）建立心肺复苏术后评估指标，对117例在ICU治疗的心肺复苏术后患者预后的进行评估并评价各指标对患者早期预后的预测价值。方法选择2010年1月至2012年12月在南方医科大学珠江医院重症医学科住院的心肺复苏术后患者117例，在入院24h内测定其炎症指标、血常规、电解质、肝肾功能，记录GCS及APACHE Ⅱ，分别留取患者入院时、住院12h及住院24h的动脉血气分析，分别计算12h及24h的乳酸清除率。在所有病例治疗7d后，根据他们的转归分为生存组和死亡组进行比较分析。结果（1）117例患者中有73例死亡，44例生存。单因素分析表明：年龄、复苏后至入ICU时间、D二聚体、FiO2、动脉血pH值、入ICU时动脉血乳酸值、GCS及APACHE Ⅱ在两组之间的差异具有统计学意义（P〈0．05或P〈0．01）。（2）二分类Logistic回归分析显示：D二聚体、GCS及APACHE Ⅱ与心肺复苏术后患者死亡与否存在显著性的相关关系，相对危险度（OR值）分别为1．000、2．091、0．531（P〈0．05或P〈0．01）。（3）受试者工作特征曲线（receiver operation characteristic curve，ROC）分析表明：GCS和APACHE Ⅱ的ROC曲线下面积（areaunder the curve，AUC）分别为0．821和0．869（P〈0．01），比D二聚体更有预测价值。当GCS等于6．5分时，预测患者生存的正确率最高，为84．6％。当APACHEⅡ等于17．5分时，预测患者死亡的正确率最高，为82．1％。结论GCS和APACHE Ⅱ与心肺复苏术后患者预后明显相关，可以分别预测重症心肺复苏术后患者7d内的存活及死亡概率，比起单一的监测指标有更大的优越性。希望此结论在今后的临床工作能对加强病情综合评估有用。

Objective To assess the early prognosis of 117 patients after carduopulmonary resuscitation （CPR） in ICU by using the markers of inflammation, Glasgow Coma Scale （GCS） and Acute Physiology and Chronic Health Evaluation Ⅱ （APACHE Ⅱ ） scores. Methods A total of 117 CPR patients admitted between 2010 January to 2012 December were enrolled for study. Within 24 h after admission, inflammatory markers, blood routine items, hepatorenal function, electrolytes of blood were measured. The GCS and APACHE Ⅱ scores were recorded. Arterial blood gas analyses were performed at 0, 12, and 24 h after hospitalization, and the 12-h and 24-h lactate clearance rates were calculated. Seven days after treatment, according to the outcomes, the patients were divided into survival group and death group, and the clinical data of two groups were analyzed. Results （ 1 ） Of them, 73 patients died and 44 survived. Factor analysis showed that age, time elapsed from resuscitation to ICU admission, D-dimer, arterial oxygenation index （FiO2 ）, arterial blood pH, arterial blood lactate concentration upon ICU admission, GCS score and APACHE Ⅱ score were significantly different between the two groups （ P 〈 0. 05 or P 〈 0. 01 ）; （2） Two classification logistic regression analysis showed that D-Dimer, GCS score and APACHE II score significantly correlated with the mortality risk of the patients in the wake of CPR with relative odds ratios of 1. 000, 2. 091, and 0. 531, respectively （P 〈 0. 05 or P 〈 0. 01 ） ; （3） Receiver operating characteristic curve analysis indicated that the area under the curve of GCS （0. 821 ） and APACHE Ⅱ （0. 869 ） had higher predictive value than D-dimer （ 0. 655 ）. The highest accuracy （ 84. 6% ） in predicting patient survival was achieved when the GCS score was 6. 5. Meanwhile, the highest accuracy （82. 1% ） in predicting patient death was achieved when the APACHE Ⅱ score was 17.5. Conclusions Both GCS score and APACHE Ⅱ score has obvious correlation with the prognosis of the critically ill patients after CPR and could be used to predict prognosis at early stage.