预测危重创伤患者死亡的一种新评分系统：死亡预警评分的预测价值

A new score system for prediction of death in patients with severe trauma： the value of death warning score

目的 提出一种综合预测危重创伤患者死亡的最佳评分指标死亡预警评分,为临床提供一种简便易行的评分方法.方法 回顾性分析2014年1月至12月第三军医大学西南医院、第三军医大学大坪医院、遵义医学院附属医院重症医学科收治的394例创伤患者的临床资料.根据患者住院期间临床结局分为存活组（330例）和死亡组（64例）.记录两组患者的性别、年龄;入院后呼吸频率、心率、收缩压;入院24 h内血肌酐（SCr）、白细胞计数（WBC）、血小板计数（PLT）、红细胞比容（Hct）的最差值;确诊24 h内急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分、格拉斯哥昏迷评分（GCS）、序贯器官衰竭评分（SOFA）、全身炎症反应综合征（SIRS）评分、损伤严重程度评分（ISS）;24 h内是否行急诊手术或急诊插管;病程中是否发生脓毒症,以及临床结局.单因素分析两组患者的各项观察指标,对导致死亡的相关因素进一步行logistic回归分析,筛选出影响危重创伤患者死亡的危险因素,并对有统计学意义的指标予以赋值,总分为死亡预警评分;绘制受试者工作特征曲线（ROC）,评价死亡预警评分对危重创伤患者死亡的预测价值.结果 与存活组比较,死亡组患者年龄大（岁：51.50±18.31比45.54±14.70,t=-2.456,P=0.016）,SCr升高（μmol/L：94.18±65.51比72.42±28.22,t=-2.611,P=0.011）,APACHEⅡ评分（分：24.30±6.23比16.38±6.19,t=-9.353,P＜0.001）和SOFA评分（分：7.84±3.68比4.43±2.75,t=-7.049,P＜0.001）升高,进行急诊插管[79.7％ （51/64）比42.7％（141/330）,x2=29.309,P＜0.001]和发生脓毒症的比例[48.4％ （31/64）比30.3％ （100/330）,x2=18.512,P＜0.001]也显著升高,PLT（x109/L：112.75±59.85比144.12±68.28,t=3.428,P=0.001）和GCS评分（分：6.44±4.20比11.02±3.93,t=8.449,P＜0.001）则显著降低;而两组性别、呼吸频率、心率、收缩压、WBC、Hct、SIRS评分、ISS、行急诊手术比例比较差异均无统计学意义.将单因素分析中有统计学意义的指标进行多因素logistic回归分析,进入回归模型的指标分别为年龄≥65岁[95％可信区间（95％CI） =0.176-1.974,P=0.019]、APACHEⅡ评分≥21分（95％CI=0.121 - 2.725,P=0.032）、GCS评分＜6分（95％CI=0.201 - 3.221,P=0.026）、发生严重脓毒症（95％CI=0.421-2.735,P=0.008）或脓毒性休克（95％CI=0.430 - 3.636,P=0.013）,并将其分别赋值为1.0、1.5、1.5、1.5、2.0分,以这5个指标的总分作为死亡预警评分.ROC曲线分析显示：死亡预警评分预测危重创伤患者死亡的ROC曲线下面积（AUC）为0.867,明显高于APACHEⅡ评分（AUC为0.812,P=0.022）和GCS评分（AUC为0.783,P=0.001）.当死亡预警评分的诊断阈值为1.5分时,敏感度为75.00％,特异度为85.40％,阳性预测值为50.0％,阴性预测值为94.6％,阳性似然比为5.16,阴性似然比为0.29,约登指数为0.605.结论 年龄≥65岁、APACHEⅡ评分≥21分、GCS＜6分、发生严重脓毒症或脓毒性休克是危重创伤患者死亡的危险因素,以这5个指标作为危重创伤患者的死亡预警评分,用它可以更加全面地评估危重创伤患者的预后,其预测效果优于单用任何一种评分.

Objective To discuss a best predictive score index in predicting death in patients with severe trauma, death warning score, and to provide a simple score for clinical use.Methods The clinical data of 394 traumatic patients admitted to Department of Critical Care Medicine of Xi＇nan Hospital of the Third Military Medical University, Daping Hospital of the Third Military Medical University, and Affiliated Hospital of Zunyi Medical College from January 2014 to December 2014 were retrospectively analyzed.The patients were divided into survival group （n =330） and non-survival group （n =64）.The clinical data in two groups were recorded as following： gender, age;respiratory rate, heart rate, and systolic blood pressure at admission;the lowest values of serum creatinine （SCr）, white blood cell count （WBC）, platelet count （PLT）, hematocrit （Hct）, respectively, within 24 hours after admission;acute physiology and chronic health evaluation Ⅱ （APACHE Ⅱ） score, Glasgow coma scale （GCS） score, sequential organ failure assessment （SOFA）, systemic inflammatory response syndrome （SIRS） score, injury severity score （ISS） within 24 hours of final diagnosis;the performance of emergency operation or intubation within 24 hours;incidence of sepsis,and clinical outcomes.Each observed indicator was analyzed by univariate analysis, and factors leading to death were further analyzed by logistic regression.Risk factors of severe trauma patients were sorted, from which the meaningful indicators were included to calculate the warning score of death.Receiver operating characteristic curve （ROC） was plotted to evaluate the predictive value of the warning score of death in severe trauma patients.Results Compared with the survival group, the age in non-survival group was older （years old： 51.50 ± 18.31 vs.45.54 ± 14.70, t =-2.456,P =0.016）;SCr was increased （μmol/L： 94.18±65.51 vs.72.42±28.22, t =-2.611, P =0.011）;APACHE Ⅱ score （24.30±6.23 vs.16.38±6.19, t =-9.353, P 〈 0.001） and SOFA score were higher （7.84±3.68 vs.4.43±2.75,t =-7.049, P 〈 0.001）;and the incidence of emergency intubation [79.7% （51/64） vs.42.7% （141/330）, x2 =29.309,P 〈 0.001] and sepsis was also higher [48.4% （31/64） vs.30.3% （100/330）, x2 =18.512, P 〈 0.001], but PLT count （x109/L： 112.75±59.85 vs.144.12±68.28, t =3.428, P =0.001） and GCS score （6.44±4.20 vs.11.02±3.93,t =8.449, P 〈 0.001） were significantly lower.There was no significant difference in gender, respiratory rate, heart rate,systolic blood pressure, WBC, Hct, SIRS score, ISS, or emergency operation between two groups.The indicators with statistically significant difference from the univariate analysis were further analyzed by multivariate logistic regression,and the indices included in the regression model were age ≥ 65 years [95% confidence interval （95%CI） =0.176-1.974,P =0.019], APACHE Ⅱ score ≥ 21 （95%CI =0.121-2.725, P =0.032）, GCS 〈 6 （95%CI =0.201-3.221, P =0.026）,severe sepsis （95%CI =0.421-2.735, P =0.008） or septic shock （95%CI =0.430-3.636, P =0.013）, with assigning scores of 1.0, 1.5, 1.5, 1.5, 2.0, respectively.Finally these five indicators were included into the warning score of death.It was shown by ROC curve analysis that the area under ROC curve （AUC） of warning score of death in predicting mortality in critically ill trauma patients was 0.867, which was significantly higher than that of the APACHE Ⅱ score （AUC =0.812, P =0.022） and GCS score （AUC =0.783, P =0.001）.When the cut-off value of warning score of death was 1.5, the sensitivity, specificity, positive predict value （＋PV）, negative predict value （-PV）, positive likelihood ratio （＋LR）, negative likelihood ratio （-LR）, and Youden index was 75.00%, 85.40%, 50.0%, 94.6%, 5.16, 0.29, and 0.605,respectively.Conclusions Age ≥ 65 years, APACHE Ⅱ score ≥ 21, GCS 〈 6, severe sepsis or septic shock were the risk factors of death in patients with severe trauma, and they can be considered as warning score of death in patients with severe trauma.With the score mortality can be better predicted than any other kind of score for patients with severe trauma.