严重脓毒症和感染性休克患者早期复苏时器官功能障碍的回顾性分析

The incidences of organ dysfunction in the early resuscitation of severe sepsis and septic shock patients： a retrospective analysis

目的探寻早期复苏时影响器官功能障碍发生及病死率的潜在危险因素。方法回顾性分析2013年1月1日至2015年12月31日昆明医科大学第二附属医院重症医学科收治的所有非心脏术后严重脓毒症／感染性休克患者的临床资料，将患者分为高龄组（≥65岁）和非高龄组（〈65岁），高降钙素原（PCT）组（PCT〉100μg/L）和对照组（PcT≤100μg/L）；早期复苏时间设为6h。统计患者急性呼吸窘迫综合征（ARDS）、急性肾损伤（AKI）及心功能不全的临床诊断时间和发生率；连续性肾脏替代治疗（CRRT）使用率；早期目标导向治疗（6hEGDT）期间患者总输液量和血管收缩药物使用时间；28d病死率。结果512例非心脏术后严重脓毒症／感染性休克患者均按照2012年“拯救脓毒症运动”（SSC）指南进行治疗，采用EGDT进行早期复苏。所有患者中ARDS发生率为80．9％（414／512），AKI发生率为71．3％（365／512），心功能不全发生率为61．9％（317／512）；高龄组205例，非高龄组307例；高PCT组154例，对照组358例；28d死亡155例，总病死率为30．3％。有90．8％的ARDS患者（376／414）在早期复苏前确诊；有95．1％的AKI患者（347／365）在早期复苏前确诊，其中14．O％（51／365）接受了CRRT治疗；有153例高龄患者的心功能不全在EGDT后12h内确诊。与非高龄组比较，高龄组ARDS和心功能不全发生率显著升高[85．9％（176／205）比77．5％（238／307），82．9％（170／205）比32．9％（147／307），均P〈0．05]，血管收缩药物使用时间显著延长（h：5．81±0．28比5．68±0．52，P〈0．05），28d病死率显著升高[42．9％（88／205）比21．8％（67／307），P〈0．05]，而AKI发生率和早期复苏期间总输液量差异无统计学意义[AKI发生率：74．1％（152／205）比69．4％（213／307），总输液量（mL）：2769±1589比2804±1611，均P〉0．05]。与对照组比较，高PCT组ARDS发生率显著升高[86．4％（133／154）比78．5％（281／358），p〈0．05]，AKI、心功能不全发生率差异无统计学意义[77．9％（120／154）比68．4％（245／358），58．4％（90／154）比63．4％（227／358），均P〉0．05]。多因素logistic回归分析显示，年龄[优势比（OR）=1．782，95％可信区间（95％CI）=1．173～2．708，P=0．007]、ARDS（OR=1．786，95％CI=1．028—3．102，P=0．040）、AKI（OR=1．878，95％CI=1．145～3．079，P=0．012）、心功能不全（OR=4．177，95％CI=2．505～6．966，P=0．000）为严重脓毒症／感染性休克患者病死率升高的危险因素，与性别无关（OR=1．112，95％CI=0．736—1．680，P=0．614）。结论非心脏术后严重脓毒症／感染性休克高龄患者的ARDS、心功能不全发生率及死亡风险均升高，其ARDS风险与感染严重程度相关，而高龄、手术及EGDT仍是导致心功能不全的潜在危险因素。

Objective To investigate the potential risk factors of organ dysfunction and mortality in the early resuscitation of severe sepsis and septic shock patients. Methods Data were retrospectively analyzed from patients with severe sepsis and septic shock receiving non-cardiac operation and admitted to Department of Critical Care Medicine of the Second Affiliated Hospital of Kunming Medical University from January 1st, 2013 to December 31st, 2015. The patients were divided into the senior group （ ≥ 65 years old） and the younger group （〈 65 years old）, the high-procalcitonin （PCT） group （PCT 〉 100 μg/L） and the control group （PCT ≤ 100 μg/L）. The stage of early resuscitation was set to the first 6 hours. The diagnostic time and the incidence of acute respiratory distress syndrome （ARDS）, acute kidney injury （AKI）, and cardiac insufficiency were observed, which also included the usage of continuous renal replacement therapy （CRRT）. The total fluid volume and the time of vasopressor usage during the first 6 hours of early goal-directed therapy （EGDT） were also recorded, which aslo included the 28-day mortality. Results 512 patients with severe sepsis and septic shock receiving non-cardiac operation were treated according to the guidelines of Surviving Sepsis Campaign： international guidelines for management of severe sepsis and septic shock： 2012. EGDT was used during the early resuscitation. The incidence of ARDS, AKI, and cardiac insufficiency was 80.9% （414/512）, 71.3% （365/512）, and 61.9% （317/512） respectively. There were 205 senior patients and 307 younger, as well as 154 in high-PCT group and 358 in control group. The 28-day mortality was 30.3% （155 died）. 90.8% of patients （376/414） combined with ARDS were diagnosed before EGDT. 95.1% of patients （347/365） combined with AKI were diagnosed before EGDT, among whom 14.0% （51/365） were treated with CRRT. 153 senior patients combined with cardiac insufficiency were diagnosed no longer than 12 hours after EGDT. Compared with the younger group, the incidences of ARDS and cardiac insufficiency were higher in the senior group [85.9% （176/205） vs. 77.5% （238/307）, 82.9% （170/205） vs. 32.9% （147/307）, both P 〈 0.05], so were the time of vasopressor usage during EGDT （hours： 5.81 ±0.28 vs. 5.68 ± 0.52, P 〈 0.05） was prolonged markedly and the 28-day mortality [42.9% （88/205） vs. 21.8% （67/307）, P 〈 0.05] was increased significantly. But the incidence of AKI and the total fluid volume during EGDT were not significantly different between the senior group and the younger group [incidence of AKI： 74.1% （152/205） vs. 69.4% （213/307）, total fluid volume （mL）： 2 769± 1 589 vs. 2 804 ± 1 611, both P 〉 0.05]. Compared with the control group, the incidence of ARDS was higher in the high-PCT group [86.4% （133/154） vs. 78.5% （281/358）, P 〈 0.05]. But the incidences of AKI and cardiac insufficiency were not significantly differentiated between the high-PCT group and the control group [77.9% （120/154） vs. 68.4% （245/358）, 58.4% （90/154） vs. 63.4% （227/358）, both P 〉 0.05]. Multiple logistic regression analysis showed that the risk factors of increase in mortality in patienfs with severe sepsis and septic shock included old age [odds ratio （OR） = 1.782, 95% confidence interval （95%CI） = 1.173-2.708, P = 0.007], ARDS （OR = 1.786, 95%CI = 1.028-3.102, P = 0.040）, AKI （OR = 1.878, 95%CI = 1.145-3.079, P = 0.012）, and cardiac insufficiency （OR = 4.177, 95%CI = 2.505-6.966, P = 0.000）, except for gender （OR = 1.112, 95%CI = 0.736-1.680, P = 0.614）. Conclusions In the senior postoperative patients with severe sepsis or septic shock, the incidence of ARDS and cardiac insufficiency, and the mortality were increased. The incidence of ARDS was correlated to the severity of infection. Old age, surgery, and EGDT could be the potential risk factors of cardiac insufficiency.