严重脓毒症与脓毒性休克患者预后分析

Prognostic analysis of patients with severe sepsis and septic shock

目的探讨严重脓毒症与脓毒性休克死亡危险因素,分层分析影响不同生存期患者预后的因素。方法回顾性分析2013年1月至2014年12月108例严重脓毒症与脓毒性休克患者临床资料,通过多因素Cox回归模型明确死亡的独立危险因素。结果总死亡率为53.7%,生存期<30 d,30 d^89 d,90 d^365 d患者死亡率分别为27.8%、24.4%与15.3%。急性生理与慢性健康评分(APACHE-Ⅱ评分)、查尔森合并症指数(CCI)与降钙素原变化率(△PCT)是影响死亡率的独立预后因素,HR(95%CI)分别为1.105(1.066~1.146)、1.390(1.210~1.596)与0.996(0.995~0.997)。分层分析,生存期<30 d者,预后因素为APACHE-Ⅱ评分(HR=1.104,95%CI:1.052~1.158)、CCI(HR=1.462,95%CI:1.204~1.775)、△PCT(HR=0.992,95%CI:0.989~0.995)与ICU住院时间(HR=0.893,95%CI:0.841~0.949);生存期30 d^89 d者,预后因素为APACHE-Ⅱ评分(HR=1.102,95%CI:1.026~1.183)与△PCT(HR=0.996,95%CI:0.994~0.998)。生存期90 d^365 d者,仅CCI(HR=1.689,95%CI:1.065~2.679)影响预后。结论 APACHE-Ⅱ评分、CCI与△PCT为影响严重脓毒症与脓毒性休克患者死亡率的独立预后因素。但对于不同生存期的死亡患者,其预后因素稍有不同,需进一步开展多中心大样本的前瞻性队列研究证实。

Objective To explore the prognostic factors for patients with severe sepsis and septic shock according to the survival periods. Methods Clinical data of 108 cases of severe sepsis and septic shock treated during Jan. 2013 and Dec. 2014 were retrospectively studied. The independent risk factors of death was analyzed with Cox porportional hazard models. Results The overall mortality was 53. 7%,and the mortality at days 0-29,30-89,and 90-365 was27. 8%,24. 4% and 15. 3%,respectively. Factors significantly associated with mortality included APACHE-Ⅱscore（ HR = 1. 105,95% CI： 1. 066-1. 146）,Charlson Comorbidities Index（ CCI）（ HR = 1. 390,95% CI： 1. 210-1. 596）and procalcitonin changes（ △PCT）（ HR = 0. 996,95% CI： 0. 995-0. 997）. Results of stratified analysis according to different survival periods indicated that,APACHE-Ⅱscore（ HR = 1. 104,95% CI： 1. 052-1. 158）,CCI（ HR = 1. 462,95% CI： 1. 204-1. 775）,△PCT（ HR = 0. 992,95% CI： 0. 989-0. 995）,and days of ICU-stay（ HR = 0. 893,95% CI：0. 841-0. 949） were the prognostic factors for patients who survived for less than 30 days; risk factors associated with mortality included APACHE-Ⅱscore（ HR = 1. 102,95% CI： 1. 026-1. 183） and △PCT（ HR = 0. 996,95% CI： 0. 994-0. 998） for patients who survived for 30 d-89 d; for patients survived for 90 d-365 d,CCI（ HR = 1. 689,95% CI：1. 065-2. 679） was the only prognostic factor. Conclusions APACHE-Ⅱscore,CCI and △PCT are the independentprognostic factors for patients with severe sepsis and septic shock,while there were slight differences among different survival periods. It is necessary to develop a multicenter large-scale prospective cohort study for further confirmation.