严重创伤患者MODS预警评分的建立及临床意义：一项多中心研究

Establishment of multiple organ dysfunction syndrome early warning score in patients with severe trauma and its clinical significance： a multicenter study

目的 探讨严重创伤患者发生多器官功能障碍综合征（MODS）的危险因素,创建MODS预警评分系统,为临床医生及时准确判断患者病情及临床结局提供更准确的评分方法.方法 回顾性分析2015年1月1日至2016年12月31日遵义医学院附属医院和第三军医大学大坪医院重症医学科（ICU）收治的342例严重创伤患者的临床资料,依据患者临床结局分为MODS组（251例）和非MODS组（91例）.记录两组患者的性别、年龄,入院后心率（HR）、血压,入院24 h内血常规、血生化、病情严重程度、创伤严重程度、是否行急诊插管或手术,以及ICU住院期间是否发生脓毒症及急性呼吸窘迫综合征（ARDS）等临床资料,并进行单因素分析;将单因素分析中有统计学意义的指标纳入多因素Logistic回归分析,筛选出影响严重创伤患者发生MODS的危险因素并赋值,其总分即为MODS预警评分;绘制受试者工作特征曲线（ROC）,评估MODS预警评分对MODS发生的预测价值.结果 与非MODS组比较,MODS组患者HR较快,血Na＋、血肌酐（SCr）、活化部分凝血活酶时间（APTT）及创伤严重度评分（ISS）、新创伤严重度评分（NISS）、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）更高,血pH值、红细胞计数（RBC）、血小板计数（PLT）、白蛋白（Alb）及格拉斯哥昏迷评分（GCS）更低,多发伤、入院时存在休克和入院24 h内输血、中心静脉置管、急诊插管、发生感染的患者更多,住院期间发生脓毒症和ARDS的患者也更多.多因素Logistic回归分析结果显示,受伤部位≥2处、入院时休克、APACHEⅡ评分≥15分、SOFA评分≥4分、APTT〉40 s是严重创伤患者发生MODS的危险因素,组成MODS预警评分,总分为7.5分.ROC曲线分析显示：MODS预警评分预测严重创伤患者发生MODS的ROC曲线下面积（AUC）为0.822,显著高于APACHEⅡ评分（AUC=0.698,P〈0.001）、APTT（AUC=0.693,P〈0.001）和SOFA评分（AUC=0.770,P=0.025）;当MODS预警评分的截断值为2.5分时,其敏感度为61.35%,特异度为90.11%,约登指数为0.515.结论 MODS预警评分由受伤部位数、入院时休克、APACHEⅡ评分、SOFA评分、APTT这5个因素组成,可作为预测严重创伤患者发生MODS的评分系统,其预测效果优于单独应用APTT、APACHEⅡ或SOFA评分,有助于临床上更加快速准确评估创伤患者的MODS发生率及其预后.

 Objective To explore the risk factors of multiple organ dysfunction syndrome （MODS） in severe trauma patients, put forward a new warning scoring system of MODS, and to provide a more accurate scoring method for doctors to judge the clinical condition and prognosis of patients. Methods Clinical data of 342 patients with severe trauma admitted to intensive care unit （ICU） of the Affiliated Hospital of Zunyi Medical College and Daping Hospital of the Third Military Medical University from January 1st, 2015 to December 31st, 2016 were retrospectively analyzed. The patients were divided into MODS groups （n = 251） and non-MODS group （n = 91） according to clinical outcomes. The clinical data of patients, including gender, age, heart rate （HR） and blood pressure within 24 hours after admission to the hospital, indicators of blood routine and blood biochemistry, severity of disease, severity of trauma, whether received the emergency intubation or surgery within 24 hours or not, whether developed sepsis or acute respiratory distress syndrome （ARDS） during hospitalization, were recorded, and univariate analysis was conducted. The indicators with statistical significance found by univariate analysis were enrolled in multivariate Logistic regression analysis, and the risk factors for MODS in patients with severe trauma were screened and assigned, and the final total score was MODS warning score. Receiver operating characteristic （ROC） curve was plotted to evaluate MODS warning score for predicting the occurrence of MODS in patients with severe trauma. Results Compared with non-MODS group, HR, Na＋, serum creatinine （SCr）, activated partial thromboplastin time （APTT）, injury severity score （ISS）, new injury severity score （NISS）, acute physiology and chronic health evaluation Ⅱ （APACHEⅡ） score and sequential organ failure assessment （SOFA） score in MODS group were significantly increased, pH value, red blood cell （RBC）, platelet （PLT）, albumin （Alb） and Glasgow coma score （GCS） were remarkably decreased, and multiple injury, the patients with shock at admission, blood transfusion, central venous catheter, emergency intubation and infection were also increased, and more patients suffered from sepsis and ARDS. Multivariate Logistic regression analysis showed that the number of injured places equal or more than 2, shock at admission, APACHEⅡ score ≥ 15, SOFA score ≥ 4 and APTT 〉 40 s were risk factors for MODS in patients with severe trauma, with total MODS warning score of 7.5. ROC curve analysis showed that the area under ROC curve （AUC） of MODS warning score for predicting MODS in patients with severe trauma was 0.822, which was significantly higher than that of APACHEⅡ score （AUC = 0.698, P 〈 0.001）, APTT （AUC = 0.693, P 〈 0.001） and SOFA score （AUC = 0.770, P = 0.025）. When the cut-off value of MODS warning score was 2.5, the sensitivity was 61.35%, the specificity was 90.11%, and Youden index was 0.515. Conclusions MODS warning score is composed of five factors, including the number of injured places, shock at admission, APACHEⅡ score, SOFA score and APTT, which could be regarded as early warning score system for predicting MODS in patients with severe trauma. MODS warning score can be more comprehensive and timely to assess the possibility of MODS and prognosis of patients with severe trauma, and the prediction result is better than the single use of APTT, APACHEⅡ or SOFA score.