CVP动态变化结合E/A对早期脓毒症患者预后评估的价值

A Study on the prognosis of patients with early sepsis by valuing dynamic changes of CVP and E/A

目的评价中心静脉压动态变化(ΔCVP)结合脉冲多普勒法记录的二尖瓣扩张早期的血流速度与心房收缩期峰值血流速度的比值(E/A)对脓毒症患者病情及预后的评估价值。方法回顾性分析2013年1月至2016年6月濮阳市人民医院ICU收治的资料完整的脓毒症患者的临床资料,按28d预后分为生存组及死亡组。所有患者均于入ICU时计算同期的急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分和序贯器官衰竭(SOFA)评分;观察两组患者ΔCVP与E/A变化,记录入科时,6、24h后相关的E/A、CVP值,计算6、24h后的动态变化的绝对值,对相关节点的记录值绘制受试者工作特征(ROC)曲线评价各指标对预后的价值。结果共入选233例脓毒症患者,28d存活122例,生存率为52.4%;死亡111例,病死率为47.6%。死亡组除入ICU时血乳酸、APACHEⅡ、SOFA评分均明显高于存活组,ICU住院时间明显短于存活组(P<0.05)外,其他临床特征比较差异均无统计学意义(P>0.05)。死亡组与存活组入ICU 0、6hE/A值,分别为0.54±0.17、0.69±0.24;0.57±0.28、0.85±0.25(P<0.05),ROC曲线下面积分别为0.792、0.818。6h后的CVP变化值Δh1与24h后的CVP变化值Δh2分别为5.67±4.16、7.82±4.81;6.58±3.89、8.82±2.40(P<0.05),ROC曲线下面积分别为0.778、0.705。其中6h时,E/A的截断值取0.75时ROC曲线下面积为0.818为单指标最高,预测灵敏度、特异度分别为74.16%、95.45%;其入ICU 6hE/A与ΔCVP的ROC曲线下面积最大为0.844,其截断点取0.471时,预后评价的灵敏度为88.32%,特异度为90.71%。结论早期的E/A可作为脓毒症的预后评价指标,结合早期ΔCVP能早期评估脓毒症患者的病情,并可预测患者的预后。

Objective To investigate the clinical values of Dynamic changes of evaluation of central venous pressure(ΔCVP)combining with the pulse Doppler records of early mitral dilatation of blood flow velocity and peak atrial systolic blood flow velocity ratio(E/A)in the diagnosis and prognosis assessment of septic patients.Methods The study totally enrolled patients who were admitted to Intensive Care Unit of the Central Hospital of Puyang during January 2013 to June 2016.By the standard of 28 days,all the cases were divided into the survival group and the dead group.All patients admitted in the intensive treatment unit(ICU)in the same period were recorded of the acute physiology and chronic health evaluation systemⅡ(APACHEⅡ)score and sequential organ failure score(SOFA).Observe the dynamic changes of the two groups of patients on central venous pressure(ΔCVP)and E/A changes record into the family,after 6 hours and 24 of the related E/A value on each node,at the same time record the related CVP values,calculated the absolute value of the dynamic change of each node in the comparison after 6 h and 24 hours,the records of the node values mapped the receiver-operating characteristic curve(ROC)to evaluate the value of each index for prognosis.Results A total of 233 cases of sepsis patients enrolled,28 d survival of 122 cases,survival rate was 52.4%;111 cases died,mortality was 47.6%.The ICU blood lactate,APACHEⅡ,SOFA score of the dead group was significantly higher than the survival group,and their stay in ICU was significantly shorter than the survival group(P<0.05),other clinical features of the difference was not statistically significant(P>0.05).The E/A value differences between the dead group and survival group into the ICU 0h and 6h were 0.54±0.17,0.69±0.24;0.57±0.28,0.85±0.25(P<0.05),the ROC curve analysis is 0.792,0.818,and there are different CVP change valueΔh2 CVP change valueΔh1,24 hours and after 6 hours of the patient,namely:5.67±4.16,7.82±4.81;6.58±3.89,8.82±2.40(P<0.05)the area under the ROC curve it was,0.778,0.705,wherein when the 6h,the cutoff value E/A 0.75 area taken under the ROC curve(AUC)was 0.818 for the highest single index,the sensitivity and specificity were forecast 74.16%,95.45%,which the ICU 6 when E/A area under the ROC curve of dynamic changes in the value of aΔCVP with CVP(AUC)of up to 0.844;0.471 to take their cut-off point,the sensitivity of the prognosis was 88.32%,specificity degree of 90.71%,better predictive strength than the other indicators,as well as sensitivity and specificity.Conclusion Early E/A can be used as prognostic evaluation of sepsis as new and important indicator,combining with dynamic changes of the early CVP as an early assessment of the clinical condition of patients with sepsis,and can be prediction of the prognosis of patients,as well as reference for the therapeutic intervention on high-risk patients.