联合检测中性粒细胞与白蛋白比值和乳酸对脓毒性休克患者早期预后的评估价值

Prognostic value of combined detection of neutrophil to albumin ratio and lactic acid on patients with septic shock

目的探讨中性粒细胞与白蛋白比值(NAR)和乳酸对脓毒性休克患者28 d死亡的预测价值。方法回顾性分析2017年10月至2019年10月南京市第一医院ICU收治的118例脓毒性休克患者的临床资料,记录所有患者的年龄、性别、体质量指数(BMI)、急性病生理学和长期健康评价(APACHE)Ⅱ评分、序贯器官衰竭估计(SOFA)评分、C反应蛋白质(CRP)、降钙素原、NAR、白细胞计数、红细胞分布宽度(RDW)、乳酸、住ICU时间、机械通气时间、行连续肾脏替代疗法(CRRT)、肺部感染、腹腔感染、泌尿系感染、血行感染和28 d死亡情况。将上述因素纳入单因素Logistic回归分析,初步筛选出相关的影响因素,再纳入多因素Logistic回归分析,得到影响脓毒性休克患者28 d死亡的独立危险因素;采用受试者工作特征(ROC)曲线分析NAR、乳酸及两者联合对脓毒性休克患者28 d死亡的预测价值,并用Z检验比较曲线下面积(AUC)。结果经单因素Logistic回归分析,初步筛选出影响脓毒性休克患者28 d死亡的9个因素,包括男性[比值比(OR)=0.345,95%置信区间(CI)(0.603,3.357),P=0.004]、SOFA评分[OR=1.183,95%CI(1.036,1.350),P=0.013]、NAR [OR=2.849,95%CI (1.487,5.457),P=0.002]、乳酸[OR=1.275,95%CI (1.108,1.467),P=0.001]、机械通气时间[OR=0.254,95%CI (1.025,1.223),P <0.001]、行CRRT [OR=4.585,95%CI(1.737,12.100),P=0.002]、存在肺部感染[OR=0.282,95%CI(0.898,4.732),P <0.001]、存在腹腔感染[OR=0.460,95%CI(0.392,1.989),P=0.002]、存在泌尿系感染[OR=0.464,95%CI(0.201,2.195),P <0.001]。将上述影响因素纳入多因素Logistic回归分析,结果显示,NAR [OR=4.424,95%CI(1.427,13.717),P=0.010]、乳酸[OR=1.267,95%CI(1.008,1.594),P=0.043]、机械通气时间[OR=1.168,95%CI(1.007,1.356),P=0.041]、行CRRT [OR=5.148,95%CI(1.069,24.794),P=0.041]是脓毒性休克患者28 d死亡的独立危险因素。ROC曲线分析结果显示,NAR [AUC=0.676,95%CI(0.572,0.780),P=0.001]、乳酸[AUC=0.696,95%CI(0.592,0.800),P <0.001]及NAR和乳酸联合[AUC=0.759,95%CI(0.699,0.850),P <0.001]均对脓毒性休克患者28 d死亡具有预测价值,且NAR和乳酸联合的AUC显著高于NAR(Z=2.110,P=0.035)及乳酸(Z=1.991,P=0.047)。结论 NAR和乳酸对脓毒性休克患者28 d死亡有一定的预测价值,且两者联合能够提高预测价值。

Objective To evaluate the prognostic value of neutrophil to albumin ratio(NAR)and lactic acid on 28-day mortality of patients with septic shock.Methods Clinical data of 118 patients with septic shock admitted to the ICU of Nanjing First Hospital from October 2017 to October 2019 were retrospectively analyzed.The age,sex,body mass index(BMI),acute physiology and chronic health evaluation(APACHE)Ⅱscore,sequential organ failure assessment(SOFA)score,C-reactive protein(CRP),procalcitonin,NAR,leukocyte count,red blood cell distribution width(RDW),lactic acid,ICU stay,mechanical ventilation time,continuous renal replacement therapy(CRRT),pulmonary infection,abdominal infection,urinary tract infection,blood transfusion infection,and 28-day death were recorded in all patients.Then they were included in the univariate Logistic regression analysis,and relative influencing factors were preliminarily screened and included in the multivariate Logistic regression analysis to obtain independent risk factors affecting 28-day mortality in patients with septic shock.The receiver operating characteristic(ROC)curve was used to analyze the predictive value of NAR,lactic acid and their combination on 28-day mortality,and the areas under the curves(AUCs)were compared with the Z-test.Results Univariate Logistic regression analysis showed that male[odds ratio(OR)=0.345,95%confidence interval(CI)(0.603,3.357),P=0.004],SOFA score[OR=1.183,95%CI(1.036,1.350),P=0.013],NAR[OR=2.849,95%CI(1.487,5.457),P=0.002],lactic acid[OR=1.275,95%CI(1.108,1.467),P=0.001],mechanical ventilation time[OR=0.254,95%CI(1.025,1.223),P<0.001],CRRT[OR=4.585,95%CI(1.737,12.100),P=0.002],pulmonary infection[OR=0.282,95%CI(0.898,4.732),P<0.001],abdominal infection[OR=0.460,95%CI(0.392,1.989),P=0.002]and urinary tract infection[OR=0.464,95%CI(0.201,2.195),P<0.001]were associated with 28-day mortality of patients with septic shock.When these factors were taken into account in the multiple Logistic regression analysis,the results showed that NAR[OR=4.424,95%CI(1.427,13.717),P=0.010],lactic acid[OR=1.267,95%CI(1.008,1.594),P=0.043],mechanical ventilation time[OR=1.168,95%CI(1.007,1.356),P=0.041]and CRRT[OR=5.148,95%CI(1.069,24.794),P=0.041]were independent risk factors for 28-day death.ROC curve analysis showed that NAR[AUC=0.676,95%CI(0.572,0.780),P=0.001],lactic acid[AUC=0.696,95%CI(0.592,0.800),P<0.001]and their combination[AUC=0.759,95%CI(0.699,0.850),P<0.001]had predictive values for 28-day death of patients with septic shock.In addition,the AUC of NAR and lactic acid combination was significantly higher than that of NAR(Z=2.110,P=0.035)and lactic acid(Z=1.991,P=0.047).Conclusion NAR and lactic acid are predictive for 28-day mortality of patients with septic shock,and their combination can improve the predictive value.