食管癌根治术后急性呼吸窘迫综合征(ARDS)的死亡危险因素分析

Risk factors of mortality in patients with acute respiratory distress syndrome(ARDS)after radical resection of esophageal carcinoma

目的分析食管癌根治术后急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)患者的死亡危险因素,以评估预后及降低死亡率。方法对复旦大学附属肿瘤医院重症监护室(intensive care unit,ICU)2014年1月至2019年6月连续收治的97例食管癌根治术后ARDS患者的临床资料进行回顾性分析,根据其90天生存情况将其分为存活组(n=76)和死亡组(n=21),采用单因素相关性分析、多因素Logistic回归对组间各临床资料的差异进行比较以探求独立的死亡危险因素,使用R软件构建列线图(nomogram)并进行bootstrap验证。结果97例患者的90天死亡率为21.65%。单因素分析显示存活组和死亡组在机械通气天数、是否行连续肾脏替代治疗、是否合并术后吻合口瘘及入ICU时的快速序贯器官衰竭评分(quick sequential organ failure assessment,qSOFA)、氧合指数、C反应蛋白、降钙素原、白蛋白、前白蛋白、视黄醇结合蛋白(retinol-binding protein,RBP)、转铁蛋白的差异有统计学意义。进一步行多因素Logistic后退法回归分析发现合并术后吻合口瘘和qSOFA评分是食管癌根治术后ARDS的死亡独立危险因素,RBP是独立保护因素。结论qSOFA评分越高、合并术后吻合口瘘、入ICU时的RBP水平越低,食管癌术后合并ARDS患者的死亡风险越高。由此,早期可以应用qSOFA评分预测食管癌术后ARDS患者的预后,增强术后营养支持、预防吻合口瘘的发生可能可以降低食管癌根治术后ARDS的死亡率。

Objective To analyze the risk factors of mortality in patients with acute respiratory distress syndrome(ARDS)after radical surgery of esophageal carcinoma,so as to evaluate its prognosis and lower the mortality.Methods We retrospectively included 97 patients treated in the intensive care unit(ICU)of Shanghai Cancer Center,Fudan University between Jan.2014 and Jun.2019,accepting mechanical ventilation support because of ARDS after radical resection of esophagus carcinoma.Clinical data were collected from the patients’electronic medical records.All the patients were divided into 2 groups,survivors(n=76)and non-survivors(n=21),according to their 90-day mortality.Univariate correlation analysis and multivariate Logistic regression analysis were used for the clinical data to identify the independent risk factors for mortality.And we used R software to construct a nomogram and verify bootstrap.Results The 90-day mortality of the 97 patients was 21.65%.Comparisons of the survivors and non-survivors group indicated significant statistical differences in mechanical ventilation days,continuous renal replacement therapy,postoperative anastomotic fistula,quick sequential organ failure assessment(qSOFA)score,as well as the value of oxygenation index,C-reactive protein,procalcitonin,albumin,prealbumin,retinol-binding protein(RBP)and transferrin.Multivariate logistic regression analysis suggested that postoperative anastomotic fistula and qSOFA score were independent risk factors of mortality in patients with ARDS after radical resection of esophageal carcinoma,while RBP played a role of protective independent factor,which was also demonstrated by nomogram.Conclusion The patients with ARDS after radical resection of esophageal carcinoma would have higher mortality if they had higher qSOFA score or lower RBP,or they complicated with anastomotic fistulas.As a result,the qSOFA score could predict the prognosis of patients with ARDS after radical resection of esophageal carcinoma.Strengthening postoperative nutritional support and preventing the incidence of anastomotic fistulas may help to reduce the mortality of such patients.