竖脊肌横截面积联合血清GDF-15对ICU机械通气患者获得性肌无力诊断及预后评估价值研究

Utility of cross-sectional area of erector spinae muscle combined with serum GDF-15 for the diagnosis and prognosis assessment of ICU-acquired weakness in mechanically ventilated patients

目的探讨ICU机械通气患者竖脊肌横截面积丢失量(ESMcsa Loss)与血清生长分化因子-15(GDF-15)的相关性,以及它们对ICU获得性肌无力(ICU-AW)的诊断价值和60 d生存状态的预测价值。方法选择2018年6月至2019年11月本院ICU收治的行有创机械通气治疗的急性呼吸衰竭患者,分别在第1天及第7天ELISA法测定血清GDF-15浓度,通过CT影像勾画并计算胸12水平左右竖脊肌总横截面积。采用英国医学研究委员会肌力评定法(MRC-score)进行肌力评分。根据患者入ICU第7天MRC-score评分将患者分为ICU-AW组和非ICU-AW组,比较并分析两组患者分别在入ICU第1天及第7天血清GDF-15、ESMcsa及MRC-score差异。分析患者第7天血清GDF-15、ESMcsa Loss、MRC-score相关性。采用受试者工作特征曲线(ROC)计算患者第7天血清GDF-15、ESMcsa Loss及竖脊肌横截面积丢失率(ESMcsa Loss Ratio)对机械通气患者ICU-AW诊断预测价值。绘制患者生存曲线图,评估GDF-15及ESMcsa Loss Ratio对患者60 d生存状态预测价值。结果最终入选92例患者,根据第7天MRC-score<48分,诊断ICU-AW组49例,非ICU-AW组43例。ICU-AW组机械通气时间,ICU住院时间及医院住院时间高于非ICU-AW组,其他基线指标差异均无统计学意义。治疗第1天,两组患者血清GDF-15、ESMcsa及MRC-score差异无统计学意义;ICUAW组第7天GDF-15浓度明显高于非ICU-AW组,ESMcsa、MRC-score显著低于非ICU-AW组[GDF-15(pg/mL):2529.53±625.67比1614.21±567.18;ESMcsa(cm2):23.76±6.85比29.15±6.51;MRC-score(分):41.10±3.35比51.23±2.84,均P<0.001]。ESMcsa Loss及ESMcsa Loss Ratio与第7天血清GDF-15水平呈显著正相关(r分别0.2355和0.3192),ESMcsa Loss及ESMcsa Loss Ratio与MRC-score评分呈显著负相关(r分别-0.3072和-0.3527)。ROC曲线分析显示,第7天血清GDF-15、ESMcsa Loss及ESMcsa Loss Ratio对机械通气患者ICU-AW均有预测价值[ROC曲线下面积(AUC)分别为0.904,0.835和0.889,均P<0.001]。绘制患者60 d生存曲线图显示,高GDF-15组生存率为60.0%,低GDF-15组生存率为77.8%高ESMcsa Loss Ratio组生存率为60.0%;低ESMcsa Loss Ratio组生存率为80.0%,差异均有统计学意义(P<0.05)。结论ICU机械通气患者住院7 d后的竖脊肌横截面积丢失与血清GDF-15浓度升高有显著相关性,均提示急性肌肉消耗及骨骼肌功能减退,对ICU获得性肌无力具有一定的诊断价值,并能够预测ICU机械通气患者60 d生存状态。

Objective To identify the clinical correlations between the cross-sectional area loss of the erector spinae muscle(ESMcsa Loss)and serum growth differentiation factor-15(GDF-15)in mechanically ventilatied patients in ICU.In addition,to investigate their diagnostic value for ICU-acquired weakness(ICU-AW)and their predictive value for 60-day survival in mechanically ventilated patients.Methods Ninety-two patients with acute respiratory failure,who required mechanical ventilation therapy,were randomly selected among hospitalized patients from June 2018 to November 2019.The serum GDF-15 level was detected by ELISA,the total cross-sectional area of the right and left erector spinae muscles was calculated by CT images,and the patient's muscle strength was assessed using the British Medical Research Council(MRC)muscle strength score on day 1 and day 7.The patients were divided into the ICU-AW group and the non-ICU-AW group according to the MRC-score on the 7th day of ICU admission.The correlations between plasma GDF-15 level,ESMcsa loss,and MRC score on day 7 were investigated.The receiver operating characteristic(ROC)curve was used to calculate the predictive value of serum GDF-15,ESMcsa loss,and ESMcsa loss ratio on day 7 of mechanically ventilated patients in the diagnosis of ICU acquired muscle weakness.Moreover,the predictive value of GDF-15 and ESMcsa loss ratio on the 90-day survival status of the patients was assessed using survival curves.Results Ninety-two patients were enrolled.According to whether the MRC-score on the 7th day was less than 48,49 cases were included in the ICU-AW group and 43 cases in the non-ICU-AW group.The mechanical ventilation time,length of ICU stay and length of hospital stay in the ICU-AW group were higher than those in the non-ICU-AW group,and there were no significant differences in other baseline indicators.There were no significant differences in serum GDF-15,ESMcsa and MRC-score between the two groups on day 1.The GDF-15 level in the ICU-AW group was significantly higher than that in the non-ICU-AW group while ESMcsa and MRC-score were significantly lower than those in the non-ICU-AW group on day 7[GDF-15(pg/mL):2529.53±625.67 vs.1614.21±567.18;ESMcsa(cm2):23.76±6.85 vs.29.15±6.5;MRC-1score:41.10±3.35 vs.51.23±2.84;all P<0.001].ESMcsa loss and ESMcsa loss ratio were significantly positively correlated with serum GDF-15 levels on day 7(r=0.2355 and 0.3192,respectively).ESMcsa loss and ESMcsa loss ratio were significantly negatively correlated with MRC-score(r=-0.3072 and-0.3527,respectively).The ROC curve analysis showed that plasma GDF-15 level,ESMcsa loss,and ESMcsa loss ratio on day 7 had predictive value for ICU-AW diagnosis in mechanically ventilated patients[Areas under the ROC curve(AUC)were 0.904,0.835,and 0.889,all P<0.001].The 60-day survival curve demonstrated that the survival rate was 60.0%in the high GDF-15 group,while was 77.8%in the low GDF-15 group;and was 60.0%in the high ESMcsa loss ratio group,while was 80.0%in the low ESMcsa loss ratio group(all P<0.05).Conclusions There was a significant correlation between the cross-sectional area loss of the erector spinae muscle and the increase of serum GDF-15 level after 7 days of mechanical ventilation in ICU,suggesting the acute muscle wasting and skeletal muscle hypofunction,which has certain diagnostic value for ICU-AW,and can predict the 60-day survival status of mechanically ventilated patients in ICU.