早期集束化干预策略对急诊隐匿性/显性脓毒性休克患者临床预后的影响

Effect of early intervention bundle on clinical prognosis of patients with latent/overt septic shock in emergency department

目的观察早期集束化干预策略对急诊隐匿性/显性脓毒性休克患者临床预后的影响,分析影响病死率的危险因素。方法回顾性分析2018年1月至2019年12月在复旦大学附属华山医院北院急诊科进修期间收治的隐匿性脓毒性休克患者(隐匿性休克组)和显性脓毒性休克患者(显性休克组)的临床资料。比较两组患者性别、年龄、主要感染部位、休克诊断时间、早期(3 h)集束化干预指标完成情况、6 h集束化治疗目标达标情况、病情稳定时间和28 d预后。运用Logistic回归分析筛选影响病死率的独立危险因素,并用受试者工作特征曲线(ROC)分析其对预后的预测价值。结果总计181例患者纳入本研究。隐匿性休克组102例,28 d病死率为15.69%(16例);显性休克组79例,28 d病死率为31.65%(25例)。与隐匿性休克组比较,显性休克组患者早期集束化干预策略完成率(93.67%比58.82%)、入院时血乳酸〔Lac(mmol/L):7.09±2.08比5.69±1.27〕、使用抗菌药物前血培养完成率(93.67%比63.73%)、第1小时和第2小时使用抗菌药物比例(45.57%比31.37%,54.43%比33.33%)、第1小时开始快速液体复苏比例(晶体液:59.49%比11.76%,晶体液联合人血白蛋白:40.51%比0%)和血管活性药物使用比例(100%比9.80%)显著增高,病情稳定时间明显延长(d:4.40±1.35比1.49±0.55),而疾病发作时间(d:1.47±0.97比2.95±1.61)、休克诊断时间(min:31.30±12.54比79.15±13.81)、6 h乳酸清除率〔(50.27±21.53)%比(61.82±13.12)%〕、第3小时抗菌药物使用比例(0%比35.29%)、第2小时和第3小时开始快速液体复苏比例(第2小时晶体液:0%比60.78%,第2小时晶体液联合人血白蛋白:0%比14.71%,第3小时晶体液:0%比12.75%)、6 h中心静脉血氧饱和度(ScvO2)达标率(60.76%比78.43%)和救治成功率(28 d病死率:31.65%比15.69%)显著下降(均P<0.05)。10例隐匿性休克患者在入院24 h内进展为显性休克,所有显性休克患者均需要使用血管活性药物维持平均动脉压(MAP)≥65 mmHg(1 mmHg=0.133 kPa)。与存活患者比较,死亡患者入院时Lac(mmol/L:7.59±2.27比5.92±1.24)和血管活性药物使用比例(65.85%比44.29%)显著增高,而6 h乳酸清除率〔(46.58±15.83)%比(59.60±17.92)%〕﹑第3小时抗菌药物使用比例(4.88%比24.29%)、6 h尿量和ScvO2达标率(56.10%比82.86%,43.90%比78.57%)显著下降(均P<0.05)。二元Logistic回归分析显示,入院时Lac、6 h乳酸清除率、第3小时使用抗菌药物、第1小时开始快速液体复苏和6 h ScvO2达标率为影响患者预后的独立危险因素〔优势比(OR)分别为1.618、0.021、0.100、0.307和3.018,均P<0.05〕。ROC曲线分析显示,入院时Lac对患者28 d预后的预测价值最高,ROC曲线下面积(AUC)为0.706;其次为6 h ScvO2达标率(AUC为0.673)。结论对于急诊隐匿性/显性脓毒性休克患者应尽早识别并给予集束化干预策略,提高6 h乳酸清除率和6 h ScvO2达标率,进而降低病死率。

Objective To observe the effect of early intervention bundle on clinical prognosis of patients with latent/overt septic shock in emergency department and analyze the risk factors for mortality.Methods Patients with latent and overt septic shock admitted to the North Hospital of Huashan Hospital Affiliated to Fudan University from January 2018 to December 2019 were retrospectively analyzed and divided into latent shock group and overt shock group.The gender,age,main infection site,the time of shock diagnosis,the indicators of early(3-hour)intervention bundle,6-hour compliance rate of intervention bundle,the remission time and 28-day prognosis were observed.Logistic regression analysis was used to identify risk factors for 28-day mortality.Receiver operating characteristic(ROC)curve was used to analyze its prognostic value.Results Totally 181 patients were included in the analysis.There were 102 cases in the latent shock group,and 28-day mortality was 15.69%(16 cases);79 cases in the overt shock group,and 28-day mortality was 31.65%(25 cases).Compared with the latent shock group,patients in overt shock group had higher compliance rate of early intervention bundle(93.67%vs.58.82%),higher blood lactate acid at admission[Lac(mmol/L):7.09±2.08 vs.5.69±1.27],higher compliance rate of blood culture before antibiotics(93.67%vs.63.73%),higher proportion of antibiotics use at the first and second hours(45.57%vs.31.37%,54.43%vs.33.33%),higher proportion of rapid fluid resuscitation at the first hour(crystal liquid:59.49%vs.11.76%,crystal fluid combined with human serum albumin:40.51%vs.0%),and higher proportion of vasoactive use at the first hour(100%vs.9.80%).The stable time was significantly prolonged(days:4.40±1.35 vs.1.49±0.55),while the onset time(days:1.47±0.97 vs.2.95±1.61),the time of diagnosis(minutes:31.30±12.54 vs.79.15±13.81),6-hour lactate clearance[(50.27±21.53)%vs.(61.82±13.12)%],the proportion of antibiotics use at the third hour(0%vs.35.29%),the proportion of rapid fluid resuscitation at the second and third hour(second hour crystal liquid:0%vs.60.78%,second hour crystal fluid combined with human serum albumin:0%vs.14.71%,third hour crystal liquid:0%vs.12.75%),6-hour compliance rate of the standard of central venous blood saturation(ScvO2,60.76%vs.78.43%)and the success rate of treatment(28-day mortality:31.65%vs.15.69%)were lower than those of the latent shock group(all P<0.05).Ten patients with latent shock developed into overt shock within 24 hours after admission.All patients with overt shock needed vasoactive drugs to maintain mean arterial pressure(MAP)≥65 mmHg(1 mmHg=0.133 kPa).Compared with the survival patients,the Lac(mmol/L:7.59±2.27 vs.5.92±1.24)and the proportion of vasoactive drugs use(65.85%vs.44.29%)were significantly increased in the death patients,while the 6-hour lactate clearance[(46.58±15.83)%vs.(59.60±17.92)%],the proportion of antibiotics use in the third hour(4.88%vs.24.29%),and 6-hour compliance rate of urine volume and ScvO2(56.10%vs.82.86%,43.90%vs.78.57%)were significantly decreased(all P<0.05).Binary Logistic regression analysis showed that Lac at admission,6-hour lactate clearance,the use of antibiotics at the third hour,rapid fluid resuscitation at the first hour,and 6-hour compliance rate of ScvO2 were independent risk factors for 28-day mortality[odds ratio(OR)was 1.618,0.021,0.100,0.307 and 3.018,all P<0.05].ROC curve analysis showed that the Lac at admission had the highest predictive value for 28-day mortality,the area under the ROC curve(AUC)was 0.706;followed by 6-hour compliance rate of ScvO2(AUC was 0.673).Conclusion Patients with latent/overt septic shock need early diagnosis and intervention bundle to improve the 6-hour blood lactate clearance and 6-hour compliance rate of ScvO2 and reduce the mortality.