不同序贯器官衰竭评分方式对重症监护病房感染患者预后评估的意义

Significance of different modes of sequential organ failure assessment scores for prognosis evaluation in patients with infection in intensive care unit

目的探讨不同序贯器官衰竭评分(SOFA)方式对重症监护病房(ICU)感染患者预后评估的意义.方法选择2018年1月1日至7月1日天津市第四中心医院综合ICU收住的330例感染患者作为研究对象,计算快速SOFA评分(qSOFA)、第1天SOFA、最大SOFA、最大SOFA和第1天SOFA的差值(ΔSOFA).按临床诊断将患者分为脓毒症组(56例)和非脓毒症组(274例).比较是否发生脓毒症两组患者qSOFA、第1天SOFA、最大SOFA、ΔSOFA的差异;采用Spearman相关分析法分析不同SOFA的相关性;绘制受试者工作特征曲线(ROC);评价不同SOFA对感染患者预后的预测价值;通过计算三分位数将第1天SOFA、最大SOFA、ΔSOFA分为3组(qSOFA仅能分为两组),比较不同亚组间病死率的差异.结果脓毒症组总住院费用、qSOFA、第1天SOFA、最大SOFA评分均明显高于非脓毒症组〔总住院费用(万元):11.53(5.47,13.72)比9.52(3.80,11.98),qSOFA(分):1.00(1.00,2.00)比1.00(0.00,1.25),第1天SOFA(分):6.50(5.00,9.75)比5.00(3.00,7.00),最大SOFA(分):8.00(6.00,13.75)比6.00(4.00,9.00),均P<0.05〕.相关性分析显示,qSOFA与第1天SOFA呈明显正相关(rs值分别为0.302、0.287,均P<0.05),第1天SOFA与最大SOFA亦呈明显正相关(rs=0.802,P<0.05),但ΔSOFA与qSOFA、第1天SOFA、最大SOFA均无明显相关性(均P>0.05).ROC曲线分析显示,第1天SOFA、最大SOFA、ΔSOFA对预测患者预后有中等价值〔ROC曲线下面积(AUC)分别为0.629,0.715,0.680,均P<0.05〕,qSOFA不能预测患者预后(AUC=0.505,P<0.05).第1天SOFA、最大SOFA及ΔSOFA随着分值的增加,病死率呈升高趋势〔第1天SOFA<4分、4~6分、>6分病死率分别为15.3%(19/124)、19.0%(20/105)、30.6%(31/101),最大SOFA<5分、5~8分、>8分的病死率分别为11.5%(14/121)、14.6%(16/109)、40.0%(40/100),ΔSOFA<0分、0~2分、>2分的病死率分别为12.5%(18/143)、21.9%(23/105)、35.3%(29/82),均P<0.05〕.结论qSOFA对于在非重症科室筛选脓毒症患者有很好的预测价值,但不能用于预测患者病死率;最大SOFA、第1天SOFA、ΔSOFA对患者结局有预测价值,应重视对ICU感染患者SOFA评分的动态评估.

Objective To explore the significance of different modes of sequential organ failure assessment(SOFA)scores on the prognosis evaluation of patients with infection in intensive care unit(ICU).Methods The 330 patients with infection admitted to the ICU of Tianjin Fourth Central Hospital from January 1 to July 1,2018 were selected as research objects,and the quick SOFA score(qSOFA),the first day SOFA score,maximum SOFA score,and difference between maximum SOFA and the first day SOFA(ΔSOFA)were calculated.According to the difference in clinical diagnosis,the patients were divided into a sepsis group(56 cases)and a non sepsis group(274 cases).The differences of qSOFA,first day SOFA,maximum SOFA and ΔSOFA between the two groups were compared;Spearman correlation analysis was used to analyze the correlation between different SOFA scores.Receiver operating characteristic curve(ROG)was drawn;the predictive values of different SOFA scores on the prognosis of infected patients were evaluated.The first day SOFA,maximum SOFA and ΔSOFA were divided into three subgroups(qSOFA can only be divided into two groups)by calculating the three quantiles,and the mortality of different subgroups was compared.Results The total hospitalization expenses,scores of qSOFA,first day SOFA and maximum SOFA in sepsis group were significantly higher than those in non sepsis group and the total expenditure in the hospital in sepsis group was higher than that in the non sepsis group[total hospitalization expenses(ten thousand Yuan):11.53(5.47,13.72)vs.9.52(3.80,11.98),qSOFA:1.00(1.00,2.00)vs.1.00(0.00,1.25),first day SOFA:6.50(5.00,9.75)vs.5.00(3.00,7.00),maximum SOFA:8.00(6.00,13.75)vs.6.00(4.00,9.00),all P<0.05].Correlation analysis showed that there was a significant positive correlation between qSOFA and first day SOFA(r8 value was 0.302,0.287,both P<0.05).There was a significant positive correlation between first day SOFA and maximum SOFA(rs=0.802,P<0.05).However,there were no significant correlations between ΔSOFA and qSOFA,first day SOFA and maximum SOFA(all P>0.05).The results of ROC curve analysis showed that the first day SOFA,maximum SOFA and ΔSOFA had medium value in predicting the prognosis of patients[areas under ROC curve(AUC)were 0.629,0.715,0.680,all P<0.05],qSOFA could not predict the prognosis of patients(AUC=0.505,P<0.05).With the increase of scores on the first day SOFA,elevation of maximum SOFA and ΔSOFA,the mortality had a trend of increasing[mortality of first day SOFA<4,4-6,>6 was 15.3%(19/124),19.0%(20/105)and 30.6%(31/101),mortality of maximum SOFA<5,5-8 and>8 was 11.5%(14/121),14.6%(16/109)and 40.0%(40/100),mortality of ΔSOFA<0,0-2 and>2 was 12.5%(18/143),21.9%(23/105)and 35.3%(29/82),respectively,allP<0.05].Conclusions The qSOFA score has a good predictive value for screening sepsis patients in non-critical care departments,but it cannot be used to predict patients'mortality.The maximum SOFA,first day SOFA and ΔSOFA have predictive values for the outcome of patients,and dynamic evaluation of SOFA scores in patients with sepsis should be emphasized.