非肺源性脓毒症和肺部感染致急性呼吸窘迫综合征患者凝血指标差异及与预后的相关性

The correlation between coagulation function and prognosis in patients with acute respiratory distress syndrome caused by extrapulmonary sepsis or pulmonary infection

目的:探究非肺源性脓毒症和肺部感染致急性呼吸窘迫综合征(ARDS)患者凝血指标差异,以及各凝血指标与预后的相关性。方法:回顾性分析2017年7月1日至2019年6月30日中国医科大学附属第一医院重症医学科收治的非肺源性脓毒症和肺部感染致ARDS患者的临床资料,包括序贯器官衰竭评分(SOFA)、凝血酶原时间(PT)、国际标准化比值(INR)、活化部分凝血活酶时间(APTT)、纤维蛋白原(Fib)、D-二聚体、纤维蛋白(原)降解产物(FDP)、抗凝血酶Ⅲ(AT-Ⅲ)、血小板计数、28 d病死率等。比较非肺源性脓毒症致ARDS者和肺部感染致ARDS者凝血功能、28 d病死率,应用有序多分类logistic回归分析对凝血指标与患者预后进行相关性分析。结果:最终纳入ARDS患者240例,其中非肺源性脓毒症致ARDS者145例,肺部感染致ARDS者95例。非肺源性脓毒症致ARDS者PT[16.90(15.40,19.45)s比15.80(14.70,18.00)s,P=0.003]、INR[1.38(1.22,1.68)比1.28(1.17,1.48),P=0.005]、APTT[48.90(42.35,56.95)s比43.50(37.50,55.00)s,P=0.012]明显高于肺部感染致ARDS者,AT-Ⅲ[56.00(42.00,72.00)%比75.00(53.50,91.00)%,P<0.001]低于肺部感染致ARDS者。非肺源性脓毒症致ARDS患者中28 d存活者93例,死亡者52例,病死率为35.9%,28 d死亡者的PT、INR、APTT显著高于生存者,AT-Ⅲ低于生存者;肺部感染致ARDS患者中28 d存活者49例,死亡者46例,病死率为48.4%,存活者与死亡者的PT、INR、APTT、Fib、D-二聚体、FDP和AT-Ⅲ差异无统计学意义(P>0.05)。多因素logistic回归分析显示,不包含PLT的SOFA(OR=1.210,95%CI 1.067~1.372,P=0.003)、INR(OR=2.408,95%CI 1.007~5.760,P=0.048)是非肺源性脓毒症致ARDS患者28 d死亡的独立危险因素。凝血指标并非预测肺部感染致ARDS患者28 d死亡的独立危险因素。结论:非肺源性脓毒症和肺部感染致ARDS患者凝血功能存在显著差异,INR是非肺源性脓毒症致ARDS患者28 d死亡的独立危险因素。

Objective To explore the difference of coagulation function and its correlation with prognosis in patients with acute respiratory distress syndrome(ARDS]caused by extrapulmonary sepsis and pulmonary infection.Methods ARDS patients caused by extrapulmonary sepsis and pulmonary infection admitted to the ICU were retrospectively analyzed at the First Affiliated Hospital of China Medical University from July 2017 to June 2019.The clinical characteristics were collected including sequential organ failure assessment(SOFA],coagulation parameters[prothrombin time(PT),international normalized ratio(INR),activated partial thromboplastin time[APTT],fibrinogen(Fib),D.Dimer(D-D),fibrinogen degradation product(FDP],antithrombin Ⅲ(AT-Ⅲ),platelet(PLT],duration of mechanical ventilation,length of stay(LOS)in ICU and 28-day mortality.According to the risk factors,the patients were divided into extrapulmonary sepsis group and pulmonary infection group.The correlation analysis between coagulation parameters and the prognosis of ARDS patients were analyzed by multivariate logistic regression analysis.Results A total of 268 ARDS patients were screened and 28 cases were excluded.Finally,240 ARDS patients were enrolled,including 145 caused by extrapulmonary sepsis and 95 by pulmonary infection.PT,INR and APTT in the extrapulmonary sepsis group were significantly higher than those in pulmonary infection group(P<0.05).AT-I level was lower than that in pulmonary infection group(P<0.05).Ninty-three patients survived at 28 days in the non-pulmonary sepsis group,the mortality rate was 35.9%(52/145).PT,INR,APTT in patients who died at 28 days were significantly higher than those of the patients who survived(P<0.05),while AT-I level was lower than those of the patients who survived([P<0.05).49 patients survived at 28 days in the pulmonary infection group,the mortality rate was 48.4%(46/95).There was no significant difference in the coagulation parameters between two groups.Multivariate logistic regression analysis showed that SOFA score without PLT(OR=1.210,95%CI 1.067-1.372,P=0.003)and INR([OR=2.408,95%CI 1.007-5.760,P=0.048)were independent risk factors for 28-day mortality in extrapulmonary sepsis group.Coagulation parameters are not independent risk factors for 28-day mortality in ARDS patients related to pulmonary infection.Conclusion There are significant differences in coagulation function between ARDS patients caused by extrapulmonary sepsis or pulmonary infection.INR is an independent risk factor for 28-day mortality in extrapulmonary sepsis group.