脓毒症患者ICU获得性衰弱的危险因素及其预测价值分析

Risk factors and their predictive value for intensive care unit acquired weakness in patients with sepsis

目的分析影响脓毒症患者发生重症监护病房获得性衰弱(ICUAW)的危险因素,并评估各危险因素对ICUAW的预测价值。方法采用病例对照的研究方法,选择2020年10月20日至2021年2月20日入住河南省人民医院重症监护病房(ICU)的60例脓毒症患者作为研究对象,以是否发生ICUAW将患者分为脓毒症ICUAW组和脓毒症非ICUAW组。收集患者的性别、年龄、体质量指数(BMI)、急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、合并症、是否机械通气、ICUAW患病时间、ICU住院时间、空腹血糖、血乳酸(Lac)、降钙素原(PCT)、C-反应蛋白(CRP)、序贯器官衰竭评分(SOFA)和转归,以及抗感染药物、糖皮质激素、镇静镇痛和血管活性药物种类等临床资料。通过单因素Logistic回归分析筛选危险因素,采用二元Logistic回归分析校正优势比(OR),P<0.05为独立危险因素;最后绘制受试者工作特征曲线(ROC曲线),分析各危险因素对ICUAW发生的预测价值。结果脓毒症ICUAW组APACHEⅡ评分明显高于脓毒症非ICUAW组(分:23.05±8.17比15.33±4.89,P<0.05),ICU总住院时间较脓毒症非ICUAW组明显延长(d:15.1±9.2比8.5±3.4,P<0.05),患者好转率较脓脓毒症非ICUAW组明显降低〔45.0%(9/20)比95.0%(38/40),P<0.05〕。经过单因素Logistic回归及多重共线性检验,可纳入二元Logistic回归模型的因素为APACHEⅡ、SOFA评分平均值、Lac平均值、机械通气比例、镇痛镇静药物、脓毒性休克、抗菌药物种类、血管活性药物种类7个因素〔OR分别为1.21、2.05、2.26、0.21、1.54、2.07、1.38,95%可信区间(95%CI)分别为1.09-1.35、1.42-2.94、1.12-4.57、0.05-0.66、1.03-2.29、1.27-3.37、0.96-2.00,均P<0.05〕。霍斯默-莱梅肖检验P=0.901,预测正确百分比为85%,说明模型拟合度良好。二元Logistic回归分析显示:APACHEⅡ和SOFA评分平均值是导致脓毒症患者ICUAW发生的独立危险因素(APACHEⅡ:OR=1.17,95%CI为1.004-1.376,P=0.044;SOFA评分平均值:OR=1.86,95%CI为1.157-2.981,P=0.01)。ROC曲线分析显示,APACHEⅡ评分和SOFA评分平均值及二者联合检测对脓毒症患者ICUAW的发生有一定预测价值,ROC曲线下面积(AUC)分别为0.787、0.881、0.905,95%CI分别为0.646-0.928、0.791-0.972、0.828-0.982,均P<0.05;当截断值为19.500分、6.225分、0.375时,其敏感度分别为75%、90%、90%,特异度分别为80%、80%、85%。结论APACHEⅡ评分和SOFA评分平均值是导致脓毒症ICUAW发生的独立危险因素,同时二者联合检测对脓毒症ICUAW发生的预测价值优于单独指标。

Objective To explore the risk factors of intensive care unit acquired weakness(ICUAW)in patients with sepsis,and to evaluate the predictive value of each risk factor for ICUAW.Methods A case control study was conducted,60 septic patients admitted to the intensive care unit(ICU)of Henan Provincial People's Hospital from October 20,2020 to February 20,2021 were enrolled.The patients were divided into two groups:sepsis ICUAW group and sepsis non-ICUAW group.The data of gender,age,body mass index(BMI),acute physiology and chronic health evaluationⅡ(APACHEⅡ)score,complications,mechanical ventilation,duration of ICUAW,length of stay in ICU,fasting blood glucose,blood lactic acid(Lac),procalcitonin(PCT),C-reactive protein(CRP),sequential organ failure assessment(SOFA)score,outcome,antimicrobial agent,glucocorticoid,sedatives and analgesics drugs and vasoactive drugs were collected.Risk factors were screened by univariate Logistic regression analysis,and odds ratio(OR)was adjusted by multivariate binary logistic regression,P<0.05 was considered as independent risk factors.Finally,the receiver operating characteristic curve(ROC curve)was drawn to analyze the predictive value of independent risk factors.Results The APACHEⅡscore of the sepsis ICUAW group was significantly higher than that of the sepsis non-ICUAW group(23.05±8.17 vs.15.33±4.89,P<0.05),the total length of stay in the ICU was significantly longer than that of the sepsis non-ICUAW group(days:15.1±9.2 vs.8.5±3.4,P<0.05),the improvement rate of patients was significantly lower than that of the sepsis non-ICUAW group[45.0%(9/20)vs.95.0%(38/40),P<0.05].After univariate Logistic regression and multicollinearity test analysis,7 factors including APACHEⅡscore,average SOFA score,blood lactic acid,proportion of mechanical ventilation,sedatives and analgesics drugs,type of antibiotics and type of vasoactive drugs were included in the binary Logistic regression model[OR:1.21,2.05,2.26,0.21,1.54,2.07,1.38,95%confidence interval(95%CI):1.09-1.35,1.42-2.94,1.12-4.57,0.05-0.66,1.03-2.29,1.27-3.37,0.96-2.00,all P<0.05].Hosmer-Lemchaw test P=0.901,and the correct percentage of prediction was 85%,indicating good model fit.Multivariate binary Logistic regression analysis showed that APACHEⅡscore and average SOFA score were independent risk factors for the occurrence of ICUAW in septic patients(APACHEⅡscore:OR=1.17,95%CI was 1.004-1.376,P=0.044;average SOFA score:OR=1.86,95%CI was 1.157-2.981,P=0.01).ROC curve analysis showed that the mean value of APACHEⅡscore,average SOFA score and their combined detection had a certain predictive value for the occurrence of ICUAW in sepsis patients,areas under ROC curve(AUC)were 0.787,0.881,0.905,95%CI was 0.646-0.928,0.791-0.972,0.828-0.982,all P<0.05.When the cut-off value was 19.500,6.225,0.375,the sensitivity was 75%,90%,90%,and the specificity were 80%,80%,85%,respectively.Conclusion APACHEⅡscore and average SOFA score can be used as independent risk factors for the occurrence of ICUAW in sepsis,and their combined predictive value is better than that of individual index.