心源性休克患者院内死亡危险因素分析

Analysis of risk factors of nosocomial death in patients with cardiogenic shock

目的探讨影响重症监护室心源性休克(cardiogenic shock,CS)患者死亡的危险因素。方法采用回顾性队列研究,收集eICU合作研究数据库v2.0(The eICU Collaborative Research Database V2.0,eICU-CRD v2.0)截止2018年5月发布的来自美国多家医院组成的重症患者临床数据。选择诊断为CS的患者,根据院内死亡情况分为生存组与死亡组,收集入选患者年龄、性别、体质量质量指数(body mass index,BMI),急性生理学与慢性健康状况评分Ⅳ(acute physiology and chronic health status scoreⅣ,APACH-Ⅳ)、首次简化急性生理学评分Ⅱ(simplified acute physiology scoreⅡ,SAPS-Ⅱ)、种族、重症监护室(intensive care unit,ICU)类型、临床合并症、入院诊断、血流动力学参数、重要治疗、临床结局等。对两组年龄、性别、BMI,APACH-Ⅳ、SAPS-Ⅱ进行倾向性匹配,对匹配结果采用多因素Logistic回归分析死亡的危险因素。受试者特征工作(receiver operator characteristic,ROC)曲线评估其临床效用。结果最终纳入33998例患者,其中院内生存组27596例,死亡6402例(占18,83%),倾向性匹配6301对;匹配后两组在急性肾衰竭发生率(29.33%vs.31.82%)、机械通气时间[(6.05±5.77)d vs.(4.97±5.11)d]、ICU时间[(101.35±154.59)h vs.(110.15±175.58)h]、总住院时间[(12.73±10.53)d vs.(9.53±10.35)d]上差异具有统计学意义(P<0.01);多变量Logistic回归分析显示:年龄、BMI、APACH-Ⅳ、SAPS-Ⅱ、部分合并症(除外起搏器植入术后)、入院诊断(心搏骤停、急性心梗、心力衰竭、呼吸系统疾病及消化道出血)及部分治疗措施[无创机械通气、血液净化、冠状动脉旁路移植(coronary artery bypass grafting,CABG)手术、血管活性药物应用]是CS患者院内死亡的危险因素(P<0.05);心脏辅助装置(ventricular assist device,VAD)植入是CS患者院内死亡的保护性治疗措施(HR[95%CI]:0.49[0.24~0.98],P=0.045);多变量ROC曲线分析结果显示:模型可较好的预测ICU病死率[AUC=0.80(95%CI:0.784~0.816),P<0.01]及在院病死率[AUC=0.779(95%CI:0.765-0.793),P<0.01]。结论在ICU的CS患者中,年龄、BMI、APACH-Ⅳ、SAPS-Ⅱ、部分合并症(除外起搏器植入术后)、入院诊断(心搏骤停、急性心梗、心力衰竭、呼吸系统疾病及消化道出血)及部分治疗措施(无创机械通气、血液净化、CABG手术、血管活性药物应用)是CS患者院内死亡的独立危险因素,VAD植入可能改善CS患者院内病死率。相关因素的ROC曲线显示模式可以较好的预测临床结局。

Objective To investigate the risk factors of death in patients with cardiogenic shock(CS)in the Intensive Care Unit(ICU).Methods This retrospective cohort study was conducted to collect the clinical data on critically ill patients from a number of hospitals in the United States released by the eICU Collaborative Research Database v2.0(eICU-CRD v2.0)as of May 2018.The patients diagnosed with CS were selected and categorized into the survival and death groups according to the death in the hospital.The age,sex,and body mass index(BMI)of the enrolled patients were recorded,along with the acute physiology and chronic health evaluationⅣ(APACHEⅣ)score,simplified acute physiology scoreⅡ(SAPSⅡ),ethnicity,ICU type,clinical complications,diagnosis at admission,hemodynamic parameters,important treatments,and clinical outcomes.A propensity score was used to match age,BMI,and APACHEⅣscore,and SAPSⅡ.Multivariate Logistic regression analysis was performed to analyze the risk factors influencing ICU and hospital mortality,and the receiver operator characteristic(ROC)curve was used to evaluate its clinical utility.Results In total,33998 in-hospital patients were included,among whom 27596 patients survived and 6402 died(18.83%),and 6301 pairs were matched in preference.After matching,there were statistically significant differences between the two groups in the incidence of acute renal failure(29.33%vs.31.82%),duration of mechanical ventilation[(6.05±5.77)d vs(4.97±5.11)d],length of ICU stay[(101.35±154.59)h vs(110.15±175.58)h]and length of hospital stay[(12.73±10.53)d vs(9.53±10.35)d,P<0.01].Multivariable logistic regression analysis revealed that age,BMI,APACHEⅣscore,SAPSⅡ,partial complications(except pacemaker implantation),diagnosis at admission(cardiac arrest,acute myocardial infarction,heart failure,respiratory system diseases,and digestive tract bleeding),and some treatments(noninvasive mechanical ventilation,blood purification,coronary artery bypass graft surgery,and vascular active drug application)were risk factors for hospital mortality in patients with CS(P<0.05).Implantation of a ventricular assist device(VAD)was a protective measure against in-hospital death in patients with CS[hazard ratio(HR)=0.49;95%confidence interval(95%CI):0.24-0.98;P=0.045).Multivariate ROC curve analysis revealed that the model could better predict ICU mortality[the area under the curve(AUC)=0.80(95%CI:0.784-0.816)]and hospital mortality[AUC=0.779(95%CI,0.765-0.793)](P<0.01).Conclusions For patients with CS in ICU,age,BMI,APACHEⅣscore,SAPSⅡ,partial complications,diagnosis at admission(cardiac arrest,acute myocardial infarction,heart failure,respiratory system diseases and digestive tract bleeding),and some treatments(noninvasive mechanical ventilation,blood purification,CABG surgery,vascular active drug application)are independent risk factors for death.Implantation of a VAD can reduce the hospital mortality rate of patients with CS.The ROC curve of the related factors revealed that the model can better predict the clinical outcomes.