游离钙和氧合指数联合快速序贯器官衰竭评分在识别成人脓毒症中的诊断效能

The diagnostic efficacy of ionized calcium,oxygenation index combined with quick sequential organ failure assessment score in identifying adult sepsis

目的研究游离钙(iCa)和氧合指数(PaO_(2)/FiO_(2))联合快速脓毒症相关序贯器官衰竭评分(qSOFA)在识别成人脓毒症患者中的诊断效能。方法回顾性分析2019年10月至2021年3月就诊于东部战区总医院抢救室的147例脓毒症患者及158例主要诊断为非脓毒症的感染性疾病患者,收集患者临床资料(包括iCa、PaO_(2)/FiO_(2)、qSOFA等指标),通过倾向性评分匹配(PSM)校正患者年龄、性别、感染部位等混杂因素,得到脓毒症组(n=93)和非脓毒症组(n=93)患者,比较PSM前后两组间的临床资料,将匹配后数据集(n=186)作为训练集,采用Logistic回归分析感染性疾病患者发生脓毒症的独立危险因素,通过受试者工作特征曲线下面积(AUC)进行诊断效能分析,比较新发低钙血症、PaO_(2)/FiO_(2)、qSOFA及三者联合模型在识别成人脓毒症患者中的诊断效能,将原数据集(n=305)作为验证集代入联合模型进行验证,并比较联合模型与脓毒症相关序贯器官衰竭评分(SOFA)间的差异和一致性。结果PSM前后脓毒症患者iCa、PaO_(2)/FiO_(2)均低于非脓毒症组(PSM前:Z=-5.138,Z=-7.743;PSM后:Z=-3.505,Z=-4.817,P<0.001),qSOFA分值高于非脓毒症组(PSM前:Z=-7.089;PSM后:Z=-4.149,P<0.001),iCa与降钙素原(PCT)、C-反应蛋白(CRP)、白细胞介素-6(IL-6)、SOFA及急性生理与慢性健康状况评分系统Ⅱ(APACHEⅡ)呈负相关(r=-0.338、-0.243、-0.271、-0.281、-0.269,P<0.05),联合模型在训练集(n=186)中识别成人脓毒症患者的AUC为0.777,95%CI为0.711~0.835,敏感度为74.19%,特异度为73.12%,阳性似然比为2.76,阴性似然比为0.35,在验证集(n=305)中识别成人脓毒症患者的AUC为0.836,95%CI为0.790~0.876,敏感度为77.55%,特异度为77.85%,阳性似然比为3.50,阴性似然比为0.29,联合模型在训练集及验证集中的AUC大于新发低钙血症、PaO_(2)/FiO_(2)及qSOFA分值(P<0.001),与SOFA进行McNemar检验提示P=0.904、一致性检验Kappa值为0.554(P<0.001)。结论新发低钙血症、PaO_(2)/FiO_(2)、qSOFA分值与感染性疾病患者发生脓毒症有回归关系,其中新发低钙血症是独立危险因素,与iCa、PaO_(2)/FiO_(2)及qSOFA单独使用相比,三者联合模型在识别成人脓毒症中的诊断效能更高。

Objective To study the diagnostic efficacy of ionized calcium(iCa),oxygenation index(PaO_(2)/FiO_(2))combined with quick sequential organ failure assessment(qSOFA)score in identifying adult sepsis.Methods A total of 147 patients with sepsis and 158 patients diagnosed as non-sepsis infectious diseases admitted to our emergency department,General Hospital of Eastern Theater Command from October 2019 to March 2021 were retrospectively analyzed.The clinical data(including iCa,PaO_(2)/FiO_(2),qSOFA score and other indicators)were collected.The confounding factors such as age,gender and infection site were corrected by propensity score matching(PSM)to obtain the sepsis group(n=93)and non-sepsis group(n=93).The differences between the two groups were compared before and after PSM.The matched data set(n=186)was used as the training set.Logistic regression was used to analyze the independent risk factors of septic patients.The diagnostic efficacy was analyzed by the area under receiver operating characteristic curve(AUC).The diagnostic efficacy of new-onset hypocalcemia,PaO_(2)/FiO_(2),qSOFA score and the combination of the three models in identifying adult septic patients was compared.The original data set(n=305)was used as the validation set and substituted into the combined model for validation.The difference and consistency between the combined model and SOFA score were also compared.Results Before and after PSM,iCa and PaO_(2)/FiO_(2)in sepsis patients were lower than those in non-sepsis group(Z=-5.138,Z=-7.743;Z=-3.505,Z=-4.817,P<0.001),qSOFA score was higher than that in non-sepsis group(Z=-7.089;Z=-4.149,P<0.001),iCa was negatively correlated with procalcitonin(PCT),C-reactive protein(CRP),interleukin-6(IL-6),SOFA score and Acute Physiology and Chronic Health Evaluation scoreⅡ(APACHEⅡ)(r=-0.338,-0.243,-0.271,-0.281,-0.269,P<0.05),AUC of combined model in identifying adult sepsis patients in training set(n=186)was 0.777(95%CI 0.711-0.835),the sensitivity was 74.19%,the specificity was 73.12%,positive likelihood ratio was 2.76,and negative likelihood ratio was 0.35.AUC of identifying adult sepsis patients in validation set(n=305)was 0.836(95%CI 0.790-0.876),the sensitivity was 77.55%,the specificity was 77.85%,positive likelihood ratio was 3.50,the negative likelihood ratio was 0.29,and the AUC of the combined model in the training set and validation set was larger than that of new-onset hypocalcemia,PaO_(2)/FiO_(2),and qSOFA score(P<0.001),McNemar test with SOFA score suggested P=0.904,and the consistency test Kappa was 0.554(P<0.001).Conclusions New-onset hypocalcemia,PaO_(2)/FiO_(2)and qSOFA score have regression relationship with sepsis,and new-onset hypocalcemia is an independent risk factor for sepsis.Compared with iCa,PaO_(2)/FiO_(2)and qSOFA score,the combined model has better diagnostic efficacy in identifying adult sepsis.