急性生理与慢性健康Ⅱ评分联合血清降钙素原、D-二聚体、乳酸清除率预测重症脓毒症患者预后不良

Acute physiological and chronic health score combined with serumprocalcitonin,D-dimerand lactate clearance rate for the prediction of poor prognosis in severe sepsis

目的探讨急性生理与慢性健康Ⅱ(APACHEⅡ)评分联合血清降钙素原(PCT)、D-二聚体(D-D)、乳酸清除率(LCR)预测重症脓毒症患者预后不良的价值。方法回顾性分析2018年5月至2020年3月四川省绵阳市川北医学院附属医院三台医院收治的92例重症脓毒症患者临床资料为观察组,另选取同期于本院体检的80例健康志愿者作为对照组。比较两组研究对象APACHEⅡ评分、血清PCT、D-D水平和6 h的LCR水平。观察组患者随访28 d,根据其预后分为预后良好组(患者痊愈或病情好转)与预后不良组(患者病情无好转、加重、甚至死亡),比较此两组患者APACHEⅡ评分、血清PCT、D-D和LCR水平。采用Cox回归分析APACHEⅡ评分、血清PCT、D-D表达水平、LCR与观察组患者预后不良的关系;采用Pearson相关分析法分析血清PCT、D-D和LCR与APACHEⅡ评分的相关性,并应用受试者工作特征曲线(ROC)评价APACHEⅡ评分联合血清PCT、D-D、LCR对重症脓毒症患者预后不良的预测价值,应用Medcalc软件行曲线下面积(AUC)的两两比较。结果观察组患者APACHEⅡ评分[(18.78±1.03)分vs.(3.38±0.57)分]、血清PCT[(7.01±1.35)μg/L vs.(0.24±0.04)μg/L]、D-D水平[(1.73±0.09)mg/L vs.(0.26±0.05)mg/L]均显著高于对照组(t=118.814、44.820、129.689,P均<0.001),而LCR显著低于对照组[(40.62±6.92)%vs.(65.92±7.80)%](t=22.541、P<0.001),差异均有统计学意义。观察组患者预后不良发生率为52.17%(48/92);预后不良患者的APACHEⅡ评分[24.99(21.26,27.15)分vs.18.14(15.59,19.26)分]、血清PCT[15.59(8.20,17.99)μg/L vs.7.84(7.00,9.14)μg/L]、D-D水平[5.38(4.03,5.77)mg/L vs.1.76(1.66,1.90)mg/L]均高于预后良好患者(U=11.019、17.751、54.995,P均<0.001),而LCR显著低于预后良好患者[29.70(26.58,38.49)%vs.40.70(36.07,45.08)%](U=9.750、P<0.001),差异均有统计学意义。APACHEⅡ评分与血清PCT(r=0.804、P<0.001)和D-D(r=0.743、P<0.001)均呈正相关,与LCR呈负相关(r=-0.758、P=0.007)。尿素氮、血肌酐、APACHEⅡ评分、PCT、D-D为重症脓毒症预后不良的独立危险因素(HR=1.044、1.027、1.256、1.036、1.024、0.609,P=0.005、0.002、0.026、0.003、0.004),血钙浓度、LCR为重症脓毒症预后不良的独立保护因素(HR=0.430、0.609,P均<0.001);APACHEⅡ评分、血清PCT、D-D、LCR联合预测重症脓毒症预后不良组的灵敏度、AUC均高于APACHEⅡ评分、血清PCT、D-D、LCR单独预测(灵敏度:χ^(2)=15.036、17.778、13.714、16.390,P均<0.001;AUC:Z=2.909、4.640、4.242、3.983,P均<0.001),但联合检测的特异度与以上指标单独预测差异均无统计学意义(χ^(2)=1.908、0.155、0.000、0.715,P=0.167、0.694、1.000、0.938)。结论重症脓毒症患者APACHEⅡ评分、血清PCT、D-D均偏高,LCR偏低,且与预后不良相关,上述指标联合可预测重症脓毒症患者预后不良。

Objective To investigate the predictive value of acute physiological and chronic healthⅡ(APACHEⅡ)score combined with serum procalcitonin(PCT),D-dimer(D-D)and lactate clearance rate(LCR)for poor prognosis in patients with severe sepsis.Methods The clinical data of 92 patients with severe sepsis treated in Santai Hospital,Affiliated Hospital of North Sichuan Medical College,Mianyang City,Sichuan Province from May 2018 to March 2020 were analyzed,retrospectively,and were recorded as observation group,while 80 healthy volunteers in hospital were selected as control group.APACHEⅡscore,levels of serum PCT,D-D and 6 h LCR were compared between the two groups.Patients in observation group were followed up for 28 days,and were divided into good prognosis group(recovered or improved)and poor prognosis group(without improvement,aggravation or even death)according to the prognosis;APACHEⅡscore,levels of serum PCT,D-D and LCR were compared between the two groups.The correlation between APACHEⅡscore,levels of serum PCT,D-D,LCR and poor prognosis were analyzed by Cox regression analysis.The correlation between serum PCT,D-D and LCR and APACHEⅡscore were analyzed by Pearson correlation analysis method.The predictive value of APACHEⅡscore combined with serum PCT,D-D and LCR for poor prognosis in patients with severe sepsis were evaluated by receiver operating characteristic curve(ROC),and area under curve(AUC)were compared by Medcalc software.Results APACHEⅡscore[(18.78±1.03)vs.(3.38±0.57)],levels of serum PCT[(7.01±1.35)μg/L vs.(0.24±0.04)μg/L)],D-D[(1.73±0.09)mg/L vs.(0.26±0.05)mg/L)]of patients in observation group were significantly higher than those of control group(t=118.814,44.820,129.689;all P<0.001),while serum LCR level of observation group was significantly lower than that of control group[(40.62±6.92)%vs.(65.92±7.80)%](t=22.541,P<0.001),with significant difference.The incidence rate of poor prognosis was 52.17%(48/92).APACHEⅡscore[24.99(21.26,27.15)vs.18.14(15.59,19.26)],levels of serum PCT[15.59(8.20,17.99)μg/L vs.7.84(7.00,9.14)μg/L],D-D[5.38(4.03,5.77)mg/L vs.1.76(1.66,1.90)mg/L]of patients with poor prognosis were significantly higher than those with good prognosis(U=11.019,17.751,54.995;all P<0.001),while LCR level was lower than that of patients with good prognosis[29.70(26.58,38.49)%vs.40.70(36.07,45.08)%](U=9.750,P<0.001),with significant difference.APACHEⅡscore was positively correlated with serum PCT(r=0.804,P<0.001)and D-D(r=0.743,P<0.001),while negatively correlated with serum LCR(r=-0.758,P=0.007).Urea nitrogen,creatinine,APACHEⅡscore,PCT,D-D were all independent risk factors for poor prognosis of severe sepsis(HR=1.044,1.027,1.256,1.036,1.024,0.60;P=0.005,0.002,0.026,0.003,0.004).Serum calcium concentration and LCR were independent protective factors for poor prognosis of severe sepsis(HR=0.430,0.609;P<0.001).The sensitivity and area under curve(AUC)of APACHEⅡscore combined with serum PCT,D-D and LCR in predicting the poor prognosis of severe sepsis were significantly higher than those of single index(sensitivity:χ^(2)=15.036,17.778,13.714,16.390,all P<0.001;AUC:Z=2.909,4.640,4.242,3.983;all P<0.001),but the specificity were without significant differences between four indexes combined and single index(χ^(2)=1.908,0.155,0.000,0.715;P=0.167,0.694,1.000,0.938).Conclusions APACHEⅡscore,levels of serum PCT,D-D are higher,and the level of serum LCR is lower in patients with severe sepsis,which are related to poor prognosis,and combination of those indexes could predict the poor prognosis of patients with severe sepsis.