腹部术后合并脓毒症患者死亡风险因素联合预测的价值

Combined predictive value of risk factors for death in patients with sepsis after abdominal surgery

目的 探讨影响重症医学科(ICU)腹部术后合并脓毒症患者死亡的风险因素及预后的可靠评估指标并建立预测模型。方法 本研究为回顾性病例对照研究,分析2018年1月至2020年12月贵州医科大学附属医院重症医学科收治的腹部术后合并脓毒症患者的临床资料。收集患者的性别、年龄、体质指数、转入ICU时的心率、平均动脉压、入ICU第1个24 h的急性生理与慢性健康评分(APACHEⅡ评分)、序贯器官衰竭评分(SOFA评分)、血常规、生化、动脉血气分析、降钙素原、手术部位、手术时间、住ICU时间、机械通气时间、总住院时间等。上述因素分别做预后影响因素分析,采用条件向前法多因素logistic回归分析自动筛选出在预测模型拟合度与自变量个数之间达到最佳平衡时的自变量并建立预测模型。结果 256例腹部术后合并脓毒症患者符合纳入标准。其中男160例,女96例,平均年龄为64(19,93)岁,存活组199例,非存活组57例,病死率22.3%。多因素logistic回归结果发现,高APACHEⅡ评分(OR=1.088,95%CI:1.007~1.175,P=0.033),心动过速(OR=1.02,95%CI:1.005~1.035,P=0.007)及合并休克(OR=5.672,95%CI:2.204~15.898,P=0.001)是影响这类患者死亡的危险因素,而高血红蛋白(OR=0.984,95%CI:0.970~0.998,P=0.024)、高碳酸氢根(OR=0.85,95%CI:0.764~0.945,P=0.003)是其保护因素。通过联合变量预测的ROC曲线下面积最大为0.856,敏感度为82.5%,特异度为72.4%,预测价值优于上述5个单变量。结论 APACHEⅡ评分、心率、脓毒性休克、血红蛋白与碳酸氢根是影响腹部术后合并脓毒症患者死亡的关键因素;联合变量预测腹部术后合并脓毒症预后的准确性优于单个变量,诊断价值更高。

Objective To explore the risk factors and reliable evaluation indicators that affect the death of patients with sepsis after abdominal surgery,and to establish a predictive model in intensive care unit(ICU)Methods This is a retrospective case-control study,analyzing the clinical data of patients with sepsis after abdominal surgery admitted to the Department of Intensive Care Medicine,Affiliated Hospital of Guizhou Medical University from January 2018 to December 2020.The information of sex,age,body mass index,heart rate,and mean arterial pressure when transferred to the ICU,the Acute Physiology and Chronic Health Evaluation Ⅱ(APACHEⅡ)score and the Sequential Organ Failure Assessment(SOFA)score for the first 24 hours of entering the ICU,and data of blood routine,biochemistry,arterial blood gas analysis,procalcitonin,surgical site,operation time,ICU length of stay,mechanical ventilation time,and total length of stay were collected and analyzed for the correlation of prognostic factors.Conditional forward method and multivariate logistic regression analysis were adopted to automatically screen the independent variables when the best balance between the fitting degree of the prediction model and the number of independent variables was achieved then the predictive model was established.Results From January 2018 to December 2020,a total of 256 patients with sepsis after abdominal surgery met the inclusion criteria.Among them,there were 160 males and 96 females,with an average age of 64(19,93)years.There were 199 cases in the survival group and 57 cases in the non-survival group.The mortality was 22.3%.Univariate analysis showed that heart rate,lactic acid,creatinine,procalcitonin,APACHEⅡ score and SOFA score within 24 hours in the non survival group were significantly higher than those in the survival group,while hemoglobin,bicarbonate and platelet were lower.The mortality of patients with septic shock and hypertension were higher.Multivariate logistic regression found that high APACHEⅡ score(OR = 1.088;95%CI:1.007 ~ 1.175;P = 0.033),tachycardia(OR = 1.02;95%CI:1.005 ~ 1.035;P = 0.007)and combined shock(OR = 5.672;95%CI:2.204 ~ 1 5.898;P = 0.001)were risk factors for death in these patients,while high hemoglobin(OR =0.984;95%CI:0.970 ~ 0.998;P = 0.024),and high bicarbonate(OR = 0.85;95%CI:0.764 ~ 0.945;P = 0.003)were protective factors.The maximum area under curve predicted by joint variables was 85.6%;the sensitivity0.856,and the specificity 72.4%.The predictive value was better than that of above-mentioned five single variables.Conclusion APACHEⅡ score,heart rate,septic shock,hemoglobin and bicarbonate are the key factors affecting the death of patients with sepsis after abdominal surgery.The accuracy of combined variables in predicting the prognosis of abdominal postoperative sepsis is higher than that of single variables,and the diagnostic value is higher.