超声心动图心室功能指标与脓毒症患者预后关系的研究

Study on the relationship between ventricular function parameters obtained by echocardiography and prognosis of patients with sepsis

目的观察脓毒性心肌病的流行病学特征, 探讨超声心动图测定的相关指标与脓毒症患者预后的关系。方法采用病例对照研究方法, 收集2018年6月至2021年6月扬州大学附属江苏省苏北人民医院重症医学科和国家电网公司北京电力医院重症医学科收治的脓毒症患者的临床资料。记录患者一般情况和28 d预后;同时记录患者入重症监护病房(ICU)24 h内行经胸超声心动图检查获得的超声相关参数。比较28 d死亡组与存活组患者超声指标的差异, 并将有统计学意义的指标纳入Logistic回归分析, 筛选脓毒症患者预后的独立危险因素;通过受试者工作特征曲线(ROC曲线)评估超声指标对脓毒症患者预后的预测价值。结果共纳入符合标准的脓毒症患者145例, 其中脓毒性休克患者106例。145例患者中, 脓毒性心肌病73例, 发生率为50.3%;其中, 左室舒张功能障碍性心肌病发生率41.4%(60例), 左室收缩功能障碍性心肌病发生率24.8%(36例), 右室收缩功能障碍性心肌病发生率12.4%(18例)。28 d存活98例, 死亡47例, 病死率32.4%。与存活组相比, 死亡组超声指标二尖瓣侧壁瓣环处舒张早期峰值速度(e’’)和右室收缩期三尖瓣环运动速度(RV-Sm)均明显降低〔e’’(cm/s):7.81±1.12比8.61±1.02, RV-Sm(cm/s):12.12±2.04比13.73±1.74, 均P<0.05〕;死亡组左室射血分数(LVEF)和左室收缩期二尖瓣环运动速度(LV-Sm)略高于存活组〔LVEF:0.550±0.042比0.548±0.060, LV-Sm(cm/s):8.92±2.11比8.23±1.71〕, 差异无统计学意义(均P>0.05)。将两组间差异有统计学意义的指标纳入Logistic回归分析, 结果显示, e’’和RV-Sm均为影响脓毒症患者28 d预后的独立危险因素〔e’’:优势比(OR)=0.623, 95%可信区间(95%CI)为0.410~0.947, P=0.027;RV-Sm:OR=0.693, 95%CI为0.525~0.914, P=0.010〕。ROC曲线分析显示, e’’预测脓毒症患者28 d预后的ROC曲线下面积(AUC)为0.657, 95%CI为0.532~0.781, P=0.016;最佳截断值为8.65 cm/s时, 敏感度为62.1%, 特异度为73.4%。RV-Sm预测脓毒症患者28 d预后的AUC为0.641, 95%CI为0.522~0.759, P=0.030;最佳截断值为14.80 cm/s时, 敏感度为96.6%, 特异度为26.6%。结论脓毒性心肌病的发生率高;早期超声心动图测量的LVEF与脓毒症患者28 d预后无关, 而RV-Sm和e’’均对脓毒症患者28 d预后具有重要的预测价值。

Objective To investigate the epidemiological characteristics of septic cardiomyopathy and explore the relationship between the relevant indexes measured by echocardiography and the prognosis of patients with sepsis.Methods A case-control study was conducted.The data of patients with sepsis admitted to the department of critical care medicine of Jiangsu Subei People's Hospital Affiliated to Yangzhou University and the department of critical care medicine of Beijing Electric Power Hospital of State Grid Corporation of China from June 2018 to June 2021 were enrolled.The general information and 28-day prognosis were recorded.At the same time,ultrasonic parameters obtained by transthoracic echocardiography within 24 hours after intensive care unit(ICU)admission were recorded.The differences in ultrasound indexes between the death group and the survival group on 28 days were compared.Parameters with significant statistical differences between the death group and the survival group were included in the Logistic regression analysis to find the independent risk factors for the prognosis of patients with sepsis,the predictive value of each index for the prognosis of patients with sepsis was evaluated by receiver operator characteristic curve(ROC curve).Results A total of 145 patients with sepsis were enrolled,including 106 patients with septic shock.Among the 145 patients,septic cardiomyopathy was found in 73 patients,with the incidence of 50.3%.The incidence of left ventricular diastolic dysfunction cardiomyopathy was 41.4%(n=60),the incidence of left ventricular systolic dysfunction cardiomyopathy was 24.8%(n=36),and the incidence of right ventricular systolic dysfunction cardiomyopathy was 12.4%(n=18).At 28 days,98 patients survived and 47 died,with the mortality of 32.4%.The peak e'velocity by tissue Doppler imaging(e')and right ventricular myocardial systolic tricuspid annulus velocity(RV-Sm)of the death group were significantly lower than those of the survival group[e'(cm/s):7.81±1.12 vs.8.61±1.02,RV-Sm(cm/s):12.12±2.04 vs.13.73±1.74,both P<0.05],left ventricular ejection fraction(LVEF)and left ventricular systolic mitral annulus velocity(LV-Sm)in the death group were slightly higher than those in the survival group[LVEF:0.550±0.042 vs.0.548±0.060,LV-Sm(cm/s):8.92±2.11 vs.8.23±1.71],without significant differences(both P>0.05).Parameters with significant statistical differences between the two groups were included in the Logistic regression analysis and showed that e'and RV-Sm were independent risk factors for the 28-day prognosis of patients with sepsis[e':odds ratio(OR)=0.623,95%confidence interval(95%CI)was 0.410-0.947,P=0.027;RV-Sm:OR=0.693,95%CI was 0.525-0.914,P=0.010].ROC curve analysis showed that the area under the ROC curve(AUC)of e'for predicting the 28-day prognosis of patients with sepsis was 0.657,95%CI was 0.532-0.781,P=0.016,the best cut-off value was 8.65 cm/s,the sensitivity was 62.1%,and the specificity was 73.4%.The AUC of RV-Sm for predicting the 28-day prognosis of patients with sepsis was 0.641,95%CI was 0.522-0.759,P=0.030,the best cut-off value was 14.80 cm/s,the sensitivity was 96.6%,and the specificity was 26.6%.Conclusions The incidence of septic cardiomyopathy is high.The LVEF measured by early echocardiography has no predictive value for 28-day prognosis in septic patients,while RV-Sm and e'are important predictors for 28-day prognosis.