基于MIMIC-Ⅳ数据库评价6种重症评分对综合ICU和专科ICU患者28 d死亡风险的预测价值

Predictive value of six critical illness scores for 28-day death risk in comprehensive and specialized intensive care unit patients based on MIMIC-Ⅳdatabase

目的探讨各类重症监护病房(ICU)患者的基本特征及入ICU首日6种重症患者疾病严重程度常用评分对28 d死亡风险的预测价值。方法提取美国重症监护医学信息数据库Ⅳ 2.0(MIMIC-Ⅳ 2.0)中2008至2019年重症患者的一般资料、疾病严重程度评分〔急性生理学评分Ⅲ(APSⅢ)、牛津急性疾病严重程度评分(OASIS)、Logistic器官功能障碍评分(LODS)、简化急性生理学评分Ⅱ(SAPSⅡ)、全身炎症反应综合征(SIRS)评分、序贯器官衰竭评分(SOFA)〕及预后等指标。绘制各类ICU中6种重症评分预测患者28 d死亡风险的受试者工作特征曲线(ROC曲线), 并计算ROC曲线下面积(AUC), 使用最大约登指数定义最佳临界值, 采用Delong法对各类ICU的AUC进行两两验证。结果共纳入53 150例重症患者, 其中内科ICU(MICU)占比最多(19.25%, 10 233例), 其次为心血管外科ICU(CVICU;17.78%, 9 450例), 而神经ICU(NICU)占比最少(6.25%, 3 320例)。心血管内科ICU(CCU)患者年龄最大〔岁:71.79(60.27, 82.33)〕。NICU患者ICU住院时间最长〔d:2.84(1.51, 5.49)〕, 且占总住院时间比例最高〔63.51%(34.61%, 97.07%)〕;综合ICU患者ICU住院时间最短〔d:1.75(0.99, 3.05)〕;CVICU患者ICU住院时间占总住院时间比例最低〔27.69%(18.68%, 45.18%)〕。在入ICU首日评分方面, NICU患者6种评分均低于其他类型ICU, MICU患者APSⅢ、LODS、OASIS、SOFA评分均高于其他ICU;而SAPⅡ、SIRS评分均在CVICU最高。预后方面, 以MICU患者28 d病死率最高(14.14%, 1 447/10 233), 而CVICU患者病死率最低(2.88%, 272/9 450)。ROC曲线分析6种评分对各类ICU患者28 d死亡风险的预测价值显示, 在综合ICU, 以APSⅢ、LODS、SAPSⅡ预测价值较大〔AUC及95%可信区间(95%CI)分别为0.84(0.83~0.85)、0.82(0.81~0.84)、0.83(0.82~0.84)〕;在外科ICU(SICU), 以OASIS、LODS、SAPSⅡ预测价值较大〔AUC及95%CI分别为0.80(0.79~0.82)、0.79(0.78~0.81)、0.79(0.77~0.80)〕;在MICU, 以APSⅢ、SAPSⅡ预测价值较大〔AUC及95%CI分别为0.84(0.82~0.85)、0.82(0.81~0.83)〕;在CCU, 以APSⅢ、SAPSⅡ预测价值较大〔AUC及95%CI分别为0.86(0.85~0.88)、0.85(0.83~0.86)〕;在创伤ICU(TICU), 以LODS、SAPSⅡ预测价值较大〔AUC及95%CI分别为0.83(0.82~0.83)、0.83(0.82~0.84)〕;在NICU, 以OASIS、SAPSⅡ预测价值较大〔AUC及95%CI分别为0.83(0.80~0.85)、0.81(0.78~0.83)〕;在CVICU则以APSⅢ、LODS、SAPSⅡ预测价值较大〔AUC及95%CI分别为0.84(0.83~0.85)、0.81(0.80~0.82)、0.78(0.77~0.78)〕。结论对于综合ICU、MICU、CCU、CVICU患者, 可应用APSⅢ或SAPSⅡ评分预测28 d死亡风险;对于SICU和NICU患者, 可应用OASIS或SAPSⅡ评分预测28 d死亡风险;对于TICU患者, 可应用SAPSⅡ或LODS评分预测28 d死亡风险;对于CVICU患者, 则可应用APSⅢ或LODS评分预测28 d死亡风险。

Objective To explore the basic characteristics of various types of intensive care unit(ICU)patients and the predictive value of six common disease severity scores in critically ill patients on the first day on the 28-day death risk.Methods The general information,disease severity scores[acute physiology scoreⅢ(APSⅢ),Oxford acute disease severity(OASIS)score,Logistic organ dysfunction score(LODS),simplified acute physiology scoreⅡ(SAPSⅡ),systemic inflammatory response syndrome(SIRS)score and sequential organ failure assessment(SOFA)score],prognosis and other indicators of critically ill patients admitted from 2008 to 2019 were extracted from Medical Information Mart for Intensive Care-Ⅳ2.0(MIMIC-Ⅳ2.0).The receiver operator characteristic curve(ROC curve)of six critical illness scores for 28-day death risk of patients in various ICU,and the area under the ROC curve(AUC)was calculated,the optimal Youden index was used to determine the cut-off value,and the AUC of various ICU was verified by Delong method.Results A total of 53150 critically ill patients were enrolled,with medical ICU(MICU)accounted for the most(19.25%,n=10233),followed by cardiac vascular ICU(CVICU)with 17.78%(n=9450),and neurological ICU(NICU)accounted for the least(6.25%,n=3320).The patients in coronary care unit(CCU)were the oldest[years old:71.79(60.27,82.33)].The length of ICU stay in NICU was the longest[days:2.84(1.51,5.49)]and accounted for the highest proportion of total length of hospital stay[63.51%(34.61%,97.07%)].The patients in comprehensive ICU had the shortest length of ICU stay[days:1.75(0.99,3.05)].The patients in CVICU had the lowest proportion of length of ICU stay to total length of hospital stay[27.69%(18.68%,45.18%)].The six scores within the first day of ICU admission in NICU patients were lower than those in the other ICU,while APSⅢ,LODS,OASIS,and SOFA scores in MICU patients were higher than those in the other ICU.SAPⅡand SIRS scores were both the highest in CVICU,respectively.In terms of prognosis,MICU patients had the highest 28-day mortality(14.14%,1447/10233),while CVICU patients had the lowest(2.88%,272/9450).ROC curve analysis of the predictive value of each score on the 28-day death risk of various ICU patients showed that,the predictive value of APSⅢ,LODS,and SAPSⅡin comprehensive ICU were higher[AUC and 95%confidence interval(95%CI)were 0.84(0.83-0.85),0.82(0.81-0.84),and 0.83(0.82-0.84),respectively].The predictive value of OASIS,LODS,and SAPSⅡin surgical ICU(SICU)were higher[AUC and 95%CI were 0.80(0.79-0.82),0.79(0.78-0.81),and 0.79(0.77-0.80),respectively].The predictive value of APSⅢand SAPSⅡin MICU were higher[AUC and 95%CI were 0.84(0.82-0.85)and 0.82(0.81-0.83),respectively].The predictive value of APSⅢand SAPSⅡin CCU were higher[AUC and 95%CI were 0.86(0.85-0.88)and 0.85(0.83-0.86),respectively].The predictive value of LODS and SAPSⅡin trauma ICU(TICU)were higher[AUC and 95%CI were 0.83(0.82-0.83)and 0.83(0.82-0.84),respectively].The predictive value of OASIS and SAPSⅡin NICU were higher[AUC and 95%CI were 0.83(0.80-0.85)and 0.81(0.78-0.83),respectively].The predictive value of APSⅢ,LODS,and SAPSⅡin CVICU were higher[AUC and 95%CI were 0.84(0.83-0.85),0.81(0.80-0.82),and 0.78(0.77-0.78),respectively].Conclusions For the patients in comprehensive ICU,MICU,CCU,and CVICU,APSⅢor SAPSⅡcan be applied for predicting 28-day death risk.For the patients in SICU and NICU,OASIS or SAPSⅡcan be applied to predict 28-day death risk.For the patients in TICU,SAPSⅡor LODS can be applied for predicting 28-day death risk.For CVICU patients,APSⅢor LODS can be applied to predict 28-day death risk.