红细胞比容动态变化对脓毒性休克早期液体复苏和死亡风险的评估价值

The value of dynamic changes in hematocrit for early fluid resuscitation and risk of death in septic shock

目的探讨脓毒性休克患者红细胞比容、早期液体治疗和临床结局之间的关系,为脓毒性休克患者液体复苏治疗及预后评估提供依据。方法收集2018年01月01日至2020年12月31日期间于温州医科大学附属第一医院急诊重症监护室(emergency intensive care unit,EICU)诊治的脓毒症休克患者的临床信息。以入院后28 d患者存活或死亡作为临床研究终点,分为存活组及死亡组。分析两组患者的基本资料后,采用单因素COX回归分析方法及多因素COX回归分析方法分析Δ红细胞比容(hematocrit,HCT)_(d2-d1)、ΔHCT_(d3-d1)对脓毒性休克患者预后情况的评估价值,同时采用Kaplan-Meier(KM)生存曲线分析其对脓毒性休克患者总体生存率的评估价值以及用平滑曲线拟合图来验证其与净液体入量及死亡的关系。结果存活组241例,死亡组67例,单因素COX分析显示急性生理与慢性健康评分Ⅱ(acute physiology and chronic health evaluationⅡ,APACHEⅡ)(P=0.0006)、红细胞分布宽度(red cell volume distribution width,RDW)(P=0.0043)、Age(P=0.0184)、ΔHCT_(d2-d1)(P=0.0136)、ΔHCT_(d3-d1)(P=0.0204)、白细胞计数(white blood cell,WBC)(P=0.0444)在死亡组与存活组之间的差异有统计学意义。多因素COX分析显示ΔHCT_(d2-d1)(P=0.0115)、ΔHCT_(d3-d1)(P=0.0029)是EICU脓毒性休克患者发生死亡的独立危险因素。将ΔHCT_(d2-d1)和ΔHCT_(d3-d1)按三位法分为高中低3组,通过KM生存曲线显示,ΔHCT_(d2-d1)三组之间总体生存率差异无统计学意义(P=0.16),ΔHCT_(d3-d1)三组之间总体生存率差异有统计学意义(P=0.025)。ΔHCT_(d3-d1)与净液体入量及预后平滑拟合曲线显示ΔHCT_(d3-d1)与净液体入量呈负相关,其中中ΔHCT_(d3-d1)组预后最好。结论ΔHCT_(d3-d1)值与脓毒性休克患者的净液体入量有关,第3天HCT适当下降可以改善脓毒性休克患者的预后。红细胞比容动态变化可以为脓毒性休克患者的液体复苏及预后评估提供一定的依据。

Objective To explore the relationship between hematocrit,early fluid therapy,and clinical outcomes in patients with septic shock,and to provide evidence for fluid resuscitation therapy and prognosis assessment in these patients.Methods The clinical information of patients with septic shock who were diagnosed and treated in the Emergency Intensive Care Unit(EICU)of the First Affi liated Hospital of Wenzhou Medical University from January 1,2018 to December 31,2020 were collected.Taking the survival or death of patients 28 days after admission as the end point of clinical research,the patients were divided into the survival and death groups.After analyzing the basic data of the two groups,the univariate and multivariate COX regression analyses were used to analyze the evaluation value ofΔHematocrit(HCT)_(d2-d1)andΔHCT_(d3-d1)on the prognosis of patients with septic shock.At the same time,the Kaplan-Meier survival curve was used to analyze the overall survival rate of patients with septic shock,and the smooth curve fitting graph was used to verify its relationship with net fluid intake and death.Results There were 241 cases in the survival group and 67 cases in the death group.Univariate COX analysis showed statistically significant differences between the survival and death groups in acute physiology and chronic health evaluationⅡ(APACHEⅡ)(P=0.0006),red cell volume distribution width(RDW)(P=0.0043),age(P=0.0184),ΔHCT_(d2-d1)(P=0.0136),ΔHCT_(d3-d1)(P=0.0204),and white blood cell(WBC)(P=0.0444).Multivariate COX analysis showed thatΔHCT_(d2-d1)(P=0.0115)andΔHCT_(d3-d1)(P=0.0029)were independent risk factors for death in EICU patients with septic shock.ΔHCT_(d2-d1)andΔHCT_(d3-d1)were divided into three groups according to the three-digit method.The KaplanMeier survival curve showed no signifi cant difference among the three groups in the overall survival rate related toΔHCT_(d2-d1)(P=0.16),but there was a statistically signifi cant difference in the overall survival rate among the three groups related toΔHCT_(d3-d1)(P=0.025).The smooth fi tting curve ofΔHCT_(d3-d1),net fl uid intake,and prognosis showed thatΔHCT_(d3-d1)was negatively correlated with net fl uid intake,and the middleΔHCT_(d3-d1)group had the best prognosis.Conclusions The value ofΔHCT_(d3-d1)is related to the net fl uid intake of patients with septic shock.An appropriate decrease in HCT on the third day can improve the prognosis of patients with septic shock.The dynamic changes of hematocrit can provide a certain basis for fl uid resuscitation and prognosis evaluation in patients with septic shock.