脓毒性休克3 h和6 h集束化治疗完成率对患者预后的影响

Impact of completion rates of 3-hour and 6-hour bundle on the prognosis of septic shock patients

目的探讨地市级三甲医院脓毒性休克患者3 h和6 h集束化治疗完成率对患者预后的影响,并筛查影响患者预后的危险因素。方法采用回顾性分析研究方法,选择2020年1月1日至2021年12月31日在山东省聊城市人民医院重症医学科重症监护病房(ICU)住院治疗的脓毒性休克患者为研究对象,收集患者的性别、年龄、急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、序贯器官衰竭评分(SOFA)、感染部位、致病菌、3 h和6 h集束化治疗完成情况、28 d预后等指标。采用Logistic回归分析筛选影响患者28 d死亡的独立危险因素。结果①159例脓毒性休克患者中,28 d存活93例,死亡66例。存活组与死亡组的性别、年龄比较差异均无统计学意义。与存活组比较,死亡组APACHEⅡ评分和SOFA评分均明显升高〔APACHEⅡ评分(分):26.85±5.04比20.67±4.29,SOFA评分(分):12.86±3.02比9.37±2.51,均P<0.05〕。②159例患者的感染部位中,腹腔感染47例(29.6%)、血流感染36例(22.6%)、肺部感染31例(19.5%)、软组织感染16例(10.1%)、泌尿系感染13例(8.2%)、胆道系统感染12例(7.5%)、其他部位感染4例(2.5%);128例检出病原菌,检出率为80.5%,其中革兰阴性(G^(-))杆菌90例(56.6%)、革兰阳性(G^(+))球菌27例(17.0%)、真菌11例(6.9%),前3位致病菌分别为大肠埃希菌49例(30.8%)、肺炎克雷伯菌21例(13.2%)、金黄色葡萄球菌15例(9.4%),差异均无统计学意义。③159例患者中101例(63.5%)完成3 h集束化治疗,其中存活组67例(72.0%)、死亡组34例(51.5%);106例(66.7%)完成6 h集束化治疗,其中存活组70例(75.3%),死亡组36例(54.5%),两组间比较差异均有统计学意义(均P<0.05)。④将单因素分析中影响预后的因素(APACHEⅡ评分、SOFA评分、3 h和6 h集束化治疗完成率)纳入二元Logistic回归分析,结果显示,APACHEⅡ评分、SOFA评分、3 h集束化治疗完成率是影响患者28 d死亡的独立危险因素〔优势比(OR)分别为1.216、1.303、0.402,均P<0.05〕。结论脓毒性休克患者APACHEⅡ评分及SOFA评分越高,病情越重,预后越差,提高3 h及6 h集束化治疗完成率,尤其是3 h集束化治疗完成率,可降低患者病死率,改善预后。

Objective To explore the impact of completion rates of 3-hour and 6-hour sepsis bundle therapy on prognosis of patients with septic shock in Prefecture-level grade A hospitals,and analyze the risk factors for prognosis.Methods A retrospective analysis was conducted to patients with septic shock in the intensive care unit(ICU)of Liaocheng People's Hospital,Shandong Province from January 1,2020 to December 31,2021.The data of gender,age,acute physiology and chronic health evaluationⅡ(APACHEⅡ),sequential organ failure assessment(SOFA),sites of infection,pathogenic microorganisms,completion rates of 3-hour and 6-hour sepsis bundle therapy,28-day prognosis were collected.Logistic regression analysis was used to identify risk factors for patients'mortality at 28-day.Results①Among 159 patients with septic shock,93 survived and 66 died with 28-day.There were no significant differences in gender and age between the survival group and death group.Compared with the survival group,APACHEⅡscore and SOFA score were significantly higher in the death group[APACHEⅡscore:26.85±5.04 vs.20.67±4.29,SOFA score:12.86±3.02 vs.9.37±2.51,both P<0.05].②Sites of infection in the 159 patients:47 cases were abdominal infection(29.6%),36 case were bloodstream infection(22.6%),31 cases were pulmonary infection(19.5%),16 cases were soft tissue infection(10.1%),13 cases were urinary tract infection(8.2%),12 cases were biliary tract infection(7.5%),and 4 cases were other sites infection(2.5%).Pathogens were found in 128 cases and the positive rate was 80.5%,including 90 cases of Gram-negative(G^(-))bacilli(56.6%),27 cases of Gram-positive(G^(+))cocci(17.0%)and 11 cases of fungi(6.9%).The top three pathogenic bacteria were Escherichia coli(49 cases,30.8%),Klebsiella pneumoniae(21 cases,13.2%)and Staphylococcus aureus(15 cases,9.4%).The differences were not statistically significant.③Among the 159 patients,101 cases completed 3-hour sepsis bundle therapy(63.5%),including 67 cases(72.0%)in survival group and 34 cases(51.5%)in death group;106 cases completed 6-hour sepsis bundle therapy(66.7%),including 70 cases(75.3%)in survival group and 36 cases(54.5%)in death group.The differences between the two groups were statistically significant(all P<0.05).④The factors(APACHEⅡscore,SOFA score and completion rate of 3-hour and 6-hour sepsis bundle therapy)affecting the prognosis in the univariate analysis were included in the binary Logistic regression analysis,and the results showed that the APACHEⅡscore,SOFA score,completion rate of 3-hour sepsis bundle therapy were independent risk factors affecting mortality within 28-day[odds ratio(OR)was 1.216,1.303,0.402,all P<0.05].Conclusions The higher APACHEⅡscore and SOFA score in septic shock,the worse the prognosis.Improving the completion rates of 3-hour and 6-hour bundle therapy especially the completion rate of 3-hour bundle therapy can reduce the mortality of patients and improve the prognosis.