早期床旁超声测量脓毒症患者股四头肌变化对住院死亡的诊断价值

Diagnostic value of early bedside ultrasound measurement of quadriceps femoris on in-hospital mortality of septic patients

目的探讨脓毒症患者股四头肌厚度及其随重症监护病房(ICU)住院时间延长的变化特点,并判断肌肉变化对ICU死亡的诊断价值。方法前瞻性研究方法,选择2020年1月至2021年12月入住济宁医学院附属医院ICU的92例脓毒症患者,收集患者入ICU后1 d(D1)、3 d(D3)、7 d(D7)超声测量下的股四头肌厚度〔包括髂前上棘与髌骨上缘的中点处及中下1/3处测得的股四头肌肌肉厚度(分别为M-QMLT、T-QMLT)〕;并计算入ICU后3 d和7 d与1 d相比的股四头肌萎缩率,两处测量位置分别为(D3-D1)/D1和(D7-D1)/D1、(TD3-TD1)/TD1和(TD7-TD1)/TD1。记录所有患者的人口统计学信息、基础疾病、入ICU生命体征以及住院生存情况,比较不同预后两组患者上述指标的差异。采用多因素Logistic回归分析股四头肌肌肉厚度及萎缩率对脓毒症患者住院死亡的影响;绘制受试者工作特征曲线(ROC曲线)分析股四头肌肌肉厚度及萎缩率对脓毒症患者住院死亡的预测价值。结果共纳入92例脓毒症重症患者,其中41例发生院内死亡,51例好转出院,院内病死率为44.6%。脓毒症重症患者的股四头肌肌肉厚度随ICU住院时间的延长而减少,入ICU 1 d和3 d时两组比较差异无统计学意义;入ICU后7 d存活组不同测量位置的股四头肌肌肉厚度均显著大于死亡组〔M-QMLT D7(cm):0.50±0.26比0.39±0.19,T-QMLT D7(cm):0.58±0.29比0.45±0.21,均P<0.05〕;存活组入ICU后3 d和7 d不同测量位置股四头肌肌肉厚度的萎缩率均显著低于死亡组〔(D3-D1)/D1:(8.33±3.44)%比(9.74±3.91)%,(D7-D1)/D1:(12.21±4.76)%比(19.80±6.15)%,(TD3-TD1)/TD1:(7.83±4.26)%比(10.51±4.75)%,(TD7-TD1)/TD1:(11.10±5.46)%比(20.22±6.05)%,均P<0.05〕。多因素Logistic回归分析显示,M-QMLT D7、T-QMLT D7、(D3-D1)/D1、(D7-D1)/D1、(TD3-TD1)/TD1、(TD7-TD1)/TD1均是脓毒症患者住院死亡的独立危险因素(均P<0.05)。调整混杂因素后结果仍稳定。ROC曲线分析显示,(TD7-TD1)/TD1〔ROC曲线下面积(AUC)为0.853,95%可信区间(95%CI)为0.773~0.934〕对脓毒症患者住院死亡的预测价值优于(D7-D1)/D1、T-QMLT D7、M-QMLT D7、(TD3-TD1)/TD1和(D3-D1)/D1〔AUC分别为0.821(0.725~0.917)、0.692(0.582~0.802)、0.683(0.573~0.794)、0.680(0.569~0.791)、0.622(0.502~0.742)〕。结论对于ICU的脓毒症患者,床旁超声监测股四头肌肌肉厚度及萎缩率对住院死亡有一定的预测价值,在临床治疗和预测脓毒症预后方面有一定指导意义。

Objective To investigate the changes of quadriceps femoris thickness with the length of stay in intensive care unit(ICU)in patients with sepsis,and to evaluate the diagnostic value of muscle changes in mortality.Methods A prospective study was conducted,and 92 patients with sepsis who were admitted to the ICU of the Affiliated Hospital of Jining Medical College from January 2020 to December 2021 were enrolled.The thickness of quadriceps femoris[including the quadriceps femoris muscle thickness at the midpoint of the anterior superior iliac spine and the upper edge of the patella(M-QMLT),and at the middle and lower 1/3 of the patella(T-QMLT)]measured by ultrasound 1 day(D1),3 days(D3),and 7 days(D7)after admission to the ICU were collected.The atrophy rate of quadriceps femoris was calculated 3 and 7 days after admission to the ICU compared with 1 day[(D3-D1)/D1 and(D7-D1)/D1,(TD3-TD1)/TD1 and(TD7-TD1)/TD1,respectively].The demographic information,underlying diseases,vital signs when admission to the ICU and in-hospital mortality of all patients were recorded,and the differences of the above indicators between the two groupswere compared.Multivariate Logistic regression was used to analyze the influence of quadriceps femoris muscle thickness and atrophy rate on in-hospital mortality of septic patients.The receiver operator characteristic curve(ROC curve)was drawn to analyze the predictive value of quadriceps femoris muscle thickness and atrophy rate on in-hospital mortality of septic patients.Results A total of 92 patients with severe sepsis were included,of which 41 patients died in hospital,51 patients discharged.The in-hospital mortality was 44.6%.The muscle thickness of quadriceps femoris in severe septic patients decreased with the prolongation of ICU stay,and there was no significant difference between the two groups at the first and third day of ICU admission.The muscle thickness of quadriceps femoris at different measuring positions in the survival group was significantly greater than those in the death group 7 days after admission to the ICU[M-QMLT D7(cm):0.50±0.26 vs.0.39±0.19,T-QMLT D7(cm):0.58±0.29 vs.0.45±0.21,both P<0.05].The atrophy rate of quadriceps femoris muscle thickness at different measuring positions 3 and 7 days after admission to ICU in the survival group was significantly lower than those in the death group[(D3-D1)/D1:(8.33±3.44)%vs.(9.74±3.91)%,(D7-D1)/D1:(12.21±4.76)%vs.(19.80±6.15)%,(TD3-TD1)/TD1:(7.83±4.26)%vs.(10.51±4.75)%,(TD7-TD1)/TD1:(11.10±5.46)%vs.(20.22±6.05)%,all P<0.05].Multivariate Logistic regression analysis showed that M-QMLT D7,T-QMLT D7,(D3-D1)/D1,(D7-D1)/D1,(TD3-TD1)/TD1,(TD7-TD1)/TD1 were independent risk factors for in-hospital mortality(all P<0.05).The results were stable after adjusting for confounding factors.ROC curve analysis showed that(TD7-TD1)/TD1[area under the ROC curve(AUC)was 0.853,95%confidence interval(95%CI)was 0.773-0.934]was superior to(D7-D1)/D1,T-QMLT D7,M-QMLT D7,(TD3-TD1)/TD1 and(D3-D1)/D1[AUC was 0.821(0.725-0.917),0.692(0.582-0.802),0.683(0.573-0.794),0.680(0.569-0.791),0.622(0.502-0.742)].Conclusions For septic patients in ICU,bedside ultrasound monitoring of quadriceps femoris muscle thickness and atrophy rate has a certain predictive value for in-hospital mortality,and a certain guiding significance in clinical treatment and predicting the prognosis of sepsis.