APACHE Ⅳ评分对严重出血性脑卒中患者机械通气治疗的影响——一项来自eICU数据库的回顾性观察性研究

The impact of acute physiology and chronic health evaluation Ⅳ score on mechanical ventilation in patients with severe hemorrhagic stroke: a retrospective observational study from emergency intensive care unit database

目的通过急性生理学与慢性健康状况评分IV(APACHE Ⅳ)评估机械通气(MV)治疗对严重出血性脑卒中(SHS)患者总病死率的影响,并分析SHS患者MV的时机。方法选取美国急诊重症监护病房数据库(eICU数据库)的个体患者数据(200859例),最终确定首要诊断为SHS患者(997例)进行统计分析,根据是否接受MV,采用1∶1倾向性评分匹配(PSM),接受MV和非MV(NMV)两组分别纳入236例,比较并分析匹配前后患者的独立预测因素,使用独立预测因素检验整个队列预测的病死率和观察到的病死率与MV之间的相互作用。结果276例(27.7%)的患者接受了MV治疗。在整个队列的多变量Logistic回归中,MV、APACHE Ⅳ评分是影响SHS患者死亡的独立危险因素〔优势比(OR)及其95%可信区间(95%CI)分别为5.616(3.785~8.334)和1.036(1.028~1.044),均P<0.001〕。在NMV组多变量Logistic回归中,APACHE Ⅳ评分〔OR(95%CI)为1.050(1.039~1.062)〕是总病死率的独立预测因素,并被用于预测整个队列的住院死亡风险。APACHE Ⅳ用于预测整个队列住院死亡风险的受试者工作特征(ROC)曲线下面积(AUC)=0.784,95%CI为0.746~0.821,P<0.001。Hosmer-Lemeshow拟合优度检验结果显示,预测值与实际观测值之间差异无统计学意义(χ^(2)=3.893,P=0.867),拟合度良好。广义线性模型的二元Logistic回归分析显示,预测的总病死率与MV之间的交互作用显著,MV和NMV的交叉率为73%,表明预测总病死率风险>73%的患者可从MV中获益。PSM后,多变量Logistic回归分析显示,MV、APACHE Ⅳ评分仍是影响SHS患者死亡的独立危险因素〔OR(95%CI)分别为4.242(2.575~6.991)和1.030(1.019~1.040)〕。APACHE Ⅳ评分预测SHS患者死亡风险的AUC=0.702,95%CI为0.649~0.754,P<0.001;Hosmer-Lemeshow拟合优度检验结果显示,预测值与实际观测值差异无统计学意义(χ^(2)=10.390,P=0.239),拟合度良好。结论APACHE Ⅳ评分对SHS具有较好的预测能力。具体来说,当APACHE Ⅳ评分预测病死率低于73%时,NMV的SHS患者预后更好,预测病死率高于73%时,MV的SHS患者预后更好。

Objective To analyze the timing of mechanical ventilation(MV)in patients with severe hemorrhagic stroke(SHS),this study evaluated the effect of MV on the total mortality of patients with SHS by acute physiology and chronic health evaluation IV(APACHE Ⅳ).Methods Based on the individual patient data(200859 cases)of the American Emergency Intensive Care Unit(eICU database),the patients who were diagnosed as hemorrhagic stroke first(997 cases)were finally determined for statistical analysis.According to whether or not they received MV,236 patients in the MV and non-MV(NMV)receiving groups were enrolled by 1∶1 propensity score matching(PSM),and the independent predictors of patients before and after matching were compared and analyzed.Independent predictors were used to test the predicted mortality of the whole cohort and the interaction between the observed mortality and MV.Results 276 patients(27.7%)received MV treatment.Multivariate Logistic regression analysis of the whole cohort showed that MV and APACHE Ⅳ score were independent risk factors for death in patients with SHS[odds ratio(OR)and 95%confidence interval(95%CI)were 5.616(3.785-8.334)and 1.036(1.028-1.044),respectively,both P<0.001].Multivariate Logistic regression analysis of NMV group showed that APACHE Ⅳ score was an independent predictor of total mortality(OR=1.050,95%CI was 1.039-1.062,P<0.001);APACHE Ⅳ was used to predict the risk of hospital death in the whole cohort.The area under curve(AUC)of receiver operating characteristic(ROC)=0.784,95%CI was 0.746-0.821,P<0.001.The result of Hosmer-Lemeshow goodness-of-fit test showed that there was no significant difference between the predicted value and the actual observed value(χ^(2)=3.893,P=0.867),and the degree of fit was good.The binary logistic regression fitting of the generalized linear model showed that there was a significant interaction between the predicted total mortality and MV,and the crossing rate of MV and NMV was 73%,indicating that patients with a predicted risk of total mortality>73%could benefit from MV.After PSM,multivariate Logistic regression analysis showed that MV and APACHE Ⅳ scores were still independent risk factors for death in SHS patients[OR and 95%CI were 4.242(2.57-6.991)and 1.030(1.019-1.040),respectively].The AUC=0.702,95%CI was 0.649-0.754(P<0.001)of APACHE Ⅳ score for predicting the risk of death in patients with SHS.The result of Hosmer-Lemeshow goodness-of-fit test showed that there was no significant difference between the predicted value and the actual value(χ^(2)=10.390,P=0.239),and the degree of fit was good.Conclusions The APACHE Ⅳ score is a good predictor of SHS.Specifically,when the predicted mortality rate of APACHE Ⅳ was lower than 73%,the prognosis of SHS patients with NMV was better,and when the predicted mortality rate was higher than 73%,the prognosis of SHS patients with MV was better.