急性胰腺炎并发急性呼吸窘迫综合征早期预警模型的建立及诊断价值分析

Establishment and diagnostic value of an early warning model for acute pancreatitis complicated with acute respiratory distress syndrome

目的建立急性胰腺炎(acute pancreatitis,AP)并发急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)的早期预警模型,并评价其诊断价值。方法选取2018年1月至2021年1月在北京大学人民医院急诊科诊治的急性胰腺炎患者为研究对象。以诊断急性胰腺炎后14 d为观察终点,根据是否发生ARDS分为ARDS组和对照组。比较两组患者一般特征、实验室检查指标、影像学指标及临床评分,先进行单因素分析,具有统计学意义及临床意义的指标再进行多因素Logistic分析,最终建立风险预测模型,计算该模型的诊断灵敏度、特异度,绘制受试者工作特征(ROC)曲线并计算曲线下面积(AUC),并与Ranson评分及BISAP评分的诊断价值进行比较。结果共纳入442例患者,ARDS组72例,对照组370例。两组患者相比,ARDS组患者早期出现发热症状的比例更高,而氧合指数更低,ARDS组患者炎症指标、γ-GGT、血淀粉酶、血尿素氮、血糖均高于对照组,而血钙、血浆白蛋白、CO_(2)结合力水平则低于对照,两组相比均差异有统计学意义。将上述差异有统计学意义的指标临床筛选后进行单因素和多因素Logistic回归分析,中性粒细胞计数升高(OR=2.838,95%CI 1.339~6.018,P=0.007)、PCT水平升高(OR=1.198,95%CI 1.025~1.399,P=0.023)、血尿素氮水平升高(OR=1.665,95%CI 1.463~1.955,P=0.027)、氧合指数下降(OR=0.603,95%CI 0.384~0.949,P=0.029)为急性胰腺炎患者并发ARDS的危险因素。根据上述因素,建立急性胰腺炎患者并发ARDS早期预警模型:Logistic ARDS/AP=35.131+1.043NEUT+0.408BUN-0.505OI+0.18PCT。该预警模型的诊断灵敏度为84.72%(61/72),特异度为85.68(317/370),阳性预测值为53.51%(61/114),阴性预测值为96.64%(317/328),诊断准确率为85.52%(378/442),ROC曲线下面积为0.894(95%CI 0.851~0.938)。该预警模型在急性胰腺炎并发ARDS中的预测能力优于Ranson评分、BISAP评分、APACHEⅡ评分及CTSI评分(AUC 0.894 vs.0.823 vs.0.756 vs.0.818 vs.0.723)。结论基于中性粒细胞计数、血尿素氮、发病早期氧合指数、降钙素原建立起来的预测模型具有早期预测急性胰腺炎并发ARDS的价值,且优于其他评分系统,可以更好的指导治疗,改善预后。

Objective To establish an early warning model for acute pancreatitis(AP)complicated with acute respiratory distress syndrome(ARDS)and to evaluate its diagnostic value.Methods Acute pancreatitis patients treated in the Emergency Department of Peking University People's Hospital from January 2018 to January 2021 were selected as the research subjects.At 14 days after the diagnosis of acute pancreatitis,the patients were divided into the ARDS group and the control group according to whether ARDS occurred.The general characteristics,laboratory examination results,imaging features,and clinical scores of the two groups of patients were compared.One-way analysis was performed fi rst,and the indicators with statistical and clinical signifi cance were then analyzed by multivariate logistic analysis.Finally,a risk prediction model was established,and the diagnostic sensitivity and specifi city of the predictive model were calculated.The receiver operating characteristic(ROC)curve was plotted,and the area under the curve(AUC)was calculated.The diagnostic value of the model was compared with the Ranson score and BISAP score.Results A total of 442 patients were selected for this study,including 72 patients in the ARDS group and 370 patients in the control group.Compared to the control group,the ARDS group had a higher proportion of early fever and a lower oxygenation index.Inflammatory indicatorsγ-GGT,blood amylase,blood urea nitrogen,and blood glucose levels in the ARDS group were significantly higher than those in the control group,while blood calcium,plasma albumin,and carbon dioxide binding capacity levels were signifi cantly lower than those in the control group.Univariate and multivariate logistic regression analysis was conducted on the statistically significant and clinically signifi cant indicators mentioned above.The increased neutrophil count(OR=2.838,95%CI:1.339-6.018,P=0.007),increased procalcitonin level(OR=1.198,95%CI:1.025-1.399,P=0.023),increased blood urea nitrogen level(OR=1.665,95%CI:1.463-1.955,P=0.027)and the decreased oxygenation index(OR=0.603,95%CI:0.384-0.949,P=0.029)were associated with acute pancreatitis complicated with ARDS.According to the above factors,an early warning model for acute pancreatitis patients complicated with ARDS was established:logistic ARDS/AP=35.131+1.043NEUT+0.408BUN-0.505OI+0.18PCT.The diagnostic sensitivity of this early warning model was 84.72%(61/72),the specifi city was 85.68%(317/370),the positive predictive value was 53.51%(61/114),the negative predictive value was 96.64%(317/328),the diagnostic accuracy was 85.52%(378/442),and the area under the ROC curve was 0.894(95%CI:0.851-0.938).The predictive ability of this early warning model in acute pancreatitis complicated with ARDS was superior to the Ranson score,BISAP score,APACHEⅡscore and CTSI score(AUC:0.894 vs.0.823 vs.0.756 vs.0.818 vs.0.723).Conclusions The prediction model based on neutrophil count,blood urea nitrogen,early oxygenation index and procalcitonin has the value of early prediction of acute pancreatitis complicated with ARDS,and is superior to other scoring systems,which can better guide treatment and improve prognosis.