成人特重度烧伤患者脓毒症预后预测指标分析

Prognosis factors for extremely severe burn patients combined with sepsis

目的探讨成人特重度烧伤脓毒症患者的预后预测指标。方法回顾性分析2017年1月至2021年12月浙江大学医学院附属第二医院收治的成人特重度烧伤并发脓毒症患者的病例资料。根据预后将患者分为死亡组和生存组。比较两组患者临床基线资料,脓毒症确诊时的临床症状、生命体征、血小板计数(platelet,PLT)、白细胞计数(white blood cell,WBC)、中性粒细胞比例、降钙素原(procalcitonin,PCT)、血钠、血糖、血红蛋白及白蛋白水平。对数据行独立样本t检验、Mann-Whitney U秩和检验和Fisher确切概率法检验。汇总单因素分析中差异有统计学意义的变量纳入Cox回归模型进行多因素分析,评估各指标对特重度烧伤脓毒症患者预后的影响。用受试者工作特征曲线(receiver operating characteristic curve,ROC)分析各指标对脓毒症预后的预测价值。结果共入选特重度烧伤脓毒症患者60例,其中男性41例,女性19例,年龄18~84岁。脓毒症确诊时间为伤后14(7,24)d。死亡组29例,生存组31例,病死率为48.3%。与生存组比较,死亡组患者脓毒症确诊时PLT和血红蛋白水平显著降低(均P<0.05),PCT和血钠水平显著增高(均P<0.05),其余指标均差异无统计学意义(均P>0.05)。多因素Cox回归分析结果显示,脓毒症确诊时的血红蛋白(HR=0.936,95%CI:0.935~0.991,P<0.05)和血钠水平(HR=1.031,95%CI:1.010~1.052,P<0.05)是影响特重度烧伤脓毒症患者预后的独立危险因素。ROC曲线分析显示,脓毒症确诊时血红蛋白、血钠、PCT对特重度烧伤脓毒症患者预后预测的ROC曲线下面积(area under the ROC curve,AUC)分别为0.747、0.811、0.690(均P<0.05);血红蛋白预测预后的临界值为77 g/L,敏感度为69.0%,特异度为74.2%;血钠的临界值为138 mmol/L,敏感度为89.7%,特异度为61.3%;PCT的临界值为3.51μg/L,敏感度为65.5%,特异度为74.2%。结论血红蛋白、血钠和PCT可能是成人特重度烧伤脓毒症患者预后的预测指标。

Objective To explore forecast indicators for the prognosis of sepsis in adult extremely severe burn patients.Methods Case data of adults with extremely severe burns combined with sepsis admitted to the Second Affiliated Hospital of Zhejiang University School of Medicine from January 2017 to December 2021 were retrospectively collected.According to the prognosis,all patients were divided into a death group and a survival group.The general conditions of the two groups were compared.The clinical symptoms,vital signs,platelet count(PLT),white blood cell count(WBC),neutrophil ratio,procalcitonin(PCT),blood sodium,blood glucose,hemoglobin and albumin levels at diagnosis of sepsis were also compared between the two groups.The independent sample t test,Mann‒Whitney U test,or Fisher's exact probability test was used for group comparison.Variables with statistical significance in univariate analysis were included in the Cox regression model for multivariate analysis to assess the effect of each index on the outcome of extremely severe burn patients with sepsis.The predictive value of each index for sepsis outcome was analyzed by the receiver operating characteristic curve(ROC).Results A total of 60 patients with particularly severe burn sepsis were selected,including 41 males and 19 females aged 18 to 84 years.The diagnosis time of sepsis was 14(7,24)days after injury.There were 29 patients in the death group and 31 patients in the survival group,and the mortality rate was 48.3%.Compared with the survival group,PLT and hemoglobin levels in the death group decreased significantly(both P<0.05),and PCT and blood sodium levels increased significantly(both P<0.05),while the other indicators did not change significantly(all P>0.05).The results of multivariate Cox regression analysis showed that hemoglobin(HR=0.936,95%CI:0.935-0.991)and serum sodium levels(HR=1.031,95%CI:1.010-1.052)at the time of sepsis diagnosis were independent risk factors affecting the prognosis of sepsis in extra-severe burn patients(both P<0.05).ROC curve analysis showed that the AUCs of hemoglobin,blood sodium and PCT for predicting the prognosis of extremely severe burn patients with sepsis were 0.747,0.811 and 0.690,respectively(all P<0.05).The cut-off value of hemoglobin for predicting prognosis was 77 g/L,with a sensitivity of 69.0%and specificity of 74.2%.The cut-off value of blood sodium for predicting prognosis was 138 mmol/L,with a sensitivity of 89.7%and specificity of 61.3%.The cut-off value of PCT was 3.51μg/L,with a sensitivity of 65.5%and specificity of 74.2%.Conclusions Hemoglobin,blood sodium and PCT may be predictors of outcome in extremely severe burn patients with sepsis.