4种早期预警评分对二级医院危重症患者预后预测作用的比较

Comparison of four early warning scores in predicting the prognosis of critically ill patients in secondary hospitals

目的:探讨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)、快速序贯器官衰竭评分(qSOFA)及改良早期预警评分(MEWS)对二级医院重症监护病房(ICU)患者预后的评估价值,为临床应用提供指导依据。方法:回顾性分析2022年10月至2023年4月重庆市万州区第一人民医院ICU收治的成人危重症患者的临床资料。按ICU临床结局将患者分为好转组和死亡组,比较两组患者一般资料以及入ICU时的血常规、心肝肾功能指标、凝血指标、血气分析,APACHEⅡ、SOFA、qSOFA和MEWS评分,应用有创机械通气(IMV)、连续性血液净化(CBP)等有无差异,并进行单因素分析,对导致死亡的相关因素进一步行多因素Logistic回归分析。用受试者工作特征曲线(ROC曲线)分析4种评分对ICU患者预后的预测价值。结果:共纳入126例患者,其中ICU死亡45例,好转转出81例。与危重症患者死亡相关的单因素分析显示,两组间降钙素原(PCT)、血肌酐(SCr)、血尿素氮(BUN)、白蛋白(ALB)、凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、D-二聚体、pH值、HCO 3-、血乳酸(Lac),应用IMV、CBP以及APACHEⅡ、SOFA、qSOFA和MEWS评分差异均有统计学意义(均 P<0.05)。多因素Logistic回归分析显示,APACHEⅡ评分〔优势比( OR)=1.115,95%可信区间(95% CI)为1.025~1.213, P=0.011〕、SOFA评分( OR=1.204,95% CI为1.037~1.398, P=0.015)、MEWS评分( OR=1.464,95% CI为1.102~1.946, P=0.009)及APTT( OR=1.081,95% CI为1.015~1.152, P=0.016)为影响ICU危重症患者病死率的独立危险因素。ROC曲线分析显示,APACHEⅡ、SOFA、qSOFA、MEWS评分均能预测ICU危重症患者的预后,其中SOFA评分的预测效能最强,其ROC曲线下面积(AUC)为0.808。4种评分计算所需的时间比较差异有统计学意义( F=117.333, P<0.001),其中MEWS评分所需的时间最短〔(1.03±0.39)min〕,APACHEⅡ评分所需的时间最长〔(2.81±1.04)min〕。 结论:APACHEⅡ、SOFA、qSOFA和MEWS评分均可用于评估危重症患者的病情严重程度和预测院内病死率。SOFA评分在预测严重程度方面优于其他评分;MEWS评分评估时间最短,可优先考虑。早期预警评分有助于二级医院早期发现潜在的危重症患者,为临床快速作出紧急决策提供帮助。

ObjectiveTo explore the predictive value of acute physiology and chronic health evaluationⅡ(APACHEⅡ),sequential organ failure assessment(SOFA),quick sequential organ failure assessment(qSOFA)and modified early warning score(MEWS)in evaluating the prognosis of patients in intensive care unit(ICU)of secondary hospitals,and to provide guidance for clinical application.MethodsThe clinical data of adult critical patients admitted to the ICU of Wanzhou District First People's Hospital from October 2022 to April 2023 were retrospectively analyzed.According to the clinical outcome of ICU,the patients were divided into improvement group and death group.The general information,blood routine,heart,liver and kidney function indicators,coagulation indicators,blood gas analysis,APACHEⅡscore,SOFA score,qSOFA score,MEWS score at the time of admission to the ICU,the number of cases of invasive mechanical ventilation(IMV)and continuous blood purification(CBP)were compared between the two groups.Univariate analysis was performed,and multivariate Logistic regression analysis was used to analyze the related factors of death.Receiver operator characteristic curve(ROC curve)was used to analyze the predictive value of the four scores in ICU patients.ResultsA total of 126 patients were included,of which 45 patients died in the ICU and 81 patients improved and transferred out.Univariate analysis of death-related critically ill patients showed that procalcitonin(PCT),serum creatinine(SCr),blood urea nitrogen(BUN),albumin(ALB),prothrombin time(PT),activated partial prothrombin time(APTT),D-dimer,pH value,HCO3-,blood lactic acid(Lac),number of patients treated with IMV and CBP,APACHEⅡscore,SOFA score,qSOFA score and MEWS score were significantly different between the two groups(all P<0.05).Multivariate Logistic regression analysis showed that the APACHEⅡscore[odds ratio(OR)=1.115,95%confidence interval(95%CI)was 1.025-1.213,P=0.011],SOFA score(OR=1.204,95%CI was 1.037-1.398,P=0.015),MEWS score(OR=1.464,95%CI was 1.102-1.946,P=0.009),and APTT(OR=1.081,95%CI was 1.015-1.152,P=0.016)were independent risk factors affecting the mortality of critically ill patients in the ICU.ROC curve analysis showed that APACHEⅡ,SOFA,qSOFA,and MEWS scores could predict the prognosis of critically ill ICU patients,among which SOFA score had the strongest predictive effect,and the area under the curve(AUC)was 0.808.There was a statistically significant difference in the time required for the four scores(F=117.333,P<0.001),among which the MEWS scoring required the shortest time[(1.03±0.39)minutes],and the APACHEⅡscoring required the longest time[(2.81±1.04)minutes].ConclusionsAPACHEⅡ,SOFA,qSOFA,and MEWS scores can be used to assess the severity of critically ill patients and predict in-hospital mortality.The SOFA score is superior to other scores in predicting severity.The MEWS is preferred because its assessment time is shortest.Early warning score can help secondary hospitals to detect potentially critical patients early and provide help for clinical rapid urgent emergency decision-making.