血糖变异系数对急诊脓毒症患者脓毒症相关性脑病的 预测价值

The predictive value of glycemic coefficient of variation(GLUcv)for sepsis-associated encephalopathy in emergency sepsis patients

目的分析血糖变异系数(GLUcv)对急诊脓毒症患者脓毒症相关性脑病(SAE)的预测价值。方法采用前瞻性队列研究方法,入选2022年3月至2024年2月在绍兴市上虞人民医院急诊重症监护病房(EICU)诊治的脓毒症患者,检测患者入院24 h内末梢血糖,并计算GLUcv。以脓毒症确诊28 d内SAE事件为研究终点,将28 d内并发SAE的患者纳入SAE组,未并发SAE患者纳入N-SAE组。比较分组后组间主要资料与指标水平的差异,通过构建Logistic回归模型,分析脓毒症并发SAE与GLUcv及其他主要指标的关系。采用限制性立方样条法,分析GLUcv与脓毒症并发SAE风险的剂量反应关系。绘制受试者工作特征(ROC)曲线与临床决策曲线,分析GLUcv对脓毒症并发SAE的预测价值。结果最终有135例患者完成研究,患者入院24 h内GLUcv结果为12.59~33.60,根据GLUcv四分位数由低到高将135例患者分为Q_(1)~Q_(4)组,Q_(4)组SAE发生率高于Q_(1)~Q_(3)组,Q_(3)和Q_(4)组急性生理学和慢性健康状况评价Ⅱ(APACHEⅡ)评分、血清淀粉样蛋白A(SAA)、白细胞介素(IL)-6及神经元特异性烯醇化酶(NSE)水平高于Q_(1)和Q_(2)组,24 h乳酸清除率低于Q_(1)和Q_(2)组(P<0.05)。患者确诊后28 d内并发SAE 57例,发生率约42.22%。SAE组入院时APACHEⅡ评分、GLUcv、IL-6及NSE水平高于N-SAE组,24 h乳酸清除率低于N-SAE组(P<0.05)。构建Logistic回归模型结果显示,脓毒症并发SAE可能与入院时APACHEⅡ评分、24 h乳酸清除率、GLUcv、IL-6、NSE及SAA有关(P<0.05)。绘制ROC曲线,GLUcv预测脓毒症患者并发SAE曲线下面积(AUC)为0.797,最佳截断值为23.24。采用限制性立方样条法分析,脓毒症患者入院24 h内GLUcv与入院28 d内SAE发生风险呈线性剂量反应关系(P<0.05),当GLUcv阈值达到23.24时,SAE风险随着GLUcv升高而增加。绘制临床决策曲线,GLUcv预测脓毒症并发SAE临床净收益情况理想,且联合其他指标能提高整体决策获益。结论脓毒症患者并发SAE与GLUcv的升高有关,SAE风险随GLUcv升高而增加,脓毒症患者入院24 h内GLUcv可预测SAE高风险人群,且联合其他指标能提高整体风险预测的净收益率。

Objective To analyze the predictive value of glycemic coefficient of variation(GLUcv)for sepsis-associated encephalopathy(SAE)in emergency sepsis patients.Methods A prospective cohort study was used to select sepsis patients who were treated in Emergency EICU Department of Shangyu People′s Hospital from March 2022 to February 2024.The peripheral blood glucose of the patients within 24 h of admission were measured and GLUcv was calculated.The SAE events within 28 d of sepsis diagnosis were considered as research endpoint.Patients who experienced SAE within 28 d were included in the SAE group,while those who did not experience SAE were included in the N-SAE group.The differences in main data and indicator levels were compared between two groups after grouping,and the relationship of sepsis complicated by SAE with GLUcv and other major indicators were analyzed by constructing a Logistic regression model.The restricted cubic spline method was used to analyze the dose-response relationship between GLUcv and the risk of sepsis complicated by SAE.The receiver operating characteristic(ROC)curves and decision curves were drawn to analyze the predictive value of GLUcv for sepsis complicated by SAE.Results A total of 135 patients completed the study,with GLUcv measurements ranging from 12.59 to 33.60 within 24 h of admission.According to the low to high quartile of GLUcv,135 patients were divided into Q_(1) to Q_(4) groups.The incidence of SAE in Q_(4) group was higher than that in Q_(1) to Q_(3) group,and the acute physiology and chronic health evaluationⅡ(APACHEⅡ),serum amyloid A protein(SAA),interleukin-6(IL-6),and neuron specific enolase(NSE)levels were higher in Q_(3) and Q_(4) groups than in Q_(1) and Q_(2) groups.The 24-hour lactate clearance rate was lower in Q_(3) and Q_(4) groups than in Q_(1) and Q_(2) groups(P<0.05).57 cases of SAE occurred within 28 d after diagnosis,with an incidence rate of approximately 42.22%.At admission,the APACHEⅡscore,GLUcv,IL-6 and NSE levels in the SAE group were higher than those in the N-SAE group,and the 24-hour lactate clearance rate was lower than that in the N-SAE group(P<0.05).The results of Logistic regression model showed that sepsis complicated by SAE may be related to APACHEⅡscore at admission,24-hour lactate clearance rate,GLUcv,serum IL-6,NSE and SAA(P<0.05).Drawing ROC curve,the area under curve(AUC)of GLUcv predicting the SAE for sepsis patients was 0.797,with an optimal cutoff value of 23.24.The restricted cubic spline method showed there was a linear dose-response relationship between GLUcv within 24 h of admission and the risk of SAE within 28 d of admission in sepsis patients(P<0.05).When the GLUcv threshold reached 23.24,the risk of SAE increased with the increase of GLUcv.Drawing a decision curve,the clinical net benefit of GLUcv predicting SAE in sepsis patients was ideal,and GLUcv combined with other indicators can improve the overall decision-making benefit.Conclusions The occurrence of SAE in sepsis patients is related to an increase of GLUcv,and the risk of SAE increases with the increase of GLUcv.Calculating the GLUcv value within 24 h of admission for sepsis patients can predict the high-risk population of SAE,and combining with other indicators can improve the net benefit rate of overall risk prediction.