摘要
目的探索重症加强治疗病房(ICU)左室舒张功能不全对脓毒性休克患者死亡风险的预测价值。方法本研究为单中心前瞻性研究,收集2016年6月至2017年10月在河北医科大学附属衡水市哈励逊国际和平医院ICU住院的脓毒性休克患者临床资料。诊断脓毒性休克后首个24h内经胸超声心电图完成血流动力学评估,明确是否存在左室舒张功能不全,同时记录入ICU24h内患者的基线资料,入ICU后首次血气分析、生化指标,住ICU期间感染部位、肾上腺素和多巴酚丁胺使用人次、去甲肾上腺素最大使用剂量,以及氢化可的松、有创机械通气和肾脏替代治疗情况。采用二分类logistic回归分析脓毒性休克死亡的危险因素,绘制受试者工作特征曲线和分析曲线下面积,评价其预测效能。结果共有138例脓毒性休克患者接受筛查,102例纳入最后分析,死亡30例(29%),合并左室舒张功能不全32例(31%)。基线资料比较,死亡组APACHEⅡ评分、SOFA评分、乳酸水平、血肌酐水平、肾上腺素使用人次及去甲肾上腺素最大剂量,均高于存活组(均P<0.05)。超声心动图方面,死亡组右室与左室舒张末期面积比值明显高于存活组[(0.77±0.43)vs(0.59±0.17)],组织多普勒二尖瓣环侧壁舒张早期纵向最大运动速度(e')明显低于存活组[(10.5±3.8)vs(12.90±4.60)],左室舒张功能不全患者比例更高(18/72vs14/30),均P<0.05。Logistic回归分析发现,去甲肾上腺素最大剂量(OR=1.69,95%CI:1.05~2.79)、SOFA评分(OR=2.24,95%CI:1.32~3.35)、e'(OR=2.23,95%CI:1.01~5.57)、乳酸(OR=2.36,95%CI:1.25~5.43)、左室舒张功能不全(OR=1.32,95%CI:1.11~3.15)是脓毒性休克死亡的重要预测因素。e'预测脓毒性休克死亡的最佳截断值为8.9cm/s,敏感度为76%,特异度为54%,曲线下面积为0.63。结论左室舒张功能不全是ICU脓毒性休克患者死亡的重要危险因素,但尚需要多中心前瞻性大样本队列研究进一步证实。
ObjectiveTo investigate the prognostic impact of left ventricular diastolic dysfunction in septic shock patients in intensive care unit (ICU).MethodsA single-center, prospective tudy was conducted. The relevant information of septic shock patients who underwent an echocardiographic assessment during the initial management were analyzed in ICU of Harrison International Peace Hospital Affiliated to Hebei Medical University from June 2016 to October 2017. Hemodynamics were evaluated using transthoracic echocardiography within the first 24 h of shock, and LV diastolic dysfunction is present if the available parameters meet the cutoff values. Patients' characteristics, arterial blood gas analysis, and blood biochemical indexes were recorded in the first 24h at ICU admission. Additionally, the following information were retrieved during ICU stay: site of infection, frequency of adrenaline and dobutamine, maximal dose of norepinephrine, use of hydrocortisone, invasive mechanical ventilation and renal replacement therapy. A multivariate analysis was performed to determine independent risk factors associated with septic shock mortality, and the receiver operating characteristic curve (ROC) was drawn to evaluate the predictive value of all risk factors on the outcome of patients.ResultsAmong the 138 patients with septic shock hospitalized in the ICU during the study period, 102 patients were enrolled [76 men (75%);aged 64±12 years] and 92 of them (90%) were mechanically ventilated. Thirty patients died in ICU with a mortality rate of 29%. LV diastolic dysfunction was observed in 32 patients (31%). No significant inter-group difference in infection characteristics was found. The death group had significantly higher APACHEⅡscore, SOFA score, lactate and creatinine levels than the survival group. Similarly, the death group received a greater dose of vasopressors and required more frequent administration of epinephrine than the survivors. While the dead group exhibited slightly yet significantly larger RV cavity, which was
作者
王金荣
杨晓亚
郭淑芬
邵立业
郭伟
崔朝勃
Wang Jinrong;Yang Xiaoya;Guo Shufen;Shao Liye;Guo Wei;Cui Zhaobo(Department of Critical Care Medicine,Harrison International Peace Hospital Affiliated to Hebei Medical University,Hengshui 053000,China)
出处
《中华急诊医学杂志》
CAS
CSCD
北大核心
2019年第1期61-67,共7页
Chinese Journal of Emergency Medicine
基金
河北省科技厅支持项目(162777279).
