外周灌注指数联合APACHE Ⅱ评分预测脓毒性休克患者28天预后的价值

doi:10.16138/j.1673-6087.2024.03.04

摘要/Abstract

摘要：

目的：研究外周灌注指数(periphral perfusion index,PPI)联合急性生理与慢性健康评价Ⅱ(acute physi-ology and chronic evaluation Ⅱ，APACHEⅡ)评分对预测脓毒性休克患者预后的价值。方法：前瞻性纳入2023年1月至8月新疆医科大学第一附属医院急诊科确诊脓毒性休克患者200例，根据患者28 d预后情况分为存活组(84例)与死亡组(116例)，记录患者姓名、年龄、性别、入院后生命体征、格拉斯哥昏迷评分量表(Glasgow coma scale，GCS)、脓毒症相关性器官功能衰竭评价(sepsis-related organ failure assessment，SOFA)、APACHEⅡ、感染部位、入院24 h补液量、抗菌药物使用情况、既往史、血管活性药物使用种类及24 h剂量、机械通气情况、血常规、肝功能、肾功能、凝血指标、发病时间、28 d预后结局等相关资料。分别测定2组患者入院即刻(0 h)、入院后6 h和入院后12 h的乳酸值及PPI值，并计算患者0~6 h、0~12 h乳酸清除率。利用COX回归筛选预测脓毒性休克患者预后的独立因素，绘制受试者操作特征曲线(receiver operator characteristic curve,ROC曲线)，分析PPI参数联合APACHEⅡ评分预测患者预后的曲线下面积(area under the curve,AUC)。结果：与死亡组患者相比，存活组GCS评分、0 hPPI、6 hPPI、12 hPPI、0~12 h乳酸清除率较高，年龄、SOFA评分、APACHEⅡ评分、0 h乳酸、12 h乳酸较低(均P<0.05)；COX回归发现12 hPPI为患者预后的独立预测因子，预测脓毒性休克患者预后AUC为0.945，12 hPPI联合预测APACHEⅡ评分预测患者预后AUC为0.996。结论：入院后12 h PPI联合APACHEⅡ评分对脓毒性休克患者28 d预后具有良好的预测价值。

关键词: 外周灌注指数, 脓毒性休克, APACHEⅡ评分, 乳酸清除率, 预后

Abstract:

Objective To study the value of peripheral perfusion index (PPI) combined with acute physiology and chronic evaluation Ⅱ(APACHEⅡ) score in predicting prognosis of septic shock patients. Methods A total of 200 patients diagnosed as septic shock in the emergency department of Xinjiang Medical University First Affiliated Hospital from January to August 2023 were prospectively included. The patients were divided into survival group (84 cases) and death group (116 cases) according to their 28-day prognosis. The patients’ information including name, age, gender, vital signs after admission, Glasgow coma scale(GCS), sepsis-related organ failure assessment(SOFA), APACHEⅡ, infection site, fluid intake within 24 h of admission, antibiotic use, past medical history, types and 24 h doses of vasopressors used, mechanical ventilation status, complete blood count, liver function, renal function, coagulation indicators, onset time, and 28-day prognosis outcomes were recorded. The lactate and PPI values of the two groups of patients were measured at the time of admission (0 h), 6 h after admission, and 12 h after admission, and the lactate clearance rate at 0-6 h and 0-12 h was calculated. Cox regression was used to screen independent factors for predicting the prognosis of septic shock patients, and the area under the ROC curve(AUC) was plotted. PPI parameter combined with APACHEⅡ score were analyzed in predicting AUC, which represented patients’ prognosis. Results Compared with the death group, the survival group had higher GCS score, 0 hPPI, 6 hPPI, 12 hPPI, 0-12 h lactic acid clearance rate, and lower in age, SOFA score, APACHEⅡ score, 0 h lactic acid, 12 h lactic acid (all P<0.05). COX regression showed that 12 hPPI was an independent predictor of the prognosis of patients with septic shock, and the AUC for predicting the prognosis of patients with septic shock was 0.945, and the 12 hPPI combined with APACHEⅡ score for predicting AUC as the prognosis of patients with was 0.996. Conclusions 12 hPPI combined with APACHEⅡ score after admission has good prognostic value for 28-day prognosis of patients with septic shock.

Key words: Peripheral perfusion index, Septic shock, APACHEⅡ score, Lactic acid clearance, Prognosis

中图分类号:

R631

巩皓, 迟骋, 张晓霞. 外周灌注指数联合APACHE Ⅱ评分预测脓毒性休克患者28天预后的价值[J]. 内科理论与实践, 2024, 19(03): 174-179.

GONG Hao, CHI Cheng, ZHANG Xiaoxia. Value of peripheral perfusion index combined with APACHEⅡ score in predicting 28-day prognosis of patients with septic shock[J]. Journal of Internal Medicine Concepts & Practice, 2024, 19(03): 174-179.

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参考文献 23

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指标	存活组(n=84)	死亡组(n=116)	t/Z/χ²	P
年龄(岁)	57(49,69)	67(59,77)	-3.753	<0.001
男性[n(%)]	48(57.1)	76(65.5)	1.450	0.228
GCS(分)	15(5,15)	3(3,3)	-9.749	<0.001
SOFA(分)	6(4,8)	12(10,14)	-10.351	<0.001
APACHEⅡ(分)	19(16,24)	37(32,40)	-11.525	<0.001
体温(℃)	36(36,39)	36(36,38)	-0.806	0.420
脉搏(次/min)	126±41	114±42	1.823	0.358
MAP(mmHg)	61(51,65)	61(51,66)	-0.773	0.440
呼吸(次/min)	26±8	25±8	0.818	0.701
氧合指数(mmHg)	185±97	195±98	-0.692	0.927
白细胞(×10⁹/L)	11(7,16)	11(7,16)	-0.124	0.901
血红蛋白(g/L)	112±40	108±39	0.686	0.982
血小板(×10⁹/L)	165(125,244)	166(127,236)	-0.288	0.773
胆红素(μmol/L)	16(10,27)	16(11,27)	-0.067	0.947
ALT(>2 ULN)[n(%)]	7（17.5）	33（82.5）	12.320	<0.001
AST(>2 ULN)[n(%)]	8(11.4)	62(88.6)	41.318	<0.001
肌酐(μmol/L)	100(65,255)	99(69,252)	-0.203	0.839
白介素-6(ng/L)	104(30,1 878)	102(38,1 507)	-0.188	0.851
降钙素原(μg/L)	1.5(0.3,11.8)	1.0(0.2,9.3)	-0.594	0.552
24 h补液量(mL)	3 386±1 914	4 895±2 090	-5.218	<0.001
24 h去甲肾上腺素剂量(mL)	0(0,50)	100(50,200)	-7.774	<0.001
24 h多巴酚丁胺剂量(mL)	0.5±5.4	4.3±14.0	-2.584	<0.001
24 h多巴胺剂量(mL)	0(0,50)	50(0,100)	-4.928	<0.001
PT(s)	13(11,15)	14(12,21)	-4.017	<0.001
APTT(s)	28±3	33±6	-7.303	<0.001
D-二聚体(μg/L)	1 076(471,3 427)	1 159(262,5 588)	-0.498	0.619
感染部位[n(%)]			0.141	0.932
肺部	59(70.2)	81(69.8)
腹盆腔	16(19.0)	24(20.7)
其他(颅内、肠道、透析管路、足部)	9(10.7)	11(9.5)
发病时间(h)	8(2,48)	5(0,20)	-3.442	<0.001
机械通气[n(%)]	21(25.0)	91(78.4)	56.485	<0.001

抗菌药物	存活组(n=84)	死亡组(n=116)	χ²	P
碳青霉烯类	32(48.5)	66(63.5)	6.892	0.009
头孢类	29(43.9)	26(25.0)	3.584	0.058
喹诺酮类	5(7.6)	12(11.5)	1.209	0.272
联合用药	9(12.0)	5(4.6)	3.069	0.080

血管活性药物	存活组(n=84)	死亡组(n=116)	χ²	P
去甲肾上腺素	25(52.1)	89(50.3)	43.839	<0.001
多巴酚丁胺	1(2.1)	10(5.6)	3.844	0.05
多巴胺	22(45.8)	78(44.1)	32.841	<0.001

指标	存活组(n=84)	死亡组(n=116)	Z	P
0 h乳酸(mmol/L)	2.30(2.00,4.40)	4.15(3.03,6.40)	-6.278	<0.001
6 h乳酸(mmol/L)	1.50(1.20，2.30)	4.15(2.70，7.25)	-7.946	<0.001
12 h乳酸(mmol/L)	1.20(1.00,1.98)	2.95(2.20,6.20)	-7.835	<0.001
0 hPPI	0.84(0.60,1.74)	0.44(0.27,0.82)	-4.996	<0.001
6 hPPI	1.92(0.87,2.62)	0.76(0.42,1.35)	-7.298	<0.001
12 hPPI	3.24(2.22,4.08)	0.92(0.46,1.53)	-10.272	<0.001
0~6 h乳酸清除率（%）	38.10(18.44,54.37)	15.84(-34.00,38.62)	-4.926	<0.001
0~12 h乳酸清除率（%）	91.29(62.96,142.86)	40.37(-27.12,118.59)	-4.450	<0.001

指标	β	SE	Wald	HR	95%CI	P
年龄	0.017	0.006	9.485	1.017	1.006~1.029	0.002
SOFA	0.248	0.025	94.654	1.281	1.219~1.347	<0.001
APACHE Ⅱ	0.106	0.010	107.473	1.112	1.090~1.134	<0.001
24 h补液量	0.000	0.000	36.181	1.000	1.000~1.000	<0.001
24 h去甲肾上腺素剂量	0.007	0.001	65.880	1.007	1.005~1.009	<0.001
24 h多巴酚丁胺剂量	0.013	0.007	3.567	1.013	1.000~1.026	0.059
24 h多巴胺剂量	0.005	0.001	25.312	1.005	1.003~1.007	<0.001
0 h乳酸	0.082	0.023	12.436	1.085	1.037~1.136	<0.001
6 h乳酸	0.125	0.020	40.194	1.133	1.090~1.178	<0.001
12 h乳酸	0.160	0.021	60.350	1.174	1.127~1.222	<0.001
0 hPPI	-0.903	0.184	24.103	0.405	0.282~0.581	<0.001
6 hPPI	-0.921	0.139	44.193	0.398	0.303~0.522	<0.001
12 hPPI	-1.237	0.126	96.614	0.290	0.227~0.371	<0.001
0~12 h乳酸清除率	-0.003	0.001	9.103	0.997	0.995~0.999	0.003