院外心脏骤停患者神经功能预后判断的回顾性研究

doi:10.16138/j.1673-6087.2022.06.005

摘要/Abstract

摘要：

目的：探讨神经系统体格检查各指标和血清神经元特异性烯醇化酶（neuron specific enolase，NSE）浓度对心脏骤停患者神经不良预后的预测价值。方法：回顾性研究院外心脏骤停患者，根据发病30 d的脑功能表现（cerebral performance category，CPC）分级分为良好组（CPC≤2级）和不良组（CPC≥3级）。血清NSE浓度和发病后3 d对光反射，根据格拉斯哥昏迷评分（Glasgow coma scale，GCS）测量的睁眼评分（eGCS）、肢体运动评分（mGCS）和两者之和（emGCS），计算3 d内eGCS改变（ΔeGCS）、mGCS改变（ΔmGCS）和emGCS改变情况（ΔemGCS）。使用重复测量评估相关性，利用Logistic回归分析寻找单因素和多因素预测指标。结果：不良组的NSE显著高于良好组（P<0.01）。3 d内ΔmGCS和ΔemGCS良好组显著高于不良组（P<0.05）。重复测量方差分析示eGCS、mGCS和emGCS与CPC分级呈负相关（P<0.001）。广义线性混合效应模型分析示不存在对光反射与心肺复苏的不良预后相关（P=0.002）。3 d eGCS、mGCS和emGCS，第2、3天对光反射，ΔmGCS、ΔemGCS和NSE为心脏骤停神经不良预后的单因素预测指标（P<0.05）。男性和第3天的mGCS低为心脏骤停患者神经不良预后的多因素预测指标（P<0.05）。结论：联合第3天的mGCS和性别为男性可预测心脏骤停患者不良神经系统预后。

关键词: 心脏骤停, 神经系统体格检查, 神经元特异性烯醇化酶, 预后, 神经功能

Abstract:

Objective To investigate the predictive power of neurological examination results and serum neuron specific enolase(NSE) concentration for the neurological outcome of cardiac arrest patients. Methods All cardiac arrest patients were retrospectively analyzed. They were divided into good outcome group [cerebral performance category (CPC)≤2] and poor outcome group (CPC≥3) according to CPC scores on day 30. According to Glasgow coma scale (GCS), serum NSE concentration, pupil light reflex, eye opening score (eGCS), limb movement score (mGCS) and the sum of two (emGCS) were compared between two groups. Repeated measures were used to evaluate the correlation, and Logistic regression analysis was used to explore the univariate and multivariate predictors. Results The serum NSE concentration in poor outcome group was significantly higher than that in good outcome group (P<0.01). The change of mGCS (Δ mGCS) and emGCS (Δ emGCS) within first 3 days in good outcome group was significantly higher than that in poor outcome group (P<0.05). Repeated measures ANOVA showed eGCS, mGCS and emGCS were significantly correlated with CPC grades(P<0.001). The analysis of generalized linear mixed model showed there was a significant correlation between absent of pupillary light reflex and poor neurological outcome (P=0.002). The eGCS, mGCS and emGCS in first 3 days, and presence of pupil light reflex on the second and third day, Δ mGCS, Δ emGCS and serum NSE levels were univariate predictors (P<0.05). Male and mGCS on day 3 were multivariate predictors (P<0.05). Conclusions The combination of male and mGCS on the 3rd day could be used to predict the poor neurological outcome in cardiac arrest patients.

Key words: Cardiac arrest, Neurological examination, Neuron specific enolase, Prognosis, Neurological function

中图分类号:

R541.78

李永德, 王杨, 李响, 李雯婕, 解迪, 江少伟, 葛晓利, 王海嵘, 高成金, 潘曙明. 院外心脏骤停患者神经功能预后判断的回顾性研究[J]. 内科理论与实践, 2022, 17(06): 447-452.

LI Yongde, WANG Yang, LI Xiang, LI Wenjie, XIE Di, JIANG Shaowei, GE Xiaoli, WANG Hairong, GAO Chengjin, PAN Shuming. A retrospective study on prediction of neurological outcome in cardiac arrest patients of out-hospital[J]. Journal of Internal Medicine Concepts & Practice, 2022, 17(06): 447-452.

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指标	预后良好组（n=30）	预后不良组（n=21）	P
女性	17 (56.67)	7 (33.33)	0.15
年龄（岁）	68.50±17.21	63.57±15.94	0.31
糖尿病	11 (36.67)	6 (28.57)	0.76
高血压	18 (60.00)	11 (52.38)	0.77
冠心病	17 (56.67)	12 (57.14)	1.00
电复律	6 (20.00)	4 (19.05)	1.00
多巴胺	20 (66.67)	15 (71.43)	0.77
去甲肾上腺素	10 (33.33)	6 (28.57)	0.77
ECMO	0 (0)	1 (4.76)	0.41
急性冠脉综合征	8 (26.67)	9 (42.86)	0.25
肺栓塞	2 (6.67)	1 (4.76)	1.00
窒息	3 (10.00)	1 (4.76)	0.63
重症心肌炎	1 (3.33)	1 (4.76)	1.00
重症肺炎	8 (26.67)	6 (28.57)	1.00
中毒	2 (6.67)	1 (4.76)	1.00
其他	6 (20.00)	2 (9.52)	0.45

项目	预后良好组（n=30）	预后不良组（n=21）	P
NSE（μg/L）	12.76 [10.60，16.61]	23.50 [14.44，33.12]	0.004
ΔeGCS（分）	0.00 [0.00，1.00]	0.00 [0.00，0.00]	0.335
ΔmGCS（分）	0.00 [0.00，1.00]	0.00 [0.00，0.00]	0.005
ΔemGCS（分）	1.00 [0.00，2.00]	0.00 [0.00，0.00]	0.019

参数	效应	F	P
eGCS	时间	14.117	<0.001
	分组	29.868	<0.001
	时间-分组	0.660	0.498
mGCS	时间	13.365	<0.001
	分组	32.477	<0.001
	时间-分组	7.340	0.001
emGCS	时间	20.761	<0.001
	分组	32.340	<0.001
	时间-分组	5.169	0.018
PLR	时间	0.068	0.934
	分组	9.527	0.002
	时间-分组	1.36	0.26

项目	预后良好组（n=30）			预后不良组（n=21）
项目	第1天	第2天	第3天	第1天	第2天	第3天
eGCS（分）	3.40±0.77	3.63±0.77^2）	3.77±0.63^2）3）	2.00±1.18	2.14±1.28	2.24±1.30^1）
mGCS（分）	4.13±1.11	4.57±1.19^2）	4.73±1.20^2）	2.29±1.55	2.33±1.56	2.38±1.63
emGCS（分）	7.53±1.81	8.20±1.86^2）	8.50±1.76^2）4）	4.29±2.72	4.48±2.80^1）	4.62±2.91^1）
存在PLR	28（93.33）	29（96.67）	29（96.67）	16（76.19）	13（61.90）	11（52.38）

模型	预测指标	OR	95%CI	P
单因素分析	第1天不存在PLR	4.375	0.759~25.204	0.099
	低eGCS	0.282	0.142~0.558	<0.001
	低mGCS	0.389	0.232~0.653	<0.001
	低emGCS	0.573	0.424~0.776	<0.001
	第2天不存在PLR	17.846	2.019~157.771	0.010
	低eGCS	0.304	0.162~0.573	<0.001
	低mGCS	0.359	0.209~0.616	<0.001
	低emGCS	0.565	0.420~0.761	<0.001
	第3天不存在PLR	26.364	3.011~230.815	0.003
	低eGCS	0.241	0.107~0.544	0.001
	低mGCS	0.375	0.227~0.621	0.000
	低emGCS	0.552	0.403~0.756	<0.001
	ΔeGCS	0.540	0.155~1.882	0.333
	ΔmGCS	0.143	0.030~0.690	0.015
	ΔemGCS	0.422	0.190~0.935	0.034
	NSE	1.081	1.002~1.165	0.044
	男性	2.615	0.820~8.339	0.100
	高龄	0.982	0.949~1.016	0.301
	糖尿病	1.447	0.435~4.821	0.547
	高血压	1.364	0.442~4.203	0.589
	冠心病	0.981	0.318~3.025	0.973
	可除颤心律	1.062	0.260~4.350	0.933
	ECMO	0.000	0.000	1.000
多因素分析	男性	9.667	1.285~72.727	0.028
	第3天mGCS	0.281	0.138~0.571	<0.001