摘要
目的观察脓毒症并发急性呼吸窘迫综合征(acute respiratory distress syndrome, ARDS)患者二尖瓣口舒张早期血流速度峰值(early diastolic transmitral velocity, E)/二尖瓣环舒张早期运动速度(early diastolic mitral annular velocity, Em)和血清可溶性血栓调节蛋白(serum soluble thrombomodulin, sTM)水平变化,探讨其与病情严重程度及预后的关系。方法脓毒症并发ARDS患者160例,根据病情严重程度分为重度组54例,中度组65例,轻度组41例。160例患者均给予规范治疗,治疗28 d内死亡72例为死亡组,存活88例为存活组。患者均于入院次日行超声心动图测量E/Em,采用ELISA法检测血清sTM水平。比较不同病情严重程度组E/Em及血清sTM水平;Pearson相关法分析脓毒症并发ARDS患者氧合指数(oxygenation index, OI)与E/Em、血清sTM水平的相关性;比较死亡组与存活组一般资料,E/Em及血清sTM水平;多因素logistic回归分析脓毒症并发ARDS患者治疗28 d内死亡的影响因素;绘制ROC曲线,评估E/Em、血清sTM预测脓毒症并发ARDS患者治疗28 d内死亡的价值。结果重度组E/Em(15.84±3.53)、血清sTM水平[(114.14±19.39)μg/L]均高于中度组[12.72±3.31、(100.28±63.92)μg/L]、轻度组[9.60±3.34、(83.76±10.36)μg/L](P<0.05),中度组均高于轻度组(P<0.05)。脓毒症并发ARDS患者OI与E/Em、血清sTM水平均呈负相关(r=—0.362,P<0.001;r=—0.317,P<0.001)。死亡组年龄[(67.06±4.73)岁]大于存活组[(64.92±5.48)岁](P<0.05),脓毒性休克比率(68.06%)、ICU住院时间≥10 d比率(63.89%)、机械通气时间≥3 d比率(58.33%)、急性生理和慢性健康评估Ⅱ(Acute Physiology and Chronic Health EvaluationⅡ, APACHEⅡ)评分[(24.12±6.35)分]、E/Em(15.37±3.14)、血乳酸[(4.17±1.14)mmol/L]及血清sTM[(113.01±21.54)μg/L]水平均高于存活组[48.86%、39.77%、36.36%、(14.15±3.92)分、10.81±4.18、(3.67±1.26)mmol/L、(90.67±11.19)μg/L](P<0.05),OI[(138.59±65.04)mm Hg]低于存活组[(235.83±79.56)mm Hg](P<0.05)。APACHEⅡ评分≥15分(OR=1.136,95%CI:0.987~1.309,P=0.044)、E/Em≥12.97(OR=1.387,95%CI:1.154~1.667,P<0.001)、血清sTM≥100.73μg/L(OR=1.082,95%CI:1.035~1.130,P<0.001)是脓毒症并发ARDS患者治疗28 d内死亡的独立危险因素,OI≥192.07 mm Hg(OR=0.986,95%CI:0.978~0.993,P<0.001)是独立保护因素。E/Em、血清sTM分别以12.09、102.08μg/L为最佳截断值,预测脓毒症并发ARDS患者治疗28 d内死亡的AUC分别为0.804(95%CI:0.733~0.862,P<0.001)、0.840(95%CI:0.774~0.893,P=0.002),灵敏度分别87.50%、72.22%,特异度分别为62.50%、87.50%;二者联合预测脓毒症并发ARDS患者治疗28 d内死亡的AUC为0.920(95%CI:0.877~0.962,P<0.001),灵敏度为76.39%,特异度为93.18%。E/Em、血清sTM联合预测脓毒症并发ARDS患者治疗28 d内死亡的AUC大于二者单独预测(Z=3.377,P=0.001;Z=2.153,P=0.002)。结论脓毒症并发ARDS患者E/Em和血清sTM水平增高提示病情重、近期预后不良,E/Em和血清sTM联合检测在评估脓毒症并发ARDS患者近期预后中有一定价值。
Objective To observe the changes of early diastolic transmitral velocity/early diastolic mitral annular velocity(E/Em) and serum soluble thrombomodulin(sTM) in sepsis patients with acute respiratory distress syndrome(ARDS), and to investigate the value of them two to the prediction of poor prognosis. Methods Totally 160 sepsis patients with ARDS were divided into severe group(n=54), moderate group(n=65) and mild group(n=41). After 28 days of treatment, 160 patients were divided into death group(n=28) and survival group(n=88). E/Em was measured by ultrasonography on the second day after admission, and the serum sTM level was detected by ELISA. The E/Em and serum sTM level were compared in patients with different severity. Pearson’s correlation method was used to analyze the correlations of oxygenation index(OI)with E/Em and serum sTM level.The general data,E/Em and serum sTM level were compared between death group and survival group.Multivariate logistic regression analysis was done to evaluate the influencing factors of death in 28 days of treatment.ROC curve was drawn to assess the value of E/Em combined with serum sTM level to the prediction of death in 28 days of treatment in sepsis patients with ARDS.Results E/Em and serum sTM level were higher in severe group[15.84±3.53,(114.14±19.39)μg/L]than those in moderate group[12.72±3.31,(100.28±63.92)μg/L)]and mild group[9.60±3.34,(83.76±10.36)μg/L)](P<0.05),and were higher in moderate group than those in mild group(P<0.05).OI was negatively correlated with E/Em and serum sTM level in sepsis patients with ARDS(r=-0.362,P<0.001;r=-0.317,P<0.001).The patients were older[(67.06±4.73)years],the percentages of patients with septic shock,leagth of ICU stay ≥10 dand mechanical ventilation time ≥ 3 d(68.06%,63.89%,58.33%), Acute Physiology and Chronic Health Evaluation Ⅱ(APACHEⅡ)score(24.12±6.35),blood lactate level[(4.17±1.14)mmol/L],E/Em(15.37±3.14),and sTM level[(113.01±21.54)μg/L]in death group were higher than those in survival group[(64.92±5.48)years,48.86%,39.77%,36.36%,14.15±3.92,(3.67±1.26)mmol/L,10.81±4.18,(90.67±11.19)μg/L](P<0.05),and OI was lower in death group [(138.59±65.04)mm Hg]than that in survival group [(235.83±79.56)mm Hg](P<0.05).APACHEⅡscore≥15(OR=1.136,95%CI:0.987-1.309,P=0.044),E/Em ≥12.97(OR=1.387,95%CI:1.154-1.667,P<0.001),and serum sTM ≥100.73μg/L(OR=1.082,95%CI:1.035-1.130,P<0.001)were the independent risk factors of death in 28 days of treatment in sepsis patients with ARDS,and OI≥192.07 mm Hg(OR=0.986,95%CI:0.978-0.993,P<0.001)was the independent protective factor.When the optimal cut-offvalues of E/EM and serum STM were 12.09 and 102.08μg/L,the AUCs of them two for predicting death in sepsis patients with ARDS in 28 days of treatment were 0.804(95%CI:0.733-0.862,P<0.001)and 0.840(95%CI:0.774-0.893,P=0.002),the sensitivities were 87.50% and 72.22%,and the specificities were 62.50% and 87.50%,respectively.The AUCof combined detection of them two for predicting death in 28 days of treatment in sepsis patients with ARDS was 0.920(95%CI:0.877-0.962,P<0.001),the sensitivity was 76.39%,and the specificity was 93.18%.The AUC of combined detection was greater than that of single detection of them two(Z=3.377,P=0.001;Z=2.153,P=0.002).Conclusion Increased E/Em and serum sTM level indicate aggravation of disease and poor short-term prognosis of sepsis patients with ARDS,and the combined detection of E/Em and serum sTM is of high value in assessing the short-term prognosis.
作者
郑艳妮
沙海旺
姜文娟
ZHENG Yan-ni;SHA Hai-wang;JIANG Wen-juan(Department of Critical Care Medicine,Affiliated Hospital of Yan'an University,Yan'an,Shaaxi 716000,China)
出处
《中华实用诊断与治疗杂志》
2022年第3期283-287,共5页
Journal of Chinese Practical Diagnosis and Therapy
基金
陕西省科研究发展计划项目(2017K16-02-29)。
