国家早期预警评分联合肾上腺髓质中段肽及降钙素原对脓毒症患者预后的预测价值研究

doi:10.12114/j.issn.1007-9572.2020.00.272

摘要/Abstract

摘要： 背景　目前脓毒症仍具有较高的发病率和死亡率，对其预后的评估方法一直是研究的热点。近年来临床上越来越多地将国家早期预警评分（NEWS）、肾上腺髓质中段肽（MR-proADM）及降钙素原（PCT）应用于评估脓毒症患者的预后，但评估效能中等。三者联合是否有更高的评估效能，尚缺乏相关研究。目的　探讨NEWS联合MR-proADM及PCT对脓毒症患者预后的预测价值，以期为急诊科医生对脓毒症患者的预后做出有效评估提供帮助。方法　回顾性选取2016年6月—2019年6月海南医学院第二附属医院急诊科收治的脓毒症患者112例为研究对象。收集患者一般资料、NEWS、MR-proADM及PCT水平。根据患者28 d预后情况将其分为死亡组和存活组。采用Logistic回归分析探讨脓毒症患者28 d死亡的危险因素；绘制受试者工作特征曲线（ROC曲线）并评估各指标对脓毒症患者28 d死亡的预测价值。结果　随访28 d后24例（21.4%）患者死亡（死亡组），88例（78.6%）患者存活（存活组）。死亡组年龄、NEWS、MR-proADM、PCT高于存活组（P1~3、>3~5、>5分患者死亡率高于NEWS≤1分患者，NEWS>5分患者死亡率高于NEWS>1~3分患者（P4.6 nmol/L患者死亡率高于MR-proADM≤1.2、>1.2~2.5 nmol/L患者（P3.6 μg/L患者死亡率高于PCT≤0.8、>0.8~1.4 μg/L患者（P<0.05）。多因素Logistic回归分析结果显示，NEWS〔OR=1.321，95%CI（1.070，1.630）〕、MR-proADM〔OR=1.254，95%CI（1.062，1.480）〕、PCT〔OR=1.179，95%CI（1.049，1.326）〕为脓毒症患者28 d死亡的危险因素（P<0.05）。NEWS、MR-proADM、PCT三者联合预测脓毒症患者28 d死亡的ROC曲线下面积（AUC）大于NEWS、MR-proADM、PCT单独预测脓毒症患者28 d死亡的AUC（Z=2.670，P=0.007；Z=2.104，P=0.043；Z=2.449，P=0.014）。结论　NEWS、MR-proADM、PCT与脓毒症患者预后密切相关，为28 d死亡的独立危险因素，三者联合能有效评估脓毒症患者的预后。

关键词: 脓毒症, 国家早期预警评分, 肾上腺髓质中段肽, 降钙素原, 预后, 预测

Abstract: Background　At present，sepsis still has high morbidity and mortality，and the evaluation method of its prognosis has been a hot topic.In recent years，the national early warning score（NEWS），midregional-proadrenomedullin（MR-proADM）and procalcitonin（PCT）have been widely used to independently evaluate the prognosis in patients with sepsis，but the evaluation efficiency of each of them is moderate.Whether the combination of the three has higher evaluation efficiency is still lack of relevant research.Objective　To explore the prognostic value of NEWS combined with MR-proADM and PCT in patients with sepsis，to provide help for emergency physicians to make an appropriate evaluation of the prognosis of such patients.Methods　A total of 112 patients with sepsis admitted to Department of Emergency，the Second Affiliated Hospital of Hainan Medical University from June 2016 to June 2019 were retrospectively selected.General data，NEWS，MR-proADM and PCT were collected.The patients were divided into the survival group and death group according to 28-day prognosis．The risk factors for 28-day mortality were explored by Logistic regression analysis.And the receiver operating characteristic（ROC）curve analysis was performed to evaluate the value of NEWS，MR-proADM and PCT，alone or in combination，in predicting 28-day mortality.Results　During the 28 days of follow-up，88（78.6%）patients survived（survival group），and 24（21.4%）died（death group）.The mean age，and mean levels of NEWS，MR-proADM and PCT in the death group were greater than those of survival group（P<0.05）.The mortality of patients with NEWS >1-3，>3-5，>5 was higher than that of those with NEWS≤1（P<0.05）.And the mortality of patients with NEWS>5 was higher than that of those with NEWS>1-3（P<0.05）.The mortality of patients with MR-proADM >4.6 nmol/L was higher than that of those with MR-proADM≤1.2 or >1.2-2.5 nmol/L（P<0.05）.The mortality of patients with PCT>3.6 μg/L was higher than that of those with PCT≤ 0.8 or > 0.8-1.4 μg/L（P<0.05）.Multivariate Logistic regression analysis showed that NEWS〔OR=1.321，95%CI（1.070，1.630）〕，MR-proADM〔OR=1.254，95%CI（1.062，1.480）〕 and PCT〔OR=1.179，95%CI（1.049，1.326）〕were independently associated with 28-day mortality（P<0.05）.The area under the ROC curve（AUC）of NEWS combined with MR-proADM and PCT for predicting 28-day mortality was significantly greater than that of each marker alone（Z=2.670，P=0.007；Z=2.104，P=0.043；Z=2.449，P=0.014）.Conclusion　NEWS，MR-proADM and PCT were closely related to the prognosis，and were independently associated with 28-day mortality in patients with sepsis．The combination of the three had higher capability to predict 28-day mortality than each alone．

Key words: Sepsis, National early warning score, Midregional-proadrenomedullin, Procalcitonin, Prognosis, Forecasting

王惠文,邢柏*. 国家早期预警评分联合肾上腺髓质中段肽及降钙素原对脓毒症患者预后的预测价值研究[J]. 中国全科医学, 2020, 23(21): 2647-2652. DOI: 10.12114/j.issn.1007-9572.2020.00.272.
WANG Huiwen,XING Bo. Prognostic value of national early warning score combined with midregional-proadrenomedullin and procalcitonin in patients with sepsis[J]. Chinese General Practice, 2020, 23(21): 2647-2652. DOI: 10.12114/j.issn.1007-9572.2020.00.272.

参考文献

［1］VAN VUGHT L A，KLEIN KLOUWENBERG P M，SPITONI C，et al．Incidence，risk factors，and attributable mortality of secondary infections in the intensive care unit after admission for sepsis［J］．JAMA，2016，315（14）：1469-1479．DOI： 10.1001/jama.2016.2691. ［2］SEYMOUR C W，LIU V X，IWASHYNA T J，et al．Assessment of clinical criteria for sepsis：for the third international consensus definitions for sepsis and septic shock（Sepsis-3）［J］．JAMA，2016，315（8）：762-774．DOI： 10.1001/jama.2016.0288. ［3］ABRAHAM E.New definitions for sepsis and septic shock：continuing evolution but with much still to be done［J］．JAMA，2016，315（8）：757-759．DOI：10.1001/jama.2016.0290. ［4］ANDALUZ-OJEDA D，NGUYEN H B，MEUNIER-BEILLARD N，et al．Superior accuracy of mid-regional proadrenomedullin for mortality prediction in sepsis with varying levels of illness severity［J］．Ann Intensive Care，2017，7（1）：15．DOI： 10.1186/s13613-017-0238-9. ［5］KEEP J W，MESSMER A S，SLADDEN R，et al．National early warning score at Emergency Department triage may allow earlier identification of patients with severe sepsis and septic shock：a retrospective observational study［J］．Emerg Med J，2016，33（1）：37-41．DOI：10.1136/emermed-2014-204465. ［6］尹承芬，李彤，高心晶，等．降钙素原对成人脓毒症诊断准确性的Meta分析［J］．中华危重病急救医学，2015，27（9）：743-749．DOI：10.3760/cma.j.issn.2095-4352.2015.09.009. YIN C F，LI T，GAO X J，et al．Accuracy of procalcitonin for diagnosis of sepsis in adults：a meta-analysis［J］．Chinese Critical Care Medicine，2015，27（9）：743-749．DOI：10.3760/cma.j.issn.2095-4352.2015.09.009. ［7］王长远，曹涛，汤辉，等．NEWS评分MEWS评分和APACHEⅡ评分对急诊内科抢救室患者的评估价值［J］．中国急救医学，2017，37（2）：123-126．DOI：10.3969/j.issn.1002-1949.2017.02.007. WANG C Y，CAO T，TANG H，et al．Use of NEWS，MEWS and APACHE Ⅱ score in predicting outcomes in patients of internal emergency room［J］．Chinese Journal of Critical Care Medicine，2017，37（2）：123-126．DOI：10.3969/j.issn.1002- 1949.2017.02.007. ［8］CHURPEK M M，SNYDER A，HAN X，et al．Quick sepsis-related organ failure assessment，systemic inflammatory response syndrome，and early warning scores for detecting clinical deterioration in infected patients outside the intensive care unit［J］．Am J Respir Crit Care Med，2017，195（7）：906-911．DOI：10.1164/rccm.201604-0854OC. ［9］宋琳琳，王琰，张向阳，等．NEWS、MEWS和MEDS对急诊感染患者预后的评估价值比较［J］．中国急救医学，2018，38（6）：465-470．DOI：10.3969/j.issn.1002-1949.2018.06.001. SONG L L，WANG Y，ZHANG X Y，et al．Comparison of NEWS，MEWS and MEDS scores for predicting mortality in emergency depart-ment patients with infection［J］．Chinese Journal of Critical Care Medicine，2018，38（6）：465-470．DOI： 10.3969/j.issn.1002-1949.2018.06.001. ［10］汪颖，王迪芬，付江泉，等．SOFA、qSOFA评分和传统指标对脓毒症预后的判断价值［J］．中华危重病急救医学，2017，29（8）：700-704．DOI：10.3760/cma.j.issn.2095-4352.2017.08.006. WANG Y，WANG D F，FU J Q，et al．Predictive value of SOFA，qSOFA score and traditional evaluation index on sepsis prognosis［J］．Chinese Critical Care Medicine，2017，29（8）：700-704．DOI：10.3760/cma.j.issn.2095-4352.2017.08.006. ［11］VALENZUELA-SáNCHEZ F，VALENZUELA-MéNDEZ B，RODRíGUEZ-GUTIéRREZ J F，et al．New role of biomarkers：mid-regional pro-adrenomedullin，the biomarker of organ failure［J］．Ann Transl Med，2016，4（17）：329．DOI： 10.21037/atm.2016.08.65. ［12］SCHUETZ P，MARLOWE R J，MUELLER B.The prognostic blood biomarker proadrenomedullin for outcome prediction in patients with chronic obstructive pulmonary disease（COPD）：a qualitative clinical review［J］．Clin Chem Lab Med，2015， 53（4）：521-539．DOI：10.1515/cclm-2014-0748. ［13］PACCHIAROTTI A，CARLOMAGNO G，ANTONINI G，et al．Effect of myo-inositol and melatonin versus myo-inositol，in a randomized controlled trial，for improving in vitro fertilization of patients with polycystic ovarian syndrome［J］． Gynecol Endocrinol，2016，32（1）：69-73．DOI：10.3109/09513590.2015.1101444. ［14］毛云，盛孝燕，朱红阳，等．血清降钙素原和可溶性髓样细胞触发受体-1及可溶性CD14亚型水平联合预测脓毒症患者28d病死率的价值研究［J］．中国全科医学，2017，20（36）：4494-4500．DOI：10.3969/j.issn.1007-9572.2017.00.177. MAO Y，SHENG X Y，ZHU H Y，et al．Predictive value of serum PCT，sTREM-1 and presepsin levels for 28-day mortality among patients with sepsis［J］．Chinese General Practice，2017，20（36）：4494-4500．DOI：10.3969/j.issn.1007- 9572.2017.00.177. ［15］JO S，YOON J，LEE J B，et al．Predictive value of the National Early Warning Score-Lactate for mortality and the need for critical care among general emergency department patients［J］．J Crit Care，2016，36：60-68．DOI： 10.1016/j.jcrc.2016.06.016. ［16］NICKEL C H，KELLETT J，COOKSLEY T，et al．Combined use of the National Early Warning Score and D-dimer levels to predict 30-day and 365-day mortality in medical patients［J］．Resuscitation，2016，106：49-52．DOI： 10.1016/j.resuscitation.2016.06.012. ［17］ABBOTT T E F，TORRANCE H D T，CRON N，et al．A single-centre cohort study of National Early Warning Score（NEWS）and near patient testing in acute medical admissions［J］．Eur J Intern Med，2016，35：78-82．DOI： 10.1016/j.ejim.2016.06.014. ［18］MOHAMMED M A，RUDGE G，WATSON D，et al．Index blood tests and national early warning scores within 24 hours of emergency admission can predict the risk of in-hospital mortality：a model development and validation study［J］．PLoS One，2013，8（5）：e64340．DOI：10.1371/journal.pone.0064340.

[1]	彰金, 丁治国, 祁烁, 李颖, 李伟强, 张媛媛, 周通. 血清甲状腺激素水平与心力衰竭患者住院期间预后的相关性研究[J]. 中国全科医学, 2023, 26(33): 4125-4129.
[2]	王秋实, 李虹伟. CHA₂DS₂-VASc卒中风险评分对冠心病三支血管或左主干病变患者主要不良心血管事件的预测价值研究[J]. 中国全科医学, 2023, 26(33): 4130-4136.
[3]	张思宇, 周郁秋, 杜晓慧, 王正君. 精神病未治期及其早期干预的研究进展[J]. 中国全科医学, 2023, 26(33): 4110-4117.
[4]	王瑜, 陈焱, 韩元元, 徐清, 陈胜岳, 吕智博, 卢川, 郑铭鑫, 赵昕. 血小板-淋巴细胞比值可预测老年急性心肌梗死患者住院期间死亡风险[J]. 中国全科医学, 2023, 26(33): 4137-4142.
[5]	孟江涛, 杨思宇, 孙蕾, 雷瑞宁, 赵晓霞. 弥散张量成像联合运动诱发电位评估脑梗死偏瘫患者运动功能预后价值的研究进展[J]. 中国全科医学, 2023, 26(32): 4098-4102.
[6]	张继方, 陈芳, 唐佳雯, 李红亮. 肿瘤出芽及肿瘤浸润淋巴细胞对食管鳞状细胞癌淋巴结转移的预测价值研究[J]. 中国全科医学, 2023, 26(32): 4038-4042.
[7]	闫可, 魏菀怡, 李曙光, 么伟楠, 董静, 王晓斌, 张雪原, 杨洁, 沈文斌, 祝淑钗. 巩固化疗对接受根治性同步放化疗的临床Ⅱ~Ⅲ期食管鳞状细胞癌患者预后的影响分析[J]. 中国全科医学, 2023, 26(30): 3772-3779.
[8]	温雯, 张凯楠, 陈玉岚, 李瑜, 张向阳. 代谢指数作为预测因子与阻塞性睡眠呼吸暂停的相关性分析[J]. 中国全科医学, 2023, 26(30): 3740-3747.
[9]	闫可, 魏菀怡, 邓文钊, 沈文斌, 李曙光, 杜星语, 张雪原, 杨洁, 祝淑钗. 颈胸上段食管鳞癌根治性同步放化疗远期预后分析及影响因素研究[J]. 中国全科医学, 2023, 26(30): 3785-3790.
[10]	马艳艳, 任付先, 王宇, 高登峰. （中性粒细胞+单核细胞）/淋巴细胞比值对心力衰竭患者住院死亡的预测价值研究[J]. 中国全科医学, 2023, 26(30): 3791-3796.
[11]	施晓琦, 罗南都, 黄娇娇, 杜作晨, 黄佩, 曹秀丽, 陈艳, 何志旭. 天冬氨酸氨基转移酶/丙氨酸氨基转移酶与儿童噬血细胞性淋巴组织细胞增生症预后的相关性研究[J]. 中国全科医学, 2023, 26(30): 3801-3808.
[12]	王珍, 申国旗, 李亚南, 朱英华, 仇航, 郑迪, 徐通达, 李文华. 急性心肌梗死患者行经皮冠状动脉介入治疗术后发生对比剂急性肾损伤风险预测模型的建立与验证研究[J]. 中国全科医学, 2023, 26(29): 3650-3656.
[13]	汤时蓝, 谢可欣, 刘玲谕, 齐甜甜, 杨燕绥. 慢性意识障碍患者康复预后及照护研究进展[J]. 中国全科医学, 2023, 26(27): 3342-3348.
[14]	《乌司他丁用于临床常见急危重症的专家共识》专家组. 乌司他丁用于临床常见急危重症的专家共识[J]. 中国全科医学, 2023, 26(26): 3207-3219.
[15]	李梓盟, 王荣, 陈帅, 赵彩丽, 王晓聪, 温雅璐, 刘龙. 基于metaPRS与APOEε4优化轻度认知障碍遗传风险统计建模策略的应用研究[J]. 中国全科医学, 2023, 26(25): 3104-3111.