中国中西医结合急救杂志
中國中西醫結閤急救雜誌
중국중서의결합급구잡지
INTEGRATED TRADITIONAL CHINESE AND WESTERN MEDICINE IN PRACTICE OF CRITICAL CARE MEDICINE
2014年
1期
58-62
,共5页
王锁柱%李丽娟%赵磊%盛博%古旭云%陈炜
王鎖柱%李麗娟%趙磊%盛博%古旭雲%陳煒
왕쇄주%리려연%조뢰%성박%고욱운%진위
感染性休克%N末端B型钠尿肽前体%血管外肺水指数%预后
感染性休剋%N末耑B型鈉尿肽前體%血管外肺水指數%預後
감염성휴극%N말단B형납뇨태전체%혈관외폐수지수%예후
Septic shock%N-terminal pro-B-type natriuretic peptide%Extravascular lung water index%Prognosis
目的：探讨感染性休克患者血浆N末端B型钠尿肽前体（NT-proBNP）水平动态变化与血管外肺水指数（EVLWI）的相关性。方法选择首都医科大学附属北京世纪坛医院重症医学科62例感染性休克患者，按28 d生存情况分为存活组（39例）和死亡组（23例），于入重症监护病房（ICU）后取静脉血，分析血浆NT-proBNP水平和血流动力学指标变化及其对临床结局的预测价值。结果存活组患者入ICU 24 h内急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分（分：23.2±2.5比28.1±2.6）、序贯器官衰竭评分〔SOFA评分（分）：7.74±2.80比12.43±3.00〕及入院后72 h时血流动力学指标EVLWI〔mL/kg：7.0（6.0，8.0）比9.0（7.0，12.0）〕、血乳酸（mmol/L：3.60±2.30比10.40±2.70）和NT-proBNP〔ng/L：945.0（228.0，1246.0）比5471.0（3308.0，11174.0）〕水平均明显低于死亡组。心排血指数〔CI（L?min-1?m-2）：4.23±0.85比3.31±0.74〕、全心射血分数（GEF：0.205±0.054比0.149±0.054）均明显高于死亡组（P＜0.05或P＜0.01）。相关分析显示，NT-proBNP与EVLWI呈显著正相关（r＝0.277，P＝0.010），与CI、GEF呈显著负相关（r1＝-0.367，P1＝0.001；r2＝-0.259，P2＝0.017），而与GEDVI、SVRI无明显相关性。受试者工作特征曲线（ROC曲线）显示，血浆NT-proBNP预测感染性休克患者结局的ROC曲线下面积（AUC）为0.869±0.042，95%可信区间（95%CI）为0.786～0.952，以敏感度和特异度之和的最大值1.695确定NT-proBNP预测感染性休克患者死亡的截断值（cut-off）为2071 ng/L，在此截断值下的敏感度为81.4%，特异度为88.1%。EVLWI预测感染性休克患者结局的AUC最大值0.690，截断值为7.5 mL/kg，在此截断值下敏感度为69.8%，特异度为66.7%。CI预测感染性休克患者结局的AUC最大值0.785，截断值为3.48 L?min-1?m-2，在此截断值下敏感度为69.8%，特异度为66.7%。GEF预测感染性休克患者结局的AUC最大值0.794，截断值为0.175，在此截断值下敏感度为76.2%，特异度为81.4%。多因素分析显示，CI和NT-proBNP水平是预后的独立预测因素〔CI：P＝0.001，优势比（OR）＝9.183，95%CI为2.362～35.694；NT-proBNP：P＝0.024，OR＝1.000，95%CI为0.999～1.000〕。结论血浆NT-proBNP水平可评价感染性休克患者病情的严重程度，其与EVLWI有明显的相关性，且可预测感染性休克患者的预后。
目的：探討感染性休剋患者血漿N末耑B型鈉尿肽前體（NT-proBNP）水平動態變化與血管外肺水指數（EVLWI）的相關性。方法選擇首都醫科大學附屬北京世紀罈醫院重癥醫學科62例感染性休剋患者，按28 d生存情況分為存活組（39例）和死亡組（23例），于入重癥鑑護病房（ICU）後取靜脈血，分析血漿NT-proBNP水平和血流動力學指標變化及其對臨床結跼的預測價值。結果存活組患者入ICU 24 h內急性生理學與慢性健康狀況評分繫統Ⅱ（APACHEⅡ）評分（分：23.2±2.5比28.1±2.6）、序貫器官衰竭評分〔SOFA評分（分）：7.74±2.80比12.43±3.00〕及入院後72 h時血流動力學指標EVLWI〔mL/kg：7.0（6.0，8.0）比9.0（7.0，12.0）〕、血乳痠（mmol/L：3.60±2.30比10.40±2.70）和NT-proBNP〔ng/L：945.0（228.0，1246.0）比5471.0（3308.0，11174.0）〕水平均明顯低于死亡組。心排血指數〔CI（L?min-1?m-2）：4.23±0.85比3.31±0.74〕、全心射血分數（GEF：0.205±0.054比0.149±0.054）均明顯高于死亡組（P＜0.05或P＜0.01）。相關分析顯示，NT-proBNP與EVLWI呈顯著正相關（r＝0.277，P＝0.010），與CI、GEF呈顯著負相關（r1＝-0.367，P1＝0.001；r2＝-0.259，P2＝0.017），而與GEDVI、SVRI無明顯相關性。受試者工作特徵麯線（ROC麯線）顯示，血漿NT-proBNP預測感染性休剋患者結跼的ROC麯線下麵積（AUC）為0.869±0.042，95%可信區間（95%CI）為0.786～0.952，以敏感度和特異度之和的最大值1.695確定NT-proBNP預測感染性休剋患者死亡的截斷值（cut-off）為2071 ng/L，在此截斷值下的敏感度為81.4%，特異度為88.1%。EVLWI預測感染性休剋患者結跼的AUC最大值0.690，截斷值為7.5 mL/kg，在此截斷值下敏感度為69.8%，特異度為66.7%。CI預測感染性休剋患者結跼的AUC最大值0.785，截斷值為3.48 L?min-1?m-2，在此截斷值下敏感度為69.8%，特異度為66.7%。GEF預測感染性休剋患者結跼的AUC最大值0.794，截斷值為0.175，在此截斷值下敏感度為76.2%，特異度為81.4%。多因素分析顯示，CI和NT-proBNP水平是預後的獨立預測因素〔CI：P＝0.001，優勢比（OR）＝9.183，95%CI為2.362～35.694；NT-proBNP：P＝0.024，OR＝1.000，95%CI為0.999～1.000〕。結論血漿NT-proBNP水平可評價感染性休剋患者病情的嚴重程度，其與EVLWI有明顯的相關性，且可預測感染性休剋患者的預後。
목적：탐토감염성휴극환자혈장N말단B형납뇨태전체（NT-proBNP）수평동태변화여혈관외폐수지수（EVLWI）적상관성。방법선택수도의과대학부속북경세기단의원중증의학과62례감염성휴극환자，안28 d생존정황분위존활조（39례）화사망조（23례），우입중증감호병방（ICU）후취정맥혈，분석혈장NT-proBNP수평화혈류동역학지표변화급기대림상결국적예측개치。결과존활조환자입ICU 24 h내급성생이학여만성건강상황평분계통Ⅱ（APACHEⅡ）평분（분：23.2±2.5비28.1±2.6）、서관기관쇠갈평분〔SOFA평분（분）：7.74±2.80비12.43±3.00〕급입원후72 h시혈류동역학지표EVLWI〔mL/kg：7.0（6.0，8.0）비9.0（7.0，12.0）〕、혈유산（mmol/L：3.60±2.30비10.40±2.70）화NT-proBNP〔ng/L：945.0（228.0，1246.0）비5471.0（3308.0，11174.0）〕수평균명현저우사망조。심배혈지수〔CI（L?min-1?m-2）：4.23±0.85비3.31±0.74〕、전심사혈분수（GEF：0.205±0.054비0.149±0.054）균명현고우사망조（P＜0.05혹P＜0.01）。상관분석현시，NT-proBNP여EVLWI정현저정상관（r＝0.277，P＝0.010），여CI、GEF정현저부상관（r1＝-0.367，P1＝0.001；r2＝-0.259，P2＝0.017），이여GEDVI、SVRI무명현상관성。수시자공작특정곡선（ROC곡선）현시，혈장NT-proBNP예측감염성휴극환자결국적ROC곡선하면적（AUC）위0.869±0.042，95%가신구간（95%CI）위0.786～0.952，이민감도화특이도지화적최대치1.695학정NT-proBNP예측감염성휴극환자사망적절단치（cut-off）위2071 ng/L，재차절단치하적민감도위81.4%，특이도위88.1%。EVLWI예측감염성휴극환자결국적AUC최대치0.690，절단치위7.5 mL/kg，재차절단치하민감도위69.8%，특이도위66.7%。CI예측감염성휴극환자결국적AUC최대치0.785，절단치위3.48 L?min-1?m-2，재차절단치하민감도위69.8%，특이도위66.7%。GEF예측감염성휴극환자결국적AUC최대치0.794，절단치위0.175，재차절단치하민감도위76.2%，특이도위81.4%。다인소분석현시，CI화NT-proBNP수평시예후적독립예측인소〔CI：P＝0.001，우세비（OR）＝9.183，95%CI위2.362～35.694；NT-proBNP：P＝0.024，OR＝1.000，95%CI위0.999～1.000〕。결론혈장NT-proBNP수평가평개감염성휴극환자병정적엄중정도，기여EVLWI유명현적상관성，차가예측감염성휴극환자적예후。
Objective To study the dynamic change in plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels and its correlation with extravascular lung water index (EVLWI) in patients with septic shock. Methods Sixty-two patients with septic shock admitted to Department of Critical Care Medicine of Beijing Shijitan Hospital were enrolled. The patients were divided into survival group(39 cases)and non-survivors group (23 cases)according to 28-day prognosis. Venous blood was collected after intensive care unit(ICU)admission. The changes in plasma NT-proBNP and hemodynamics indexes levels were analyzed to evaluate their predictive value for clinical outcomes. Results Acute physiology and chronic health evaluation Ⅱ(APACHEⅡ)score(23.2±2.5 vs. 28.1±2.6),sequential organ failure assessment(SOFA score:7.74±2.80 vs. 12.43±3.00)and hemodynamics indexes including EVLWI〔ml/kg:7.0(6.0,8.0)vs. 9.0(7.0,12.0)〕,blood lactate(mmol/L):3.60±2.30 vs. 10.40±2.70)and NT-proBNP〔ng/L:945.0(228.0,1 246.0)vs. 5 471.0(3 308.0,11 174.0)〕in survivors were significantly lower than those in non-survivors,and cardiac index〔CI(L?min-1?m-2):4.23±0.85 vs. 3.31±0.74〕, global ejection fraction(GEF:0.205±0.054 vs. 0.149±0.054)were significantly higher than those in non-survivors (P<0.05 or P<0.01). Correlation analysis showed a positive correlation was found between NT-proBNP and EVLWI (r=0.277,P=0.010),and negative correlations were found between NT-proBNP and CI(r=-0.367,P=0.001), GEF(r=-0.259,P=0.017). No correlation was found between NT-proBNP and GEDVI,SVRI. Receiver operating characteristic curve(ROC curve)analysis showed that the area under the ROC curve(AUC)for plasma NT-proBNP predicting the outcome of septic shock patients was 0.869±0.042,95% confidence interval(95%CI)was 0.786-0.952,with the maximum sum of sensitivity and specificity 1.695 to determine NT-proBNP predicting septic shock patient's death cut-off value was 2 071 ng/L,under this cut-off value,the sensitivity was 81.4% and specificity,88.1%. The maximum AUC for EVLWI predicting the outcome of patients with septic shock was 0.690,cut-off value was 7.5 mL/kg,under this cut-off value,the sensitivity was 69.8% and specificity,66.7%. Maximum AUC for CI predicting the outcome of patients with septic shock was 0.785,cut-off value was 3.48 L?min-1?m-2,under this cut-off value,the sensitivity was 69.8%and specificity,66.7%. Maximum AUC for GEF predicting the outcome of septic shock patients was 0.794,cut-off value 0.175,under this cut-off value,the sensitivity was 76.2% and specificity, 81.4%. Multivariate analyses showed CI and NT-proBNP levels were independent predictors of the prognosis〔CI:P=0.001,odds ratio(OR)=9.183,95%CI 2.362-35.694;NT-proBNP:P=0.024,OR=1.000,95%CI 0.999-1.000〕. Conclusion The plasma NT-proBNP level which is correlated significantly to EVLWI can evaluate the severity of septic shock and can predict the prognosis of such patients.
