目的 提出一种综合预测危重创伤患者死亡的最佳评分指标死亡预警评分,为临床提供一种简便易行的评分方法.方法 回顾性分析2014年1月至12月第三军医大学西南医院、第三军医大学大坪医院、遵义医学院附属医院重症医学科收治的394例创伤患者的临床资料.根据患者住院期间临床结局分为存活组(330例)和死亡组(64例).记录两组患者的性别、年龄;入院后呼吸频率、心率、收缩压;入院24 h内血肌酐(SCr)、白细胞计数(WBC)、血小板计数(PLT)、红细胞比容(Hct)的最差值;确诊24 h内急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、格拉斯哥昏迷评分(GCS)、序贯器官衰竭评分(SOFA)、全身炎症反应综合征(SIRS)评分、损伤严重程度评分(ISS);24 h内是否行急诊手术或急诊插管;病程中是否发生脓毒症,以及临床结局.单因素分析两组患者的各项观察指标,对导致死亡的相关因素进一步行logistic回归分析,筛选出影响危重创伤患者死亡的危险因素,并对有统计学意义的指标予以赋值,总分为死亡预警评分;绘制受试者工作特征曲线(ROC),评价死亡预警评分对危重创伤患者死亡的预测价值.结果 与存活组比较,死亡组患者年龄大(岁:51.50±18.31比45.54±14.70,t=-2.456,P=0.016),SCr升高(μmol/L:94.18±65.51比72.42±28.22,t=-2.611,P=0.011),APACHEⅡ评分(分:24.30±6.23比16.38±6.19,t=-9.353,P＜0.001)和SOFA评分(分:7.84±3.68比4.43±2.75,t=-7.049,P＜0.001)升高,进行急诊插管[79.7％ (51/64)比42.7％(141/330),x2=29.309,P＜0.001]和发生脓毒症的比例[48.4％ (31/64)比30.3％ (100/330),x2=18.512,P＜0.001]也显著升高,PLT(×109/L:112.75±59.85比144.12±68.28,t=3.428,P=0.001)和GCS评分(分:6.44±4.20比11.02±3.93,t=8.449,P＜0.001)则显著降低;而两组性别、呼吸频率、心率、收缩压、WBC、Hct、SIRS评分、ISS、行急诊手术比例比较差异均无统计学意义.将单因素分析中有统计学意义的指标进行多因素logistic回归分析,进入回归模型的指标分别为年龄≥65岁[95％可信区间(95％CI) =0.176～1.974,P=0.019]、APACHEⅡ评分≥21分(95％CI=0.121 ～ 2.725,P=0.032)、GCS评分＜6分(95％CI=0.201 ～ 3.221,P=0.026)、发生严重脓毒症(95％CI=0.421～2.735,P=0.008)或脓毒性休克(95％CI=0.430 ～ 3.636,P=0.013),并将其分别赋值为1.0、1.5、1.5、1.5、2.0分,以这5个指标的总分作为死亡预警评分.ROC曲线分析显示:死亡预警评分预测危重创伤患者死亡的ROC曲线下面积(AUC)为0.867,明显高于APACHEⅡ评分(AUC为0.812,P=0.022)和GCS评分(AUC为0.783,P=0.001).当死亡预警评分的诊断阈值为1.5分时,敏感度为75.00％,特异度为85.40％,阳性预测值为50.0％,阴性预测值为94.6％,阳性似然比为5.16,阴性似然比为0.29,约登指数为0.605.结论 年龄≥65岁、APACHEⅡ评分≥21分、GCS＜6分、发生严重脓毒症或脓毒性休克是危重创伤患者死亡的危险因素,以这5个指标作为危重创伤患者的死亡预警评分,用它可以更加全面地评估危重创伤患者的预后,其预测效果优于单用任何一种评分.
目的 提齣一種綜閤預測危重創傷患者死亡的最佳評分指標死亡預警評分,為臨床提供一種簡便易行的評分方法.方法 迴顧性分析2014年1月至12月第三軍醫大學西南醫院、第三軍醫大學大坪醫院、遵義醫學院附屬醫院重癥醫學科收治的394例創傷患者的臨床資料.根據患者住院期間臨床結跼分為存活組(330例)和死亡組(64例).記錄兩組患者的性彆、年齡;入院後呼吸頻率、心率、收縮壓;入院24 h內血肌酐(SCr)、白細胞計數(WBC)、血小闆計數(PLT)、紅細胞比容(Hct)的最差值;確診24 h內急性生理學與慢性健康狀況評分繫統Ⅱ(APACHEⅡ)評分、格拉斯哥昏迷評分(GCS)、序貫器官衰竭評分(SOFA)、全身炎癥反應綜閤徵(SIRS)評分、損傷嚴重程度評分(ISS);24 h內是否行急診手術或急診插管;病程中是否髮生膿毒癥,以及臨床結跼.單因素分析兩組患者的各項觀察指標,對導緻死亡的相關因素進一步行logistic迴歸分析,篩選齣影響危重創傷患者死亡的危險因素,併對有統計學意義的指標予以賦值,總分為死亡預警評分;繪製受試者工作特徵麯線(ROC),評價死亡預警評分對危重創傷患者死亡的預測價值.結果 與存活組比較,死亡組患者年齡大(歲:51.50±18.31比45.54±14.70,t=-2.456,P=0.016),SCr升高(μmol/L:94.18±65.51比72.42±28.22,t=-2.611,P=0.011),APACHEⅡ評分(分:24.30±6.23比16.38±6.19,t=-9.353,P＜0.001)和SOFA評分(分:7.84±3.68比4.43±2.75,t=-7.049,P＜0.001)升高,進行急診插管[79.7％ (51/64)比42.7％(141/330),x2=29.309,P＜0.001]和髮生膿毒癥的比例[48.4％ (31/64)比30.3％ (100/330),x2=18.512,P＜0.001]也顯著升高,PLT(×109/L:112.75±59.85比144.12±68.28,t=3.428,P=0.001)和GCS評分(分:6.44±4.20比11.02±3.93,t=8.449,P＜0.001)則顯著降低;而兩組性彆、呼吸頻率、心率、收縮壓、WBC、Hct、SIRS評分、ISS、行急診手術比例比較差異均無統計學意義.將單因素分析中有統計學意義的指標進行多因素logistic迴歸分析,進入迴歸模型的指標分彆為年齡≥65歲[95％可信區間(95％CI) =0.176～1.974,P=0.019]、APACHEⅡ評分≥21分(95％CI=0.121 ～ 2.725,P=0.032)、GCS評分＜6分(95％CI=0.201 ～ 3.221,P=0.026)、髮生嚴重膿毒癥(95％CI=0.421～2.735,P=0.008)或膿毒性休剋(95％CI=0.430 ～ 3.636,P=0.013),併將其分彆賦值為1.0、1.5、1.5、1.5、2.0分,以這5箇指標的總分作為死亡預警評分.ROC麯線分析顯示:死亡預警評分預測危重創傷患者死亡的ROC麯線下麵積(AUC)為0.867,明顯高于APACHEⅡ評分(AUC為0.812,P=0.022)和GCS評分(AUC為0.783,P=0.001).噹死亡預警評分的診斷閾值為1.5分時,敏感度為75.00％,特異度為85.40％,暘性預測值為50.0％,陰性預測值為94.6％,暘性似然比為5.16,陰性似然比為0.29,約登指數為0.605.結論 年齡≥65歲、APACHEⅡ評分≥21分、GCS＜6分、髮生嚴重膿毒癥或膿毒性休剋是危重創傷患者死亡的危險因素,以這5箇指標作為危重創傷患者的死亡預警評分,用它可以更加全麵地評估危重創傷患者的預後,其預測效果優于單用任何一種評分.
목적 제출일충종합예측위중창상환자사망적최가평분지표사망예경평분,위림상제공일충간편역행적평분방법.방법 회고성분석2014년1월지12월제삼군의대학서남의원、제삼군의대학대평의원、준의의학원부속의원중증의학과수치적394례창상환자적림상자료.근거환자주원기간림상결국분위존활조(330례)화사망조(64례).기록량조환자적성별、년령;입원후호흡빈솔、심솔、수축압;입원24 h내혈기항(SCr)、백세포계수(WBC)、혈소판계수(PLT)、홍세포비용(Hct)적최차치;학진24 h내급성생이학여만성건강상황평분계통Ⅱ(APACHEⅡ)평분、격랍사가혼미평분(GCS)、서관기관쇠갈평분(SOFA)、전신염증반응종합정(SIRS)평분、손상엄중정도평분(ISS);24 h내시부행급진수술혹급진삽관;병정중시부발생농독증,이급림상결국.단인소분석량조환자적각항관찰지표,대도치사망적상관인소진일보행logistic회귀분석,사선출영향위중창상환자사망적위험인소,병대유통계학의의적지표여이부치,총분위사망예경평분;회제수시자공작특정곡선(ROC),평개사망예경평분대위중창상환자사망적예측개치.결과 여존활조비교,사망조환자년령대(세:51.50±18.31비45.54±14.70,t=-2.456,P=0.016),SCr승고(μmol/L:94.18±65.51비72.42±28.22,t=-2.611,P=0.011),APACHEⅡ평분(분:24.30±6.23비16.38±6.19,t=-9.353,P＜0.001)화SOFA평분(분:7.84±3.68비4.43±2.75,t=-7.049,P＜0.001)승고,진행급진삽관[79.7％ (51/64)비42.7％(141/330),x2=29.309,P＜0.001]화발생농독증적비례[48.4％ (31/64)비30.3％ (100/330),x2=18.512,P＜0.001]야현저승고,PLT(×109/L:112.75±59.85비144.12±68.28,t=3.428,P=0.001)화GCS평분(분:6.44±4.20비11.02±3.93,t=8.449,P＜0.001)칙현저강저;이량조성별、호흡빈솔、심솔、수축압、WBC、Hct、SIRS평분、ISS、행급진수술비례비교차이균무통계학의의.장단인소분석중유통계학의의적지표진행다인소logistic회귀분석,진입회귀모형적지표분별위년령≥65세[95％가신구간(95％CI) =0.176～1.974,P=0.019]、APACHEⅡ평분≥21분(95％CI=0.121 ～ 2.725,P=0.032)、GCS평분＜6분(95％CI=0.201 ～ 3.221,P=0.026)、발생엄중농독증(95％CI=0.421～2.735,P=0.008)혹농독성휴극(95％CI=0.430 ～ 3.636,P=0.013),병장기분별부치위1.0、1.5、1.5、1.5、2.0분,이저5개지표적총분작위사망예경평분.ROC곡선분석현시:사망예경평분예측위중창상환자사망적ROC곡선하면적(AUC)위0.867,명현고우APACHEⅡ평분(AUC위0.812,P=0.022)화GCS평분(AUC위0.783,P=0.001).당사망예경평분적진단역치위1.5분시,민감도위75.00％,특이도위85.40％,양성예측치위50.0％,음성예측치위94.6％,양성사연비위5.16,음성사연비위0.29,약등지수위0.605.결론 년령≥65세、APACHEⅡ평분≥21분、GCS＜6분、발생엄중농독증혹농독성휴극시위중창상환자사망적위험인소,이저5개지표작위위중창상환자적사망예경평분,용타가이경가전면지평고위중창상환자적예후,기예측효과우우단용임하일충평분.
Objective To discuss a best predictive score index in predicting death in patients with severe trauma, death warning score, and to provide a simple score for clinical use.Methods The clinical data of 394 traumatic patients admitted to Department of Critical Care Medicine of Xi'nan Hospital of the Third Military Medical University, Daping Hospital of the Third Military Medical University, and Affiliated Hospital of Zunyi Medical College from January 2014 to December 2014 were retrospectively analyzed.The patients were divided into survival group (n =330) and non-survival group (n =64).The clinical data in two groups were recorded as following: gender, age;respiratory rate, heart rate, and systolic blood pressure at admission;the lowest values of serum creatinine (SCr), white blood cell count (WBC), platelet count (PLT), hematocrit (Hct), respectively, within 24 hours after admission;acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score, Glasgow coma scale (GCS) score, sequential organ failure assessment (SOFA), systemic inflammatory response syndrome (SIRS) score, injury severity score (ISS) within 24 hours of final diagnosis;the performance of emergency operation or intubation within 24 hours;incidence of sepsis,and clinical outcomes.Each observed indicator was analyzed by univariate analysis, and factors leading to death were further analyzed by logistic regression.Risk factors of severe trauma patients were sorted, from which the meaningful indicators were included to calculate the warning score of death.Receiver operating characteristic curve (ROC) was plotted to evaluate the predictive value of the warning score of death in severe trauma patients.Results Compared with the survival group, the age in non-survival group was older (years old: 51.50 ± 18.31 vs.45.54 ± 14.70, t =-2.456,P =0.016);SCr was increased (μmol/L: 94.18±65.51 vs.72.42±28.22, t =-2.611, P =0.011);APACHE Ⅱ score (24.30±6.23 vs.16.38±6.19, t =-9.353, P ＜ 0.001) and SOFA score were higher (7.84±3.68 vs.4.43±2.75,t =-7.049, P ＜ 0.001);and the incidence of emergency intubation [79.7％ (51/64) vs.42.7％ (141/330), x2 =29.309,P ＜ 0.001] and sepsis was also higher [48.4％ (31/64) vs.30.3％ (100/330), x2 =18.512, P ＜ 0.001], but PLT count (× 109/L: 112.75±59.85 vs.144.12±68.28, t =3.428, P =0.001) and GCS score (6.44±4.20 vs.11.02±3.93,t =8.449, P ＜ 0.001) were significantly lower.There was no significant difference in gender, respiratory rate, heart rate,systolic blood pressure, WBC, Hct, SIRS score, ISS, or emergency operation between two groups.The indicators with statistically significant difference from the univariate analysis were further analyzed by multivariate logistic regression,and the indices included in the regression model were age ≥ 65 years [95％ confidence interval (95％CI) =0.176-1.974,P =0.019], APACHE Ⅱ score ≥ 21 (95％CI =0.121-2.725, P =0.032), GCS ＜ 6 (95％CI =0.201-3.221, P =0.026),severe sepsis (95％CI =0.421-2.735, P =0.008) or septic shock (95％CI =0.430-3.636, P =0.013), with assigning scores of 1.0, 1.5, 1.5, 1.5, 2.0, respectively.Finally these five indicators were included into the warning score of death.It was shown by ROC curve analysis that the area under ROC curve (AUC) of warning score of death in predicting mortality in critically ill trauma patients was 0.867, which was significantly higher than that of the APACHE Ⅱ score (AUC =0.812, P =0.022) and GCS score (AUC =0.783, P =0.001).When the cut-off value of warning score of death was 1.5, the sensitivity, specificity, positive predict value (+PV), negative predict value (-PV), positive likelihood ratio (+LR), negative likelihood ratio (-LR), and Youden index was 75.00％, 85.40％, 50.0％, 94.6％, 5.16, 0.29, and 0.605,respectively.Conclusions Age ≥ 65 years, APACHE Ⅱ score ≥ 21, GCS ＜ 6, severe sepsis or septic shock were the risk factors of death in patients with severe trauma, and they can be considered as warning score of death in patients with severe trauma.With the score mortality can be better predicted than any other kind of score for patients with severe trauma.
