感染性休克引起心肌损伤的临床研究
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摘要
目的探讨影响感染性休克引起心肌损伤患者的易患因素和影响预后的因素。方法回顾性分析重症医学科收治的、临床资料完整的感染性休克患者94例,按是否发生心肌损伤分为心肌损伤组与非心肌损伤组,根据患者的预后分为存活组和死亡组,分析其临床资料,用t检验、秩和检验、χ~2检验、Spearman相关性分析和多因素分析等进行统计学处理。结果与感染性休克非心肌损伤组比较,心肌损伤组患者入院时血清白蛋白较低,且序贯器官衰竭评估(SOFA)评分较高(P<0.05);诊断感染性休克时,心肌损伤组患者的中心静脉压(CVP)、B型钠尿肽前体(NT-proBNP)、血乳酸脱氢酶(LDH)、肌钙蛋白(cTnI)和SOFA评分也较高(P<0.05)。与存活组比较,死亡组患者入院时肌红蛋白(MYO)、NT-proBNP,以及诊断感染性休克时肌酸激酶(CK)和SOFA评分及病程中胱抑素C最高值均明显升高(P<0.05);多因素Logistic回归分析显示SOFA评分高和低蛋白血症是独立危险因素(P<0.05)。入院时患者的cTnI与天门冬氨酸氨基转移酶(AST)、丙氨酸氨基转移酶(ALT)、天冬氨酸氨基转移酶线粒体同工酶(mAST)、LDH、NT-proBNP、谷氨酰转肽酶(GGT)及MYO呈正相关(P<0.05),诊断感染性休克时,cTnI与CVP、NT-proBNP、AST、ALT、LDH呈正相关(P<0.05),而与血清白蛋白呈负相关(P<0.05)。结论低蛋白血症和SOFA评分高是感染性休克引起心肌损伤的独立危险因素,心肌损伤常与肝脏、骨胳肌及线粒体损伤同时发生;血MYO、NT-proBNP、病程中胱抑素C及SOFA评分明显升高预示患者的预后不佳。
Objective To investigate the predisposing and prognostic factors in the patients with myocardial injury caused by septic shock.Methods A retrospective analysis of 94 patients with septic shock who admitted to the intensive care unit(ICU) from July 2015 to March 2018 was performed. The patients were divided into the myocardial injury group and non-myocardial injury group according to whether they had myocardial injury, and the survival group and death group according to the prognosis. The clinical data were analyzed by t test, rank sum test, chi-square test, Spearman correlation and multi-factor analysis.Results Compared with the non-myocardial injury group in septic shock, the patients with myocardial injury had lower of albumin and higher scores of sequential organ failure assessment(SOFA) at admission. When the septic shock was diagnosed, the patients in myocardial injury group had higher the central venous pressure(CVP), type B natriuretic peptide precursors(NT-proBNP), lactate dehydrogenase(LDH), troponin I(cTnI), and SOFA scores(P<0.05). Compared with the survival group, the patients′myoglobin(MYO), NT-proBNP in the death group increased at the time of admission significantly. The creatine kinase(CK), SOFA scores during the septic shock and the highest value of cystatin C during the course of the disease were higher in the death group(P<0.05). Multivariate logistic regression analysis showed that SOFA score and albumin were independent risk factors. cTnI and aspartate aminotransferase(AST), alanine aminotransferase(ALT), aspartate aminotransferase mitochondrial isoenzyme(mAST), LDH, NT-proBNP, glutamyltranspeptidase(GGT) and MYO was positively correlated(P<0.05). When the septic shock was diagnosed, cTnI was correlated positively with CVP, NT-proBNP, AST, ALT and LDH(P<0.05), however, cTnI was negatively correlated with serum albumin(P<0.05).Conclusion Low proteinemia and high SOFA scores are independent risk factors for patients with septic shock myocardial injury, myocardial injury often occurs simultaneously with liver, skeletal muscle and mitochondrial damage; blood MYO, NT-proBNP, cystatin C and SOFA scores in the course of the disease are significantly elevated, indicating poor prognosis.
Objective To investigate the predisposing and prognostic factors in the patients with myocardial injury caused by septic shock.Methods A retrospective analysis of 94 patients with septic shock who admitted to the intensive care unit(ICU) from July 2015 to March 2018 was performed. The patients were divided into the myocardial injury group and non-myocardial injury group according to whether they had myocardial injury, and the survival group and death group according to the prognosis. The clinical data were analyzed by t test, rank sum test, chi-square test, Spearman correlation and multi-factor analysis.Results Compared with the non-myocardial injury group in septic shock, the patients with myocardial injury had lower of albumin and higher scores of sequential organ failure assessment(SOFA) at admission. When the septic shock was diagnosed, the patients in myocardial injury group had higher the central venous pressure(CVP), type B natriuretic peptide precursors(NT-proBNP), lactate dehydrogenase(LDH), troponin I(cTnI), and SOFA scores(P<0.05). Compared with the survival group, the patients′myoglobin(MYO), NT-proBNP in the death group increased at the time of admission significantly. The creatine kinase(CK), SOFA scores during the septic shock and the highest value of cystatin C during the course of the disease were higher in the death group(P<0.05). Multivariate logistic regression analysis showed that SOFA score and albumin were independent risk factors. cTnI and aspartate aminotransferase(AST), alanine aminotransferase(ALT), aspartate aminotransferase mitochondrial isoenzyme(mAST), LDH, NT-proBNP, glutamyltranspeptidase(GGT) and MYO was positively correlated(P<0.05). When the septic shock was diagnosed, cTnI was correlated positively with CVP, NT-proBNP, AST, ALT and LDH(P<0.05), however, cTnI was negatively correlated with serum albumin(P<0.05).Conclusion Low proteinemia and high SOFA scores are independent risk factors for patients with septic shock myocardial injury, myocardial injury often occurs simultaneously with liver, skeletal muscle and mitochondrial damage; blood MYO, NT-proBNP, cystatin C and SOFA scores in the course of the disease are significantly elevated, indicating poor prognosis.
引文
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[15] 周茂松,褚俊.老年杓型高血压晨峰早期肾损害及Hcy、hs-CRP的检测价值[J].安徽医科大学学报,2015,50(1):94-7.
[2] Fleischmann C,Scherag A,Adhikari N K,et al.Assessment of global incidence and mortality of hospital-treated sepsis.Current estimates and limitations[J].Am J Respir Crit Care Med,2016,193(3):259-72.
[3] Mayr F B,Yende S,Angus D C.Epidemiology of severe sepsis[J].Virulence,2014,5(1):4.
[4] Ortíz G,Dueňas C,Rodríguez F,et al.Epidemiology of sepsis in Colombian intensive care units[J].Biomedica,2014,34(1):40-7.
[5] Sato R,Kuriyama A,Takada T,et al.Prevalence and risk factors of sepsis-induced cardiomyopathy:A retrospective cohort study[J].Medicine,2016,95(39):e5031.
[6] 刘炳炜,刘长文,胡炜,等.川芎嗪对脓毒症心肌损伤患者血清细胞因子及心功能的影响[J].中国中西医结合急救杂志,2017,24(1):17-20.
[7] Hultkvist H,Holm J,Svedjeholm R,et al.Rise and fall of NT-proBNP in aortic valve intervention[J].Open Heart,2018,5(1):e000739.
[8] Riché F,Chousterman B G,Valleur P,et al.Protracted immune disorders at one year after ICU discharge in patients with septic shock[J].Crit Care,2018,22(1):42.
[9] 李登辉,胡德林,李亚南,等.益赛普对脓毒症大鼠心肌损伤与炎症因子表达的影响[J].安徽医科大学学报,2015,50(7):925-8.
[10] Landesberg G,Jaffe A S,Gilon D,et al.Troponin elevation in severe sepsis and septic shock:the role of left ventricular diastolic dysfunction and right ventricular dilatation[J].Crit Care Med,2014,42(4):790-800.
[11] 范泉,张泓.脓毒症患者预后危险因素的Logistic回归分析[J].安徽医科大学学报,2014,49(10):1479-81.
[12] Su W L,Shui H A,Lan C C,et al.Cardiovascular parameters associated with troponin I as indicators for 14-day mortality in patients with septic shock[J].Am J Med Sci,2018,356(3):244-53.
[13] 叶静,陈尔真,望亭松,等.血清肌红蛋白和急性生理学与慢性健康状况评分系统评分在危重病评估中的应用价值比较[J].中国危重病急救医学,2008,20(9):538-41.
[14] 陈炜,赵磊,刘平,等.血浆N末端B型利尿肽前体对脓毒性休克心肌抑制因子患者严重程度及预后的预测价值[J].中华危重病急救医学,2013,25(1):40-4.
[15] 周茂松,褚俊.老年杓型高血压晨峰早期肾损害及Hcy、hs-CRP的检测价值[J].安徽医科大学学报,2015,50(1):94-7.