MEWS评分改良及用于血液系统恶性肿瘤感染患者的评价
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摘要
目的探讨影响血液系统恶性肿瘤化疗后粒细胞缺乏期并发感染患者预后的危险因素,以期形成适合血液系统恶性肿瘤感染预警的校正MEWS评分表,实现更好的预警效果。方法回顾性收集符合纳入标准的179例患者资料,釆用多因素Logistic回归方法分析影响患者预后的独立危险因素,形成校正MEWS评分表,依据患者预后及是否实施应急处置,比较分析两种MEWS评分的预测效能,评估其分辨度及最佳截断点。结果多器官功能障碍综合征(MODS)、电解质紊乱、呼吸频率、血氧饱和度及意识变化是影响患者预后的独立危险因素(均P<0.01);两种评分在死亡组、应急处置组中的分值均分别高于存活组、非应急处置组(均P<0.01);两种评分在预后的分辨度评价上具有中等程度预测价值,且校正MEWS评分(AUROC=0.898)的预测价值明显高于MEWS评分(AUROC=0.810),最佳截断点分别为8.5、4.5分;在预测实施应急处置上,校正MEWS评分具有中等程度预测价值(AUROC=0.730),最佳截断点为5.5分,而MEWS评分的预测价值较低(AUROC=0.692),最佳截断点为4.5分。结论校正MEWS评分在患者预后及应急处置中呈现中等程度预测价值,更适合血液系统恶性肿瘤化疗后粒细胞缺乏期并发感染患者的病情评估及预警。
Objective To investigate the risk factors of hematologic malignancies patients developing infection in granulocyte deficiency period of chemotherapy, to form a corrected MEWS score suitable for early warning of indection in hematological malignancies patients, and to achieve better early warning results.Methods A retrospective study was conducted to collect data of 179 patients who met the inclusion criteria.Multivariate logistic regression analysis was used to identify the independent risk factors which affected the prognosis of patients, and a corrected MEWS score was formed.According to the patient′s prognosis and whether to implement emergency treatment, the predictive efficacy of the two MEWS scores was compared, and the discrimination and the best cut-off points were evaluated.Results Multiple organ dysfunction syndrome(MODS), electrolyte imbalance, and changes in respi-ratory rate, SaPO_2, and consciousness were independent risk factors for prognosis. The scores of the two instruments in the death group and the emergency treatment group were higher than those in the survival group and non-emergency treatment group(P<0.01 for both). The two instruments had moderate predictive value in the prognostic discrimination, and the predicted value of the corrected MEWS score(AUROC=0.898) was significantly higher than the MEWS score(AUROC=0.810), the best cutoff points being 8.5 and 4.5 respectively. In predicting the implementation of emergency response, the corrected MEWS score had medium predictive value(AUROC=0.730), and the optimal cut-off point was 5.5 points, versus lower predictive value(AUROC=0.692) and 4.5 points by MEWS score.Conclusion The corrected MEWS score had a moderate predictive value in prognostic discrimination and emergency implementation, which would be more suitable for the evaluation of hematologic malignancies patients developing infection in granulocyte deficiency period.
Objective To investigate the risk factors of hematologic malignancies patients developing infection in granulocyte deficiency period of chemotherapy, to form a corrected MEWS score suitable for early warning of indection in hematological malignancies patients, and to achieve better early warning results.Methods A retrospective study was conducted to collect data of 179 patients who met the inclusion criteria.Multivariate logistic regression analysis was used to identify the independent risk factors which affected the prognosis of patients, and a corrected MEWS score was formed.According to the patient′s prognosis and whether to implement emergency treatment, the predictive efficacy of the two MEWS scores was compared, and the discrimination and the best cut-off points were evaluated.Results Multiple organ dysfunction syndrome(MODS), electrolyte imbalance, and changes in respi-ratory rate, SaPO_2, and consciousness were independent risk factors for prognosis. The scores of the two instruments in the death group and the emergency treatment group were higher than those in the survival group and non-emergency treatment group(P<0.01 for both). The two instruments had moderate predictive value in the prognostic discrimination, and the predicted value of the corrected MEWS score(AUROC=0.898) was significantly higher than the MEWS score(AUROC=0.810), the best cutoff points being 8.5 and 4.5 respectively. In predicting the implementation of emergency response, the corrected MEWS score had medium predictive value(AUROC=0.730), and the optimal cut-off point was 5.5 points, versus lower predictive value(AUROC=0.692) and 4.5 points by MEWS score.Conclusion The corrected MEWS score had a moderate predictive value in prognostic discrimination and emergency implementation, which would be more suitable for the evaluation of hematologic malignancies patients developing infection in granulocyte deficiency period.
引文
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[10] 邓倩,唐亦舒,成倩,等.恶性血液病患者革兰阳性菌血流感染的影响因素及预后分析[J].中华医院感染学杂志,2018,28(24):3771-3775,3803.
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[15] 田凌云.三种预警评分对急诊危急重症患者病情预警及评估的比较研究[D].长沙:中南大学,2014.
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[17] 袁海龙,古力巴旦木·艾则孜,曹海洲,等.血液肿瘤患者感染病原菌分布与耐药性研究[J].中华医院感染学杂志,2016,26(4):812-814.
[18] Tumbarello M, Spanu T, Caira M, et al.Factors associated with mortality in bacteremic patients with hematologic malignancies[J].Diagn Microbiol Infect Dis,2009,64(3):320-326.
[19] 袁瑞亭.老年重症肺炎患者电解质紊乱的治疗与预后[J].中国实用医刊,2012,39(12):85-86.
[20] Hladik A, Lynshue K.Dyshemoglobinemias and pulse oximetry: a therapeutic challenge[J].J Pediatr Hematol Oncol,2008,30(11):850-852.
[21] 王小刚,高丁,李涛,等.院前应用格拉斯哥昏迷分级评分评估颅脑损伤患者与预后的相关性分析[J].中国临床医生杂志,2015,43(8):36-39.
[22] 李超,杨如玉,马海龙,等.急性白血病患者感染性休克的临床特点分析[J].中华医院感染学杂志,2014,24(10):2464-2466.
[2] 汤华,樊春凤,刘泽法,等.恶性血液病患者医院感染临床分析[J].实用临床医药杂志,2012,16(1):105-106.
[3] 王爱红,王占聚,唐英,等.急性白血病医院感染危险因素分析[J].山东医药,2011,51(27):97-98.
[4] 曹海武,赵晓红,陆时运,等.恶性血液病患者化疗后并发感染与机体免疫功能及肠道微生态的关系[J].中国病原生物学杂志,2017,12(5):456-459.
[5] 麦泉云,赵开亮,张凤莲,等.改良早期预警评分结合心电图、休克指数、血氧饱和度对评估急诊患者病情危重程度的价值[J].广西医学,2012,34(10):1305-1308.
[6] Prytherch D R, Smith G B, Schmidt P E, et al.ViEWS towards a national early warning score for detecting adult inpatient deterioration[J].Resuscitation,2010,81(8):932-937.
[7] 中华人民共和国卫生部.医院感染诊断标准(试行)[J].中华医学杂志,2001,81(5):315-316.
[8] 中国医师协会急诊医师分会.中国急诊感染性休克临床实践指南[J].中国急诊医学杂志,2016,25(3):193-206.
[9] 张容莉,韩明哲.中性粒细胞缺乏伴发热血液病患者感染治疗指南解读[J].中国循证医学杂志,2015,15(7):764-766.
[10] 邓倩,唐亦舒,成倩,等.恶性血液病患者革兰阳性菌血流感染的影响因素及预后分析[J].中华医院感染学杂志,2018,28(24):3771-3775,3803.
[11] 晁志.恶性血液病合并念珠菌败血症临床特征及归因死亡的回顾性分析[D].广州:南方医科大学,2016.
[12] 陈侠,闫昱江,王红,等.老年恶性血液病患者化疗后急性心力衰竭的危险因素[J].中国肿瘤临床与康复,2018,25(10):1266-1269.
[13] Subbe C P, Kruger M, Rutherford P, et al.Validation of a modified Early Warning Score in medical admissions[J].QJM,2001,94(10):521-526.
[14] 王金金,刁永云,倪元红,等.改良早期预警评分在急诊120患者分诊中的应用[J].护理学杂志,2013,28(9):11-12.
[15] 田凌云.三种预警评分对急诊危急重症患者病情预警及评估的比较研究[D].长沙:中南大学,2014.
[16] 李旭玲.恶性血液病侵袭性真菌感染的研究进展[J].世界最新医学信息文摘,2018,18(59):34-35.
[17] 袁海龙,古力巴旦木·艾则孜,曹海洲,等.血液肿瘤患者感染病原菌分布与耐药性研究[J].中华医院感染学杂志,2016,26(4):812-814.
[18] Tumbarello M, Spanu T, Caira M, et al.Factors associated with mortality in bacteremic patients with hematologic malignancies[J].Diagn Microbiol Infect Dis,2009,64(3):320-326.
[19] 袁瑞亭.老年重症肺炎患者电解质紊乱的治疗与预后[J].中国实用医刊,2012,39(12):85-86.
[20] Hladik A, Lynshue K.Dyshemoglobinemias and pulse oximetry: a therapeutic challenge[J].J Pediatr Hematol Oncol,2008,30(11):850-852.
[21] 王小刚,高丁,李涛,等.院前应用格拉斯哥昏迷分级评分评估颅脑损伤患者与预后的相关性分析[J].中国临床医生杂志,2015,43(8):36-39.
[22] 李超,杨如玉,马海龙,等.急性白血病患者感染性休克的临床特点分析[J].中华医院感染学杂志,2014,24(10):2464-2466.