不同诊断标准在重症监护病房脓毒症患者中的精确性与实用性
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摘要
目的评估重症监护病房(ICU)内根据Sepsis 1. 0和Sepsis 3. 0标准诊断的脓毒症患者的预后差异及对院内死亡率的预测效能。方法回顾性分析2017年1-8月收入北京大学人民医院外科ICU、急诊ICU及呼吸ICU患者的病历资料,入选413例患者。分别根据Sepsis 1. 0和3. 0标准筛选脓毒症患者,比较其预后指标的差异,应用受试者工作特征(ROC)曲线比较2种诊断标准预测患者院内死亡率的效能;探讨序贯器官功能衰竭(SOFA)评分、全身炎性反应综合征(SIRS)、机械通气治疗、年龄等对脓毒症患者严重程度的影响。结果根据新旧诊断标准筛选脓毒症患者,其中符合Sepsis 1.0标准的患者共169例(40. 9%),符合Sepsis 3. 0标准的患者共151例(36. 6%)。Sepsis 3. 0和Sepsis 1. 0诊断的脓毒症患者预后情况指标存在明显差异,符合Sepsis 3. 0的脓毒症患者预后更差(P<0. 01)。SOFA评分预测患者院内死亡率的ROC曲线下面积大于SIRS(0.654比0. 508)(P <0.05)。患者预后情况随SOFA评分升高而变差(P <0.05)。不同年龄段患者及是否机械通气的患者预后存在明显差异(P <0.05)。结论 Sepsis 3.0诊断的脓毒症患者较Sepsis 1. 0诊断的脓毒症患者预后更差,且Sepsis 3. 0预测感染患者院内死亡率的效能更好。SOFA评分分级可反映脓毒症患者严重程度,高龄及机械通气患者预后较差。
Objective To assess the predictive values of the Sepsis 1. 0 and Sepsis 3. 0 diagnostic criteria for prognosis and in-hospital mortality of sepsis in intensive care unit(ICU). Methods Clinical data of 413 patients admitted to ICU of surgery, emergency and respiratory departments of Peking University People' s Hospital from January to August 2017 were studied according to Sepsis 1. 0 and 3. 0 diagnostic criteria. Predictive values of the two criteria for in-hospital mortality were analyzed by receiver operating characteristic(ROC) curve. Prognostic indicators such as Sequential Organ Failure Assessment( SOFA), systemic inflammatory response syndrome(SIRS), mechanical ventilation and age were analyzed. Results Respectively 169(40. 9%) and 151( 36. 6%)sepsis patients were confirmed by Sepsis 1.0 and 3.0 criteria. There were significant differences of the prognositic indicators between them and sepsis patients according with Sepsis 3. 0 had worse prognosis(P <0. 01). Area under ROC curve of SOFA score predicting in-hospital mortality was greater than that of SIRS(0. 654 vs 0.508)(P <0. 05). The prognosis was poorer with the increase of SOFA score(P < 0.05). There were also significant differences of the prognosis between patients of different ages and whether they were mechanically ventilated(P <0. 05). Conclusions Sepsis patients diagnosed by Sepsis 3.0 show worse prognosis than those who are diagnosed by Sepsis 1.0. Sepsis 3. 0 shows a high prediction efficiency for in-hospital mortality. High SOFA score, advanced age and mechanical ventilation indicate poor prognosis.
Objective To assess the predictive values of the Sepsis 1. 0 and Sepsis 3. 0 diagnostic criteria for prognosis and in-hospital mortality of sepsis in intensive care unit(ICU). Methods Clinical data of 413 patients admitted to ICU of surgery, emergency and respiratory departments of Peking University People' s Hospital from January to August 2017 were studied according to Sepsis 1. 0 and 3. 0 diagnostic criteria. Predictive values of the two criteria for in-hospital mortality were analyzed by receiver operating characteristic(ROC) curve. Prognostic indicators such as Sequential Organ Failure Assessment( SOFA), systemic inflammatory response syndrome(SIRS), mechanical ventilation and age were analyzed. Results Respectively 169(40. 9%) and 151( 36. 6%)sepsis patients were confirmed by Sepsis 1.0 and 3.0 criteria. There were significant differences of the prognositic indicators between them and sepsis patients according with Sepsis 3. 0 had worse prognosis(P <0. 01). Area under ROC curve of SOFA score predicting in-hospital mortality was greater than that of SIRS(0. 654 vs 0.508)(P <0. 05). The prognosis was poorer with the increase of SOFA score(P < 0.05). There were also significant differences of the prognosis between patients of different ages and whether they were mechanically ventilated(P <0. 05). Conclusions Sepsis patients diagnosed by Sepsis 3.0 show worse prognosis than those who are diagnosed by Sepsis 1.0. Sepsis 3. 0 shows a high prediction efficiency for in-hospital mortality. High SOFA score, advanced age and mechanical ventilation indicate poor prognosis.
引文
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[10] Shankar-Hari M, Phillips GS, Levy ML, et al. Developing a new definition and assessing new clinical criteria for septic shock:for the third international consensus definitions for sepsis and septic shock(Sepsis-3)[J]. JAMA, 2016,315(8):775-787. DOI:10. 1001/jama. 2016.0289.
[11] Raith EP, Udy AA, Bailey M, et al. Prognostic accuracy of the SOFA Score, SIRS Criteria, and qSOFA score for in-hospital mortality among adults with suspected infection admitted to the intensive care unit[J]. JAMA, 2017,317(3):290-300. DOI:10.1001/jama. 2016.20328.
[12] Keppler U, Schmoch T, Siegler BH, et al. Implementation of the Sepsis-3 definition in German university intensive care units:a survey[J]. Anaesthesist, 2018,67(9):647-653. DOI:10.1007/s00101-018-0465-y.
[13] Estenssoro E, Kanoore Edul VS, Loudet CI, et al. Predictive validity of Sepsis-3 definitions and sepsis outcomes in critically ill patients:a cohort study in 49 ICUs in argentina[J]. Crit Care Med,2018,46(8):1276-1283. DOI:10.1097/CCM.0000000000003208.
[14] Kaukonen KM, Bailey M, Pilcher D, et al. Systemic inflammatory response syndrome criteria in defining severe sepsis[J]. N Engl J Med, 2015,372(17):1629-1638. DOI:10.1056/NEJMoal415236.
[2] Stoller J, Halpin L, Weis M, et al. Epidemiology of severe sepsis:2008-2012[J]. J Crit Care, 2016,31(1):58-62. DOI:10.1016/j. jcrc. 2015.09.034.
[3] Tillmann B, Wunsch H. Epidemiology and outcomes[J]. Crit Care Clin, 2018,34(1):15-27. DOI:10.1016/j.ccc.2017.08.001.
[4] Perner A, Rhodes A, Venkatesh B, et al. Sepsis:frontiers in supportive care, organisation and research[J]. Intensive Care Med,2017,43(4):496-508. DOI:10.1007/s00134-017-4677-4.
[5] Henning DJ, Puskarich MA, Self WH, et al. An emergency department validation of the SEP-3 sepsis and septic shock definitions and comparison with 1992 consensus definitions[J]. Ann Emerg Med, 2017,70(4):544-552, e5. DOI:10. 1016/j. annemergmed. 2017.01.008.
[6] Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock(Sepsis-3)[J].JAMA, 2016,315(8):801-810. DOI:10.1001/jama.2016.0287.
[7] Seymour CW, Liu VX, Iwashyna TJ, 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.
[8] Cheng B, Li Z, Wang J, et al. Comparison of the performance between sepsis-1 and sepsis-3 in ICUs in China:a retrospective multicenter study[J]. Shock, 2017,48(3):301-306. DOI:10.1097/SHK. 0000000000000868.
[9] Sharawy N, Lehmann C. New directions for sepsis and septic shock research[J]. J Surg Res, 2015, 194(2):520-527. DOI:10.1016/j. jss. 2014.12.014.
[10] Shankar-Hari M, Phillips GS, Levy ML, et al. Developing a new definition and assessing new clinical criteria for septic shock:for the third international consensus definitions for sepsis and septic shock(Sepsis-3)[J]. JAMA, 2016,315(8):775-787. DOI:10. 1001/jama. 2016.0289.
[11] Raith EP, Udy AA, Bailey M, et al. Prognostic accuracy of the SOFA Score, SIRS Criteria, and qSOFA score for in-hospital mortality among adults with suspected infection admitted to the intensive care unit[J]. JAMA, 2017,317(3):290-300. DOI:10.1001/jama. 2016.20328.
[12] Keppler U, Schmoch T, Siegler BH, et al. Implementation of the Sepsis-3 definition in German university intensive care units:a survey[J]. Anaesthesist, 2018,67(9):647-653. DOI:10.1007/s00101-018-0465-y.
[13] Estenssoro E, Kanoore Edul VS, Loudet CI, et al. Predictive validity of Sepsis-3 definitions and sepsis outcomes in critically ill patients:a cohort study in 49 ICUs in argentina[J]. Crit Care Med,2018,46(8):1276-1283. DOI:10.1097/CCM.0000000000003208.
[14] Kaukonen KM, Bailey M, Pilcher D, et al. Systemic inflammatory response syndrome criteria in defining severe sepsis[J]. N Engl J Med, 2015,372(17):1629-1638. DOI:10.1056/NEJMoal415236.