不同评分系统对ICU严重脓毒症患者1个月预后判定的临床价值对比

Comparison of clinical value of different scoring systems in predicting one-month prognosis of patients with severe sepsis in ICU

摘要:

目的探讨5 种评分系统对急诊严重脓毒症患者1 个月预后判定的临床价值。方法选取2012 年6 月至2014 年6 月在该院重症加强护理病房（ICU）被确诊为严重脓毒症的268 例患者。收集其24 h 内最差生理数据，采用5 种不同的评分系统对其进行评价。评分系统包括：急性生理与慢性健康评分Ⅱ（APACHEⅡ）、序贯器官衰竭评分系统（SOFA）、简化急性生理学评分Ⅱ（SAPSⅡ）、简化急性生理学评分Ⅲ（SAPSⅢ）和急诊脓毒症死亡风险评分（MEDS）。根据患者1 个月后的生存状态将此268 例患者分为生存组和死亡组。分析影响患者预后生存状态的生理指标和评分系统，并对5 个系统判定患者预后的能力进行比较，确定最优评分系统的预后界值。结果268 例患者最终有93 例在1 个月以内死亡，其余175 例患者存活。两组患者年龄比较，差异有统计学意义（P <0.05），死亡组> 生存组。两组患者APACHEⅡ、SOFA、SAPSⅡ、SAPSⅢ和MEDS 得分比较，差异有统计学意义（P <0.05），死亡组5 种评分系统得分更高，但两组患者性别比较差异没有统计学意义（P >0.05）。同时，死亡组中患有原发性高血压、恶性肿瘤、肾功能不全、肺部感染和细菌感染的患者多于生存组。APACHEⅡ评分、SAPSⅡ评分、SOFA 评分、MEDS 评分、SAPSⅢ评分、患有恶性肿瘤和肺部发生感染这7 种因素为影响严重脓毒症患者预后的预测因素。MEDS 评分系统的工作特征曲线（ROC）下面积与其余4 种评分系统比较，差异有统计学意义（P <0.05），MEDS 评分系统大于其余4 种评分系统，其余4 种评分系统的ROC 曲线下面积之间差异没有统计学意义（P >0.05）；当MEDS 评分为92.3 时，敏感性为91.3%，特异性为89.7%，1 个月以内严重脓毒症患者的病死率为86.5%。结论MEDS 相比于APACHEⅡ、SOFA、SAPSⅡ和SAPSⅢ，对ICU 严重脓毒症患者预后预测能力更优，其界值为92.3；其余4 种评分系统对ICU 严重脓毒症患者预后预测能力基本一致。

Abstract:

Objective To explore the clinical value of five scoring systems for predicting one-month prognosis of patients with severe sepsis in the ICU. Methods A total of 268 patients diagnosed with severe sepsis in the ICU of our hospital from June 2012 to June 2014 were selected as study objects. Five different scoring systems were used to evaluate the worst physiological data within 24 h. The scoring systems included Acute Physiology and Chronic Health Evaluation Ⅱ(APACHEⅡ), Sequential Organ Failure Assessment(SOFA), Simplified Acute Physiology Score II (SAPSII), Simplified Acute Physiology Score Ⅲ(SAPSⅢ), and Mortality in Emergency Department Sepsis (MEDS).According to the patient's survival status after one month, the 268 patients were divided into survival group and death group. The physiological indexes and the scoring systems influencing the prediction of prognosis were analyzed, and the ability of the five systems to predict the prognosis of the patients was compared. Results Of the 268 cases, 93 patients died within one month, and the remaining 175 patients survived. The age of the dead patients was significantly older than that of the survival group (P < 0.05) . The APACHEⅡ, SOFA, SAPSⅡ, SAPSⅢand MEDS scores were higher in the death group (P < 0.05), but there was no significant difference in gender between the two groups (P > 0.05). At the same time, there were more patients with essential hypertension, malignant tumors, renal insufficiency, pulmonary infection and bacterial infection in the death group than in the survival group (P <0.05). APACHEⅡscore, SAPSⅡscore, SOFA score, MEDS score, SAPSⅢscore, malignant tumor and pulmonary infection were the seven factors influencing the prognosis of the patients with severe sepsis. The area under the receiver operating characteristic curve of MEDS scoring system was significantly larger than that of the other four scoring systems (P < 0.05), but there were no significant differences among the area under the ROC curve of the other four scoring systems (P > 0.05). When the MEDS score was 92.3, the sensitivity was 91.3%, the specificity was89.7%, and the mortality rate within one month was 86.5% in the patients with severe sepsis. Conclusions MEDS is superior to APACHEⅡ, SOFA, SAPSⅡand SAPSⅢin predicting the prognosis of patients with severe sepsis in ICU, and its boundary value is 92.3. The other four scoring systems are basically consistent in the predictive ability of ICU patients with severe sepsis.