摘要目的 探讨急诊脓毒症死亡风险(MEDS)评分联合血乳酸对急诊严重脓毒症患者危险分层的价值.方法 选取2011年5月至2012年12月急诊室拟诊为严重脓毒症的665例住院患者,进行MEDS评分、急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分和动脉血乳酸测定,记录28 d转归情况.通过logistic回归分析评价各预测因子与预后的关系,通过受试者工作特征曲线(ROC曲线)评估各预测因子及MEDS评分联合血乳酸对预后的预测能力.结果 655例患者28 d病死率为34.6％,MEDS评分12～27分组患者病死率明显高于MEDS评分＜12分组[51.0％(156/306)比20.6％(74/359),x2=28.414,P=0.000],APACHEⅡ评分和血乳酸亦明显高于MEDS评分＜12分组[APACHEⅡ评分(分):26.4±10.6比21.7±8.1,t=-3.555,P=0.002；血乳酸(mmol/L):4.9(2.3,9.9)比3.9(1.5,8.9),Z=-2.352,P=0.023].Kaplan-Meier生存分析显示两组存在显著差异(Log Rank检验36.71,P＜0.01).死亡组3个预测因子均明显高于存活组[MEDS评分(分):14.1±6.7比8.2±4.5,t=-6.929,P=0.000；APACHEⅡ评分(分):28.1±7.1比22.2±11.3,t=-6.472,P=0.000；血乳酸(mmol/L):5.4(2.9,11.0)比3.8(1.2,9.1),Z=-3.955,P=0.004].MEDS、APACHEⅡ评分及血乳酸的ROC曲线下面积(AUC)分别为0.813、0.706、0.727,MEDS评分对28 d病死率预测能力优于血乳酸(P=0.008)及APACHEⅡ评分(P=0.005).MEDS评分联合血乳酸对28 d病死率预测能力(AUC为0.865)优于MEDS评分(P＜ 0.001),其敏感度(83.1％)、特异度(93.2％)、阳性预测值(PPV,62.4％)和阴性预测值(NPV,92.1％)在各预测因子中均最高.结论 MEDS评分联合血乳酸对于急诊严重脓毒症患者是良好的危险分层工具,预后能力优于MEDS评分、APACHEⅡ评分和血乳酸.

abstractsObjective To evaluate the combination of the mortality in emergency department sepsis (MEDS) score with blood lactate level in the risk stratification of patients with severe sepsis in the emergency department (ED).Methods 665 adult patients with severe sepsis admitted from May 2011 to December 2012 in ED were found to be eligible for the study.MEDS score,acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score,and arterial blood lactate was determined,and the outcomes in 28 days were recorded.Logistic regression analysis was used to evaluate the relationship between each predictive factor score and prognosis.Each predictive factor was compared with the areas under the receiver operating characteristics (ROC) curve (AUC).Results The mortality in 28 days was 34.6％ in 665 patients.The mortality in group of MEDS score 12-27 was significantly higher than that group of MEDS score＜12 [51.0％ (156/306) vs.20.6％ (74/155),x2=28.414,P=0.000].In the meantime,APACHE Ⅱ score and blood lactate level were also significantly higher in group of MEDS score 12-27 than those in group with MEDS score＜12 [APACHE Ⅱ score:26.4 ± 10.6 vs.21.7 ± 8.1,t=-3.555,P=0.002; lactate (mmol/L):4.9 (2.3,9.9)vs.3.9 (1.5,8.9),Z=-2.352,P=0.023].Kaplan-Meier survival analysis showed significantdifference in the two groups (the Log Rank test 36.71,P ＜0.01).The levels of 3 predictive factors were predominantly higher in non-survivors than survivors [MEDS score:14.1 ± 6.7 vs.8.2 ± 4.5,t=-6.929,P=0.000; APACHE Ⅱ score:28.1 ±7.1 vs.22.2± 11.3,t=-6.472,P=0.000; lactate (mmol/L):5.4 (2.9,11.0) vs.3.8 (1.2,9.1),t=-6.472,P=0.004].The AUCs were 0.813,0.706 and 0.727 for MEDS score,APACHE Ⅱ score and blood lactate respectively.The predictive ability for 28-day mortality of MEDS score was better than blood lactate (P=0.008) and APACHE Ⅱ score (P=0.005).The AUC of MEDS score combined with lactate was 0.865,and 28-day mortality prediction was better than MEDS score (AUC 0.865 vs.0.813,P＜0.001).The sensitivity (83.1％),specificity (93.2％),positive prediction value (PPV,62.4％),and negative prediction value (NPV,92.1％) for MEDS score combined with lactate were highest among all predictors.Conclusion MEDS score combined with lactate is a good risk stratification tool for emergency patients with severe sepsis,and its prognostic capability is better than either MEDS score,APACHE Ⅱ score or blood lactate.