摘要目的 探讨查尔森合并症指数(WIC)、序贯器官衰竭评分(SOFA)联合降钙素原(PCT)对重症医学科(ICU)脓毒症患者预后的评估价值.方法 采用前瞻队列研究方法,选择2015年7月至2018年6月四川省人民医院ICU收治的118例脓毒症患者.收集患者的性别、年龄、致病因素、感染部位、基础疾病和28 d预后等临床资料,计算入ICU时WIC评分、入ICU 24 h内急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)和SOFA 评分,测定入ICU 1 h内血清PCT水平.根据患者28 d治疗转归分为死亡组和存活组,比较不同预后患者的临床资料;采用多因素Logistic回归模型分析WIC评分、SOFA 评分及血清PCT水平与患者预后结局之间的关系;绘制受试者工作特征曲线(ROC),评估WIC评分、SOFA 评分及血清PCT水平对脓毒症患者预后的评估价值.结果 118例脓毒症患者均纳入最终分析,其中28 d存活94例,死亡24例,28 d病死率20.3%.与存活组相比,死亡组患者年龄更大,APACHEⅡ评分、WIC评分、SOFA评分及血清PCT水平更高.致病因素构成分析显示,死亡组肺部感染比例较高(62.5%);而存活组则主要为多发伤(36.2%),其次为肺部感染(30.9%).基础疾病构成分析显示,死亡组合并肿瘤、2型糖尿病、慢性肺病、脑血管疾病、慢性肾病、慢性肝病、慢性心功能不全的比例均明显高于存活组.多因素Logistic回归分析显示,年龄〔优势比(OR)＝1.279,95%可信区间(95%CI)为1.065～1.536〕、APACHEⅡ评分(OR＝1.255,95%CI为1.083～1.455)、WIC评分(OR＝1.429, 95%CI为1.304～1.568)、SOFA评分(OR＝1.331,95%CI为1.456～1.545)、血清PCT水平(OR＝1.497,95%CI为1.146～1.547)均与脓毒症患者28 d预后相关,是预测脓毒症患者28 d预后的独立危险因素(均P＜0.01).ROC曲线分析显示,WIC、SOFA评分和血清PCT水平以及三者合并预测概率的ROC曲线下面积(AUC)分别为0.712(95%CI为0.588～0.836)、0.801(95%CI为0.695～0.908)、0.889(95%CI为0.798～0.979)、0.943(95%CI为0.884～1.000),以三者联合预测的AUC最大,说明其预测生存结局的准确率大于任何单项指标,敏感度91.7%,特异度83.0%.结论 WIC评分和SOFA评分联合血清PCT水平可以提高预测脓毒症患者28 d预后的准确性.

abstractsTo assess the prognostic value of Charlson weighted index of comorbidities (WIC) combined with sequential organ failure assessment (SOFA) score and procalcitonin (PCT) in sepsis patients in intensive care unit (ICU). Methods A prospective cohort study was conducted. 118 patients with sepsis admitted to ICU of Sichuan Provincial People's Hospital from July 2015 to June 2018 were enrolled. The clinical data of the patients including gender, age, pathogenic factors, site of infection, underlying diseases and 28-day prognosis were collected, while the WIC score at ICU admission, the acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) score and SOFA score within 24 hours after ICU admission, serum PCT level within 1 hour after ICU admission were recorded. The patients were divided into survival group and death group according to 28-day prognosis, and the clinical data of patients with different prognosis were compared. Multivariate Logistic regression model was used to analyze the relationship between WIC score, SOFA score, PCT level and the outcomes of patients. The receiver operating characteristic (ROC) curve was drawn to evaluate the value of WIC score, SOFA score, and PCT level for predicting the prognosis of patients with sepsis. Results In this study, 118 eligible sepsis patients were enrolled, and 94 patients survived at 28 days, and 24 patients died with a 28-day mortality of 20.3%. Compared with the survival group, the patients in the death group were older and had higher APACHEⅡ score, WIC score, SOFA score, and serum PCT levels. Pathogenic factors analysis showed that the proportion of pulmonary infection in the death group was the highest (62.5%), while in the survival group the main cause was multiple injury (36.2%), followed by pulmonary infection (30.9%). Basic diseases analysis showed that the proportions of tumor, type 2 diabetes, chronic lung disease, cerebrovascular disease, chronic kidney disease, chronic liver disease, and chronic cardiac insufficiency in the death group were significantly higher than those in the survival group. The age [odds ratio (OR) = 1.279, 95% confidence interval (95%CI) was 1.065-1.536], APACHEⅡ score (OR = 1.255, 95%CI was 1.083-1.455), WIC score (OR = 1.429, 95%CI was 1.304-1.568), SOFA score (OR = 1.331, 95%CI was 1.456-1.545), and serum PCT level (OR = 1.497, 95%CI was 1.146-1.547) were related to the 28-day prognosis of patients with sepsis, and were independent predictors of 28-day prognosis in patients with sepsis (all P < 0.01). ROC curve analysis showed that the area under ROC curve (AUC) of WIC score, SOFA score, serum PCT level and combined prediction probability was 0.712 (95%CI was 0.588-0.836), 0.801 (95%CI was 0.695-0.908), 0.889 (95%CI was 0.798-0.979), 0.943 (95%CI was 0.884-1.000), respectively, indicating that the accuracy of combined parameters to predict survival outcome was higher than that of any single parameter with the sensitivity of 91.7% and the specificity of 83.0%. Conclusion WIC score, SOFA score combined with serum PCT level can improve the accuracy of predicting the 28-day prognosis in patients with sepsis.