摘要目的 探讨序贯器官衰竭评分(SOFA)联合急性胃肠损伤(AGI)分级系统对老年脓毒症患者预后的预测价值.方法 回顾性分析2014年3月至2015年12月广州军区广州总医院老年内科重症加强治疗病房(MICU)连续收治的住院时间>48 h、年龄>60岁的脓毒症患者.记录患者年龄、性别、急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、入科时SOFA(SOFAinitial)与AGI评分(AGIinitial),1周内最高SOFA(SOFAmax)及AGI评分(AGImax),入科时相关生化指标如降钙素原(PCT)、C-反应蛋白(CRP)、白蛋白(ALB)、血小板计数(PLT)、血红蛋白(Hb)、血乳酸(Lac),重症加强治疗病房(ICU)住院时间、器官支持情况(如是否行机械通气、血液滤过).主要临床终点为28 d病死率.采用二分类变量logistic回归分析老年脓毒症患者死亡的危险因素.应用Hosmer-Lemeshow检验对评分系统的拟合优度进行评价.利用受试者工作特征曲线(ROC)评价各评分对老年脓毒症患者预后的预测价值.结果 共纳入患者91例老年脓毒症患者,AGI发生率为100%;28 d死亡34例,病死率为37.4%.死亡组APACHEⅡ、SOFAinitial、SOFAmax、AGIinitial、AGImax评分及机械通气、血液滤过比例均显著高于存活组;二分类变量logistic回归分析显示,SOFAmax〔优势比(OR)=1.576〕、AGImax(OR=5.695)为老年脓毒症患者28 d死亡的独立危险因素(均P<0.01).SOFAmax+AGImax预测老年脓毒症患者的ROC曲线下面积(AUC)和95%可信区间(95%CI)明显大于SOFAinitial、SOFAmax、AGIinitial、AGImax、APACHEⅡ评分〔0.806(0.710~0.881)比0.723(0.619~0.812)、0.786(0.688~0.865)、0.641(0.533~0.739)、0.633(0.526~0.881)、0.638(0.531~0.736),均P<0.05〕.SOFAmax+AGImax的约登指数(55.37)和阳性预测值(5.51)最大,其最佳临界值为14时,敏感度为67.65%,特异度为87.72%.将APACHEⅡ、SOFAinitial、SOFAmax、AGImax评分进行分层,结果显示各评分越高,病死率越高.结论 SOFA联合AGI可提高老年脓毒症患者预后的预测价值.

abstractsObjective To explore the predictive value of sequential organ failure assessment (SOFA) score combined the acute gastrointestinal injury (AGI) grading system in critical elderly patients with sepsis.Methods A retrospective analysis was conducted. Elderly patients with sepsis aged > 60 years admitted to medical intensive care unit (MICU) of General Hospital of Guangzhou Military Command from March 2014 to December 2015 and experiencing critical care over 48 hours were enrolled. Age, gender, acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score, sequential organ failure assessment (SOFA) score and AGI score at admission (SOFAinitial, AGIinitial), the highest SOFA score and AGI score within the first week (SOFAmax, AGImax), serum procalcitonin (PCT), C-reactive protein (CRP), albumin (ALB), platelet (PLT), hemoglobin (Hb) and lactate (Lac) levels, length of ICU stay, usage of mechanical ventilation and renal replacement therapy were recorded. The primary end point was 28-day mortality. To extract factors affecting 28-day mortality, the risk factor of death of the senile sepsis patients were analyzed by binary logistic regression analysis (stepwise method). Fitness of the model was assessed by the Hosmer-Lemeshow test and calibration plot (P > 0.05). Receiver operating characteristic (ROC) analysis was performed for APACHE Ⅱ score, SOFAinitial score, SOFAmax score, AGIinitial score, AGImax score and SOFAmax and combined AGImax score.Results Ninety-one patients were enrolled, the incidence of AGI in elderly patients with sepsis was 100%;34 patients died 28 days after the admission, and the 28-day mortality rate was 37.4%. Non-survivors presented a higher APACHE Ⅱ score, SOFAinitial score, SOFAmax score, AGIinitial score, AGImax score and longer usage of mechanical ventilation and renal replacement therapy. SOFAmax score [odds ratio (OR) = 1.576] and AGImax score (OR = 5.695) were associated with 28-day mortality in binary logistic regression analysis (bothP < 0.01). The area under the curve (AUC) and 95% confidence interval (95%CI) of SOFAmax score combined AGImax score was significantly higher than that of SOFAinitial score, SOFAmax score, AGIinitial score, AGImax score and APACHE Ⅱ score [0.806 (0.710-0.881) vs. 0.723 (0.619-0.812), 0.786 (0.688-0.865), 0.641 (0.533-0.739), 0.633 (0.526-0.881), 0.638 (0.531-0.736), allP < 0.05]. TheYouden index (55.37) and positive predict value (5.51) of SOFAmax score combined AGImax score were the largest. When its cut-off value reached 14, the sensitivity and specificity was 67.65% and 87.72%, respectively. According to score of APACHE Ⅱ, SOFAinitial, SOFAmax or AGImax, the higher of each score, the higher mortality rate could be.Conclusion The combination of SOFAmax score and AGImax score enable accurate prediction in elderly patients with sepsis.