摘要目的 探讨早期床旁心脏超声及心脏生物学标志物对严重脓毒症患者预后的预测价值.方法 采用单中心回顾性研究,选择2013年1月至2017年12月北京世纪坛医院重症医学科(ICU)收治的严重脓毒症患者(除外急性冠脉综合征和终末期肾病患者),记录其入院6 h内的急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、N末端B型钠尿肽前体(NT-proBNP)、心肌肌钙蛋白I(cTnI)、肌红蛋白(MYO)、肌酸激酶(CK)、肌酸激酶同工酶(CK-MB)及确诊后6 h内的床旁超声心动图指标〔左室射血分数(LVEF)、二尖瓣舒张早期血流速度峰值与二尖瓣舒张晚期血流速度峰值的比值(E/A)〕等.比较心脏收缩功能受损(LVEF<0.50)患者与正常患者以及28 d死亡患者与存活患者之间各指标的差异;通过受试者工作特征曲线(ROC)和Logistic回归分析,评估各指标对患者预后的预测价值及影响因素.结果 ① 纳入316例患者中有89例(占28.2%)心脏收缩功能受损,269例(占85.1%)心脏舒张功能受损;同时合并收缩和舒张功能受损者有79例(占25.0%).② 心功能是否受损两组患者间NT-proBNP、cTnI差异有统计学意义,而APACHE Ⅱ评分及预后指标差异并无统计学意义;进一步Logistic回归分析显示,NT-proBNP与LVEF降低明确相关〔β=-1.311,优势比(OR)=0.269,P<0.001〕.③28 d死亡82例,28 d病死率为25.9%.与存活组比较,死亡组E/A<1的比例、APACHEⅡ评分、NT-proBNP、cTnI、MYO、CK、CK-MB均显著升高;ROC曲线分析显示,上述各指标对预后均有一定的预测价值,其中NT-proBNP及cTnI的预测价值较高〔其ROC曲线下面积(AUC)分别为0.920、0.901,均P<0.001〕,接近APACHEⅡ评分的预测价值(AUC=0.913,P<0.001);多因素Logistic回归分析显示, APACHEⅡ评分(β=0.282,OR=1.326,P<0.001)和NT-proBNP(β=0.402,OR=1.261,P<0.001)是影响严重脓毒症患者预后的独立危险因素.结论 对于严重脓毒症患者,早期心脏超声测量的LVEF值对28 d预后无预测价值,而APACHEⅡ评分、E/A比值、NT-proBNP、cTnI、MYO、CK及CK-MB均对28 d预后有一定的预测价值;APACHEⅡ评分和NT-proBNP是评估患者预后的早期独立因素.

abstractsObjective To assess the predictive value of early phrase echocardiography and cardiac biomarkers in patients with severe sepsis. Methods A retrospective analysis of severe septic patients (patients with acute coronary syndrome and end stage renal disease were excluded) in department of intensive care unit of Capital Medical University Affiliated Beijing Shijitan Hospital from January 2013 to December 2017 was conducted. The acute physiology and chronic health evaluation Ⅱ(APACHEⅡ) score, N-terminal prohormone of brain natriuretic peptide (NT-proBNP), cardiac troponin I (cTnI), myoglobin (MYO), creatine kinase (CK), MB isoenzyme of creatine kinase (CK-MB) within 6 hours after admission, and bedside echocardiography indexes [left ventricular ejection fraction (LVEF), the ratio of the peak blood flow velocity in the early stage of the mitral valve and the peak blood flow rate of the mitral valve (E/A ratio)] within 6 hours after diagnosis were recorded. The differences of indexes between patients with decreased contractile function (LVEF < 0.50) group and normal group, and the difference between dead group and survival group within 28-day were compared. Receiver operating characteristic (ROC) curve and Logistic regression analysis were conducted to assess the early detected prognostic value in severe sepsis patients. Results ① A total of 316 patients were enrolled in the survey period. Decreased cardiac systolic function (LVEF < 0.50) was found in 89 cases (28.2%), and cardiac diastolic function impaired (E/A ratio < 1) in 269 cases (85.1%); while 79 cases (25.0%) had both systolic function and diastolic function impairment. ② NT-proBNP and cTnI were statistically different between cardiac systolic function impaired group and normal group. Further Logistic regression analysis showed that only NT-proBNP was significantly correlated with LVEF [β=-1.311, odds ratio (OR) = 0.269, P < 0.001]. ③ Eighty-two of 316 cases were died in 28-day, and the 28-day mortality rate was 25.9%. Compared with the survival group, the ratio of E/A < 1, APACHEⅡ score, NT-proBNP, cTnI, MYO, CK and CK-MB were significantly increased in death group. The ROC curve analysis showed that the above indexes had diagnosed value for prognosis in severe sepsis patient, among which NT-proBNP and cTnI had higher predictive value [the area under ROC curve (AUC) were 0.920 and 0.901 respectively, both P < 0.001]. Multivariate Logistic regression analysis showed that APACHEⅡ score (β= 0.282, OR = 1.326, P < 0.001) and NT-proBNP (β= 0.402, OR = 1.261, P < 0.001) were independent risk factors for prognosis in patients with severe sepsis. Conclusions The LVEF values measured by echocardiography in early phrase were unrelated to 28-day prognosis. APACHEⅡ score, E/A ratio, NT-proBNP, cTnI, MYO, CK and CK-MB were related to 28-day prognosis. APACHEⅡ scores and NT-proBNP were independent prognostic factors in severe sepsis patient.