摘要目的 探讨血清降钙素原(PCT)、血乳酸(LAC)、序贯器官衰竭评分(SOFA)及急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)对脓毒症患者预后的评估价值.方法 选择2017年8月至2018年6月在首都医科大学附属北京朝阳医院急诊科就诊的140例感染患者为研究对象,依据Sepsis-3诊断标准将患者分为非脓毒症组(58例)、脓毒症组(66例)及脓毒性休克组(16例).对比3组患者就诊时的血清PCT、LAC、SOFA评分、APACHEⅡ评分及28 d预后,以及PCT、LAC的阳性检出率.用Logistic回归分析脓毒症患者28 d死亡的独立影响因素;用受试者工作特征曲线(ROC)分析PCT、LAC、SOFA评分及APACHEⅡ评分对脓毒症患者28 d死亡的预测价值.结果 脓毒症组和脓毒性休克组入院时PCT、LAC、SOFA评分、APACHEⅡ评分及28 d病死率均显著高于非脓毒症组,且脓毒性休克组PCT、LAC、APACHEⅡ评分及28 d病死率较脓毒症组进一步升高〔PCT(μg/L):38.1±12.6比4.6±2.3,LAC(mmol/L):3.3±2.1比2.4±2.1,APACHEⅡ(分):14.9±2.4比9.5±4.3,28 d病死率:75.0%比24.2%,均P＜0.05〕.脓毒症组和脓毒性休克组PCT及LAC的阳性检出率显著高于非脓毒症组(PCT阳性检出率:56.1%、81.3%比32.8%,LAC阳性检出率:42.4%、62.5%比13.7%,均P＜0.01).Logistic回归分析显示,PCT、LAC、SOFA评分及APACHEⅡ评分是脓毒症患者28 d病死率的独立影响因素〔PCT:优势比(OR)＝0.933,95%可信区间(95%CI)＝0.878～0.991;LAC:OR＝0.539, 95%CI＝0.347～0.838 ;SOFA :OR＝0.291,95%CI＝0.514～0.741 ;APACHE Ⅱ:OR＝0.808,95%CI＝0.669～0.976 ;均P＜0.05〕.ROC曲线分析显示,PCT、LAC、SOFA评分及APACHEⅡ评分预测脓毒症患者28 d死亡的ROC曲线下面积(AUC)分别是0.76、0.86、0.81、0.87.APACHEⅡ评分、LAC对死亡的预测价值显著高于PCT(Z1＝2.56,Z2＝2.45,均P＜0.01),SOFA评分与PCT的预测效果相似.结论 PCT、LAC、SOFA评分及APACHEⅡ评分有助于评估患者感染性疾病严重程度;APACHEⅡ评分和LAC对脓毒症患者28 d死亡预测效果优于SOFA评分和PCT.

abstractsTo investigate the assessment values of procalcitonin (PCT), lactic acid (LAC), sequential organ failure assessment (SOFA) score and acute physiology and chronic health evaluationⅡ (APACHEⅡ) score in patients with sepsis. Methods 140 patients with suspicious bacterial infection admitted to emergency department of Beijing Chaoyang Hospital of the Capital Medical University from August 2017 to June 2018 were enrolled. They were divided into three groups according to diagnostic criteria of Sepsis-3: non-sepsis group (n = 58), sepsis group (n = 66) and septic shock group (n = 16). The PCT, LAC, SOFA score, APACHEⅡscore, 28-day prognosis, and positive detection rate of PCT and LAC were compared among three groups. Independent predictors of 28-day mortality were analyzed by Logistic regression; predictive values of PCT, LAC, SOFA score and APACHEⅡscore for 28-day mortality in sepsis patients were analyzed by receiver operating characteristic (ROC) curve. Results PCT, LAC, SOFA score, APACHEⅡscore at admission, and 28-day mortality in sepsis group and septic shock group were significantly higher than those in non-sepsis group, and PCT, LAC, APACHEⅡ score, and 28-day mortality in sepsis shock group were further higher than those in sepsis group [PCT (μg/L): 38.1±12.6 vs. 4.6±2.3, LAC (mmol/L):3.3±2.1 vs. 2.4±2.1, APACHEⅡ score: 14.9±2.4 vs. 9.5±4.3, 28-day mortality: 75.0% vs. 24.2%, all P < 0.05]. The positive detection rate of PCT and LAC in sepsis group and septic shock group were higher than those in non-sepsis group (positive detection rate of PCT: 56.1%, 81.3% vs. 32.8%; positive detection rate of LAC: 42.4%, 62.5% vs. 13.7%; all P < 0.01). Logistic regression analysis showed that PCT, LAC, SOFA score and APACHEⅡ score were independent predictors of 28-day mortality [PCT: odds ratio (OR) = 0.933, 95% confidence interval (95%CI) = 0.878-0.991; LAC:OR = 0.539, 95%CI = 0.347-0.838; SOFA score: OR = 0.291, 95%CI = 0.514-0.741; APACHEⅡ score: OR = 0.808, 95%CI = 0.669-0.976; all P < 0.05]. ROC curve analysis showed that the area under ROC curve (AUC) of PCT, LAC, SOFA score and APACHEⅡ score predicting 28-day mortality was 0.76, 0.86, 0.81 and 0.87, respectively. The assessment values of APACHEⅡscore and LAC were higher than PCT in predicting 28-day mortality (Z1 = 2.56, Z2 = 2.45, both P < 0.01), and the performance of SOFA score was similar to PCT. Conclusions PCT, LAC, SOFA score and APACHEⅡscore were reliable indexes to evaluate disease severity for patients diagnosed with infection. The assessment values of APACHEⅡscore and LAC in 28-day mortality were superior to SOFA score and PCT.