摘要目的:基于床旁超声评估脓毒性右心功能障碍（SRVD）的预后，并探讨其危险因素。方法:采用前瞻性观察性研究方法，选择2021年2月至2022年1月宁夏医科大学总医院重症监护病房（ICU）收治的脓毒症和脓毒性休克患者作为研究对象。于患者入ICU 24 h内应用M型超声测量三尖瓣环收缩期位移（TAPSE），依据TAPSE结果将研究对象分为SRVD组（TAPSE<16 mm）和非SRVD组（TAPSE≥16 mm）。收集两组患者性别、年龄、脓毒性休克发生情况、基础疾病、患者来源、急性生理学与慢性健康状况评分Ⅱ（APACHEⅡ）、序贯器官衰竭评分（SOFA）、入ICU 24 h内最高体温、感染部位及数量、机械通气时间及28 d病死率；记录入ICU 24 h内血流动力学参数、器官功能指标、氧疗参数及动脉血气分析指标。比较两组间上述指标的差异；采用二元多因素Logistic回归分析筛选SRVD独立危险因素，并绘制SRVD危险因素列线图。结果:最终纳入116例脓毒症和脓毒性休克患者，其中发生SRVD 24例（占20.7%），92例未发生SRVD（占79.3%）。与非SRVD组相比，SRVD组患者急诊转入和感染部位≥2处比例、APACHEⅡ评分、SOFA评分更高，入ICU 24 h内肌钙蛋白I（cTnI）、肌红蛋白（Mb）、肌酸激酶同工酶（CK-MB）、N末端脑钠肽前体（NT-proBNP）、血肌酐（SCr）、动脉血乳酸（Lac）更高，左室射血分数（LVEF）、血小板计数（PLT）更低，且使用去甲肾上腺素和连续性肾脏替代治疗（CRRT）比例更高。二元多因素Logistic回归分析显示，LVEF〔优势比（ OR）＝0.918，95%置信区间（95% CI）为0.851~0.991， P＝0.028〕、PLT（ OR＝0.990，95% CI为0.981~0.999， P＝0.035）、SCr（ OR＝1.008，95% CI为1.001~1.016， P＝0.025）、是否使用去甲肾上腺素（ OR＝15.198，95% CI为1.541~149.907， P＝0.020）是脓毒症和脓毒性休克患者发生SRVD的独立危险因素。基于上述4个独立危险因素绘制SRVD危险因素列线图，结果显示，LVEF为0.50时评分为64分，SCr为100 μmol/L时评分为18分，PLT为100×10 9/L时评分为85分，使用去甲肾上腺素时评分为39分；当总分达到253分时，SRVD发生风险为88%。与非SRVD组相比，SRVD组患者机械通气时间略有延长〔h：80.0（28.5，170.0）比47.0（10.0，135.0）， P>0.05〕，28 d病死率显著升高〔41.7%（10/24）比21.7%（20/92）， P<0.05〕。 结论:脓毒症患者早期可出现右心功能障碍，且肾功能受损，病死率升高；LVEF和PLT降低、SCr升高及使用去甲肾上腺素是脓毒症患者发生SRVD的独立危险因素。

abstractsObjective:To evaluate the prognosis of septic right ventricular dysfunction (SRVD) based on bedside ultrasound and explore its risk factors.Methods:A prospective observational study was conducted involving septic and septic shock patients admitted to the intensive care unit (ICU) of the General Hospital of Ningxia Medical University from February 2021 to January 2022. Tricuspid annular plane systolic excursion (TAPSE) was measured by M-mode ultrasound within 24 hours after ICU admission. According to the results of TAPSE, the subjects were divided into SRVD group (TAPSE < 16 mm) and non-SRVD group (TAPSE≥16 mm). The gender, age, occurrence of septic shock, underlying diseases, source of patients, acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) score, sequential organ failure assessment (SOFA) score, maximal body temperature within 24 hours after ICU admission, location and number of infections, duration of mechanical ventilation, and 28-day mortality were collected. Hemodynamic parameters, organ function indexes, oxygen therapy parameters and arterial blood gas analysis indexes were recorded within 24 hours after ICU admission. The differences of the above indexes between the two groups were compared. Binary multivariate Logistic regression analysis was used to screen out the independent risk factors for SRVD, and a nomogram of SRVD risk factors was drawn.Results:116 patients with sepsis and septic shock were enrolled, of which 24 (20.7%) had SRVD and 92 (79.3%) had no SRVD. Compared with the non-SRVD group, the patients in the SRVD group had higher emergency transfer and infection site ≥ 2 ratio, APACHEⅡ score, SOFA score, higher cardiac troponin I (cTnI), myoglobin (Mb), MB isoenzyme of creatine kinase (CK-MB), N-terminal pro-brain natriuretic peptide (NT-proBNP), serum creatinine (SCr), arterial blood lactic acid (Lac) and lower left ventricular ejection fraction (LVEF), platelet count (PLT) within 24 hours after ICU admission, and higher proportion of norepinephrine application and continuous renal replacement therapy (CRRT). Binary multivariate Logistic regression analysis showed that LVEF [odds ratio ( OR) = 0.918, 95% confidence interval (95% CI) was 0.851-0.991, P = 0.028], PLT ( OR = 0.990, 95% CI was 0.981-0.999, P = 0.035), SCr ( OR = 1.008, 95% CI was 1.001-1.016, P = 0.025), and the usage of norepinephrine ( OR = 15.198, 95% CI was 1.541-149.907, P = 0.020) were independent risk factors for SRVD in patients with sepsis and septic shock. Based on the above four independent risk factors, a nomogram of SRVD risk factors was drawn. The results showed that the score was 64 when LVEF was 0.50, 18 when SCr was 100 μmol/L, 85 when PLT was 100×10 9/L, and 39 when norepinephrine was used. When the total score reached 253, the risk of SRVD was 88%. Compared with non-SRVD group, the duration of mechanical ventilation in SRVD group was slightly longer [hours: 80.0 (28.5, 170.0) vs. 47.0 (10.0, 135.0), P > 0.05], and the 28-day mortality was significantly higher [41.7% (10/24) vs. 21.7% (20/92), P < 0.05]. Conclusions:Patients with sepsis may have right ventricular dysfunction, impaired renal function and increased mortality in the early stage. The decrease in LVEF and PLT, the increase in SCr and the application of norepinephrine are independent risk factors for SRVD in patients with sepsis.