查爾森合并癥指數(shù)對(duì)膿毒癥患者預(yù)后的評(píng)估價(jià)值

邊士淇，壽松濤，李 望，趙靜靜

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查爾森合并癥指數(shù)對(duì)膿毒癥患者預(yù)后的評(píng)估價(jià)值

邊士淇，壽松濤，李 望，趙靜靜

膿毒癥；查爾森合并癥指數(shù)；急性生理與慢性健康狀況評(píng)分系統(tǒng)Ⅱ；預(yù)后；死亡

邊士淇，壽松濤，李望，等.查爾森合并癥指數(shù)對(duì)膿毒癥患者預(yù)后的評(píng)估價(jià)值[J].中國(guó)全科醫(yī)學(xué)，2015，18(14)：1637-1640.[www.chinagp.net]

Bian SQ，Shou ST，Li W，et al.Appraisal value of charlson comorbidities index in the prognosis of septic patients[J].Chinese General Practice，2015，18(14)：1637-1640.

膿毒癥癥狀復(fù)雜，主要受遺傳、感染類型、治療時(shí)機(jī)、治療方法以及其他不確定因素的影響[1]。感染高發(fā)于酗酒者、營(yíng)養(yǎng)不良者、慢性肝腎或心血管疾病者，以及癌癥或糖尿病患者[2-3]。據(jù)統(tǒng)計(jì)，癌癥患者中約有9%死于膿毒癥，而1/6的膿毒癥患者患有癌癥[4]。因此，有學(xué)者指出，膿毒癥合并癥增加了死亡風(fēng)險(xiǎn)。

Charlson等[5]提出的查爾森合并癥指數(shù)(CCI)已被證明對(duì)重癥監(jiān)護(hù)病房(ICUs)住院患者的1年生存率具有很高的預(yù)測(cè)價(jià)值。對(duì)于住院危重患者病死率也有很好的預(yù)測(cè)價(jià)值[6-9]。與其他評(píng)分量表，如急性生理與慢性健康狀況評(píng)分系統(tǒng)(Acute Physiology and Chronic Health Evaluation，APACHE)及膿毒癥相關(guān)性器官功能衰竭評(píng)分(Sepsis-related Organ Failure Assessment，SOFA)相比，CCI基本上可以單獨(dú)依靠病歷資料進(jìn)行評(píng)估，且計(jì)算快速、簡(jiǎn)便、價(jià)廉。然而CCI相較于其他疾病評(píng)分對(duì)危重患者結(jié)局預(yù)測(cè)的有效性和實(shí)用性目前僅得到了有限的數(shù)據(jù)支持[6-7,10]，在膿毒癥患者中的研究也較少[11-12]。本研究分析了CCI對(duì)膿毒癥患者死亡風(fēng)險(xiǎn)的評(píng)估價(jià)值，并與APACHEⅡ評(píng)分進(jìn)行比較。

1 資料與方法

1.1 一般資料 回顧性分析2012年12月—2014年7月入住天津醫(yī)科大學(xué)總醫(yī)院急診醫(yī)學(xué)科病房，出院診斷為膿毒癥患者的病歷資料。納入標(biāo)準(zhǔn)：(1)患者出院診斷為膿毒癥；(2)年齡≥18歲；(3)患者病歷資料齊全。排除標(biāo)準(zhǔn)：(1)手術(shù)后的患者；(2)入院時(shí)間不滿24 h者。

1.2 診斷標(biāo)準(zhǔn) 膿毒癥及嚴(yán)重膿毒癥的診斷標(biāo)準(zhǔn)按照美國(guó)胸科醫(yī)師協(xié)會(huì)/危重病醫(yī)學(xué)會(huì)(ACCP/SCCM)聯(lián)席會(huì)議制定的標(biāo)準(zhǔn)[13]?；颊叩墓芾砑爸委熅凑障嚓P(guān)的指南標(biāo)準(zhǔn)執(zhí)行[13-14]。

1.3 觀察指標(biāo)及分組 收集患者的一般資料，包括性別、年齡、既往基礎(chǔ)疾病、28 d預(yù)后、出院時(shí)轉(zhuǎn)歸、住院時(shí)間等。按照患者28 d預(yù)后情況分為死亡組和存活組。根據(jù)APACHEⅡ量表收集患者入院24 h內(nèi)各項(xiàng)指標(biāo)的最差值，計(jì)算APACHEⅡ評(píng)分[15]。根據(jù)患者基礎(chǔ)疾病情況計(jì)算CCI評(píng)分[5],評(píng)分量表見(jiàn)表1。

表1 CCI評(píng)分量表

2 結(jié)果

2.1 基本資料及臨床指標(biāo)對(duì)預(yù)后的影響 共204例患者納入研究：其中男125例(61.3%)，女79例(38.7%)；膿毒癥121例(59.3%)，嚴(yán)重膿毒癥66例(32.4%)，膿毒癥休克17例(8.3%)；存活組132例(64.7%)，死亡組72例(35.3%)。年齡(66.5±17.4)歲，APACHEⅡ評(píng)分(13.2±7.2)分，CCI評(píng)分(2.9±2.3)分。

單因素分析結(jié)果顯示，年齡、APACHEⅡ評(píng)分、CCI評(píng)分、感染情況、充血性的心力衰竭、中/重度腎臟疾病及中/重度肝臟疾病對(duì)膿毒癥患者28 d預(yù)后有影響(P<0.05，見(jiàn)表2)。

表2 膿毒癥患者28 d預(yù)后的單因素分析

注：APACHEⅡ=急性生理與慢性健康狀況評(píng)分系統(tǒng)Ⅱ，CCI=查爾森合并癥指數(shù)；*為t值

2.3 Logistic回歸分析 選取單因素分析中有統(tǒng)計(jì)學(xué)意義的變量為自變量，以預(yù)后(死亡/存活)為因變量進(jìn)行多因素Logistic回歸分析，結(jié)果顯示：APACHEⅡ評(píng)分和CCI評(píng)分是預(yù)測(cè)膿毒癥患者28 d預(yù)后的獨(dú)立因素(P<0.01，見(jiàn)表4)。

2.4 CCI評(píng)分和APACHEⅡ評(píng)分評(píng)估膿毒癥患者預(yù)后的ROC曲線 繪制兩種評(píng)分評(píng)估膿毒癥患者28 d預(yù)后的ROC曲線，CCI評(píng)分ROC曲線下面積為0.708〔95%CI(0.635，0.782)，P<0.01〕，APACHEⅡ評(píng)分ROC曲線下面積為0.816〔95%CI(0.758,0.874),P<0.01,見(jiàn)圖1〕,兩評(píng)分ROC曲線下面積間差異有統(tǒng)計(jì)學(xué)意義(Z=2.269，P<0.05)。

表3 不同CCI評(píng)分膿毒癥患者28 d病死率〔n(%)〕

Table 3 Comparison of 28 days mortality rate of septic patients with different CCI scores

CCI評(píng)分(分)例數(shù)病死率CCI評(píng)分(分)例數(shù)病死率0253(12.0)684(4/8)1376(16.2)785(5/8)23310(30.3)840 34419(43.2)941(1/4)42610(38.5)1010 5136(46.2)1110

表4 影響膿毒癥患者28 d預(yù)后的多因素Logistic回歸分析

Table 4 Multivariable Logistic regression analysis on influencing factors for 28 days prognosis of septic patients

臨床指標(biāo)bSEWaldχ2值dfP值OR(95%CI)年齡0.0050.0140.14010.7091.005(0.979,1.032)APACHEⅡ評(píng)分0.1700.03227.5761<0.0011.185(1.112,1.263)CCI評(píng)分0.2480.0937.06410.0081.281(1.067,1.538)嚴(yán)重膿毒癥-0.9630.8512.07110.1870.387(0.113,1.447)膿毒癥休克-1.0530.7212.13010.1440.349(0.085,1.132)充血性心力衰竭-0.3220.4990.41710.5190.725(0.272,1.927)中/重度腎臟疾病-0.4140.5820.50610.4770.661(0.211,2.069)中/重度肝臟疾病-0.8660.7221.43610.2310.421(0.102,1.734)常數(shù)-2.7131.2804.49610.0340.066

圖1 CCI評(píng)分和APACHEⅡ評(píng)分預(yù)測(cè)膿毒癥患者28 d預(yù)后的ROC曲線

Figure 1 ROC curves of CCI and APACHEⅡ score for predicting 28 d prognosis of septic patients

3 討論

3.1 CCI評(píng)分 多項(xiàng)研究分析了膿毒癥患者的致死因素，并指出除了急性器官損害的定量數(shù)據(jù)，基礎(chǔ)疾病情況也與其病死率相關(guān)[2,17-20]。因此，惡性腫瘤、肝硬化、充血性心力衰竭及HIV感染等，被認(rèn)為與不良結(jié)局有關(guān)[21]，而感染本身的特點(diǎn)對(duì)預(yù)后的影響似乎不是很大[19,22-23]。Charlson等[5]提出了CCI評(píng)分系統(tǒng)，提供了一個(gè)可靠的分層方法，其包括19種基礎(chǔ)疾病，按疾病權(quán)重計(jì)分，累加之和即為患者的基礎(chǔ)疾病評(píng)分。

一些研究認(rèn)為，CCI評(píng)分對(duì)于腹膜透析[24]、不同類型惡性腫瘤[25-26]、感染性心內(nèi)膜炎[27]及金黃色葡萄球菌血癥患者[12]能夠準(zhǔn)確預(yù)測(cè)病死率。在與膿毒癥相關(guān)的研究中，有學(xué)者指出，合并癥是影響膿毒癥患者病死率及醫(yī)療資源利用的重要因素之一，通過(guò)CCI評(píng)分可以較好地預(yù)測(cè)膿毒癥患者的預(yù)后[11]。本研究結(jié)果顯示，死亡組與存活組CCI評(píng)分間有顯著差異，提示患者死亡風(fēng)險(xiǎn)與CCI評(píng)分相關(guān)。趨勢(shì)χ2檢驗(yàn)顯示，隨CCI評(píng)分升高(0～7分)，病死率相應(yīng)增加；CCI評(píng)分在8～10分時(shí)，與病死率相關(guān)性不明顯。其原因可能為8～10分段患者例數(shù)較少，造成誤差較大。Logistic回歸分析顯示：CCI評(píng)分和APACHEⅡ評(píng)分均是預(yù)測(cè)膿毒癥患者28 d預(yù)后的獨(dú)立因素。

3.2 CCI評(píng)分和APACHEⅡ評(píng)分比較 APACHEⅡ是Knaus等[15]在APACHEⅠ基礎(chǔ)上進(jìn)行修訂，于1985年提出的評(píng)分系統(tǒng)，包括年齡評(píng)分、急性生理學(xué)評(píng)分及慢性健康狀況評(píng)分3部分，是目前應(yīng)用最為廣泛的評(píng)分量表之一。本研究通過(guò)與APACHEⅡ評(píng)分進(jìn)行對(duì)比，發(fā)現(xiàn)CCI評(píng)分的預(yù)測(cè)效能遜于APACHEⅡ評(píng)分，這與既往研究結(jié)果一致[7,26,28]。但APACHEⅡ評(píng)分需要根據(jù)量表收集患者入院后24 h內(nèi)各項(xiàng)指標(biāo)的最差值進(jìn)行計(jì)算[15]，高度依賴于臨床情況和實(shí)驗(yàn)室檢查結(jié)果，項(xiàng)目較多且計(jì)算較為繁瑣。而CCI評(píng)分僅依據(jù)病史資料，計(jì)算簡(jiǎn)便。相較而言，CCI評(píng)分更為便捷。在患者臨床情況難以判斷、實(shí)驗(yàn)室數(shù)據(jù)尚不完善時(shí)，CCI評(píng)分可以發(fā)揮更顯著的優(yōu)勢(shì)，為患者危險(xiǎn)度分層、治療策略的制定爭(zhēng)取寶貴的時(shí)間。

3.3 不足與展望 本研究還存在一些不足之處：(1)作為回顧性研究，納入病例數(shù)相對(duì)較少；(2)沒(méi)有對(duì)患者入院28 d后的轉(zhuǎn)歸進(jìn)行記錄與分析；(3)在收集患者臨床資料過(guò)程中可能存在潛在的偏倚。

鑒于其簡(jiǎn)便、快捷、高性價(jià)比等特點(diǎn)，CCI評(píng)分有較大的應(yīng)用價(jià)值，尤其對(duì)于急診及新入院患者的病情評(píng)估。希望今后有多中心大樣本量的前瞻性隊(duì)列研究，進(jìn)一步驗(yàn)證本研究結(jié)論，并使CCI評(píng)分得到推廣。

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(本文編輯：趙躍翠)

Appraisal Value of Charlson Comorbidities Index in the Prognosis of Septic Patients

BIANShi-qi，SHOUSong-tao，LIWang，etal.

GeneralHospitalofTianjinMedicalUniversity,Tianjin300052,China

Sepsis；CCI；APACHEⅡ；Prognosis；Death

300052天津市，天津醫(yī)科大學(xué)總醫(yī)院

R 631

A

10.3969/j.issn.1007-9572.2015.14.009

2014-11-20；

2015-03-10)