早期液体复苏入量及相关临床指标对老年脓毒性休克患者预后评估分析

Analysis of Prognostic Evaluation of Early Fluid Resuscitation Intake and Related Clinical Indicators in Elderly Patients with Septic Shock

摘要: 目的：研究早期液体复苏入量及相关临床指标包括血尿素氮(BUN)、乳酸清除率(LCR)、下腔静脉变异度(IVCV)及急性生理与慢性健康(APACHE II)评分、序贯器官衰竭估计(SOFA)评分对老年脓毒性休克患者预后评估价值。方法：研究纳入2020年10月至2023年10月青岛市市立医院东院区收治的70例老年脓毒性休克患者，根据患者28天预后结果分为存活组(34例，48.6%)和死亡组(36例，51.4%)，比较两组患者入院时的一般资料及入院6 h时的液体复苏入量、LCR、IVCV及入院24小时内APACHE II评分、SOFA评分，应用二元Logistic回归分析法分析影响老年脓毒性休克患者28天预后的独立危险因素，并绘制受试者工作特征(ROC)曲线，评估各指标对老年脓毒性休克患者28天预后的评估价值。结果：死亡组的BUN、APACHE II评分、SOFA评分高于存活组，6 h LCR低于存活组，且死亡组入院6 h无下腔静脉变异度(完全机械通气患者IVCV < 18%或自主呼吸患者IVCV < 50%)的患者明显多于存活组(P < 0.05)。死亡组患者在入院6小时内接受了更多的液体入量(P < 0.05)。应用二元Logistic回归分析校正了年龄、性别、BMI、白蛋白、CRP、PCT、基础疾病等混杂因素后，结果显示BUN (OR = 1.087, P < 0.05)、6 h LCR (OR = 0.983, P < 0.05)、6 h IVCV (OR = 15.557, P < 0.01)、APACHE II评分(OR = 1.175, P < 0.01)、SOFA评分(OR = 1.586, P < 0.01)、及入院6 h液体复苏入量(OR = 1.001, P < 0.05)均是影响老年脓毒性休克患者死亡的独立危险因素。绘制ROC曲线分析显示BUN、6 h LCR、APACHE II评分、SOFA评分、6 h液体复苏入量对老年脓毒性休克患者28天预后均有一定预测价值(P < 0.05)。其中APACHE II评分(AUC = 0.737, Cut-off = 26.50, P < 0.01)、SOFA评分(AUC = 0.735, Cut-off = 9.50, P < 0.01)预测老年脓毒性休克患者28天预后的AUC高于其他指标，低于四者联合指标(AUC = 0.785, P < 0.01)。上述六个指标联合对老年脓毒性休克患者28天预后的预测价值最好(AUC = 0.824, P < 0.01)。结论：入院6 h液体复苏入量、BUN、6 h LCR、6 h IVCV及APACHE II评分、SOFA评分均是影响老年脓毒性休克患者28天死亡的独立危险因素。在老年脓毒性休克患者液体复苏治疗时，不宜短时间内摄入过多液体(最佳截断值为1042.50 mL，灵敏度为72.2%，特异度为55.9%)。入院6 h液体复苏入量、BUN、6 h LCR、6 h IVCV及APACHE II评分、SOFA评分六项指标联合对老年脓毒性休克患者28天预后预测价值最高。

Abstract: Objective: Research on early fluid resuscitation volume and associated clinical indicators involves blood urea nitrogen (BUN), lactate clearance rate (LCR), inferior vena cava variability (IVCV), acute physiology and chronic health evaluation II (APACHE II) score, sequential organ failure assessment (SOFA) score for prognostic assessment in elderly patients with septic shock. Methods: The study included 70 elderly septic shock patients admitted in the East Hospital District of Qingdao Municipal Hospital from October 2020 to October 2023. According to the 28-day prognosis of patients, they were divided into survival group (34 cases, 48.6%) and death group (36 cases, 51.4%), Compare the general information of two groups of patients upon admission, as well as the fluid resuscitation volume, LCR, IVCV at 6 hours of admission, and APACHE II and SOFA scores within 24 hours of admission, the application of binary logistic regression analysis to analyze the independent risk factors affecting the 28-day prognosis of elderly patients with septic shock, and plot the working characteristics of the subjects (ROC) curve to evaluate the evaluation value of each indicator for the 28-day prognosis of elderly patients with septic shock. Results: The BUN, APACHE II and SOFA scores in the death group were higher than those in the survival group, 6 h LCR was lower than in the survival group, and the patients who were admitted to the death group for 6 hours without inferior vena cava variation (IVCV < 18% in patients with complete mechanical ventilation or IVCV < 50% in patients with autonomous breathing) were obvious, more than the surviving group (P < 0.05). The patients in the dead group received more fluid intake (P < 0.05) within 6 hours of admission. After applying binary logistic regression analysis to correct age, gender, BMI, albumin, CRP, PCT, basic diseases and other mixed factors, the results showed BUN (OR = 1.087, P < 0.05), 6 h LCR (OR = 0.983, P < 0.05), 6 h IVCV (OR = 15.557, P < 0.01), APACHE II score (OR = 1.175, P < 0.01), SOFA score (OR = 1.586, P < 0.01), and admission 6 h liquid resuscitation input (OR = 1.001, P < 0.05) are independent risk factors affecting the death of elderly patients with septic shock. The ROC curve analysis shows that BUN, 6 h LCR, APACHE II score, SOFA score, and 6 h fluid resuscitation input have a certain predictive value for the 28-day prognosis of elderly patients with septic shock (P < 0.05). Among them, The APACHE II score (AUC = 0.737, Cut off = 26.50, P < 0.01) and SOFA score (AUC = 0.735, Cut off = 9.50, P < 0.01) predict a higher AUC than other indicators for the 28-day prognosis of elderly patients with septic shock, and lower the four combined indicators (AUC = 0.785, P < 0.01). The combination of six indicators has the best predictable value for the 28-day prognosis of elderly patients with septic shock (AUC = 0.824, P < 0.01). Conclusion: 6 h liquid resuscitation intake, BUN, 6 h LCR, 6 h IVCV and APACHE II scores, and SOFA scores are all independent risk factors affecting the 28-day death of elderly patients with septic shock. In the treatment of fluid resuscitation in elderly patients with septic shock, it is not appropriate to ingest too much fluid in a short period of time (the optimal truncation value is 1042.50 mL, the sensitivity is 72.2%, and the specificity is 55.9%). Six indicators of admission 6 h liquid resuscitation input, BUN, 6 h LCR, 6 h IVCV and APACHE II score, and SOFA score have the highest prognostic value for 28 days of elderly patients with septic shock.