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摘要:
目的 探讨重症医学科感染性休克患者二尖瓣反流与预后的关系。 方法 回顾分析四川大学华西医院重症医学科SHOCK-ICU数据库(NCT03082326)中2016年4月至8月感染性休克患者的一般临床资料及心脏瓣膜功能，按照入组后28 d是否死亡将患者分为死亡组和生存组，建立Logistic回归模型，比较二尖瓣反流及其他瓣膜血流异常对患者预后的影响；通过生存分析比较二尖瓣反流对感染性休克患者28 d生存率的影响。 结果 共计111例符合纳入和排除标准的感染性休克患者入选本研究，其中男67例，女44例，平均年龄(57.5±18.5)岁，平均急性生理学及慢性健康状况评分Ⅱ(Acute Physiology and Chronic Health Evaluation Ⅱ，APACHE Ⅱ)为(23.6±8.6)分，28 d病死率为46.8%(52/111)。单因素分析显示，死亡组二尖瓣反流及肺部超声评分显著高于生存组(P=0.039和P=0.020)；多因素分析显示，二尖瓣反流、肺部超声失充气评分是感染性休克患者28 d死亡的独立危险因素(P=0.015和P=0.020)。生存分析显示，合并二尖瓣反流患者的28 d生存率(38.2%，13/34)显著低于未合并者(59.7%，46/77)(P=0.039)。 结论 合并二尖瓣反流的感染性休克患者预后较差。 Abstract:Objective The aim of this study was to investigate the prognostic value of mitral regurgitation for patients with septic shock in the department of critical care medicine. Methods General clinical information and cardiac valves function of patients with septic shock from April to August 2016 in the Department of Critical Care Medicine, West China Hospital of Sichuan University were collected and analyzed retrospectively from the database of SHOCK-ICU(NCT03082326). All the patients were divided into the survival group and the death group based on whether they died in 28 days after enrollment. The effects of regurgitation of the mitral valve and other valves on the prognosis were compared by the Logistic regression model. The effect of mitral regurgitation on the survival of 28 days in patients with septic shock was analyzed. Results Totally 111 cases met the inclusion and exclusion criteria, including 67 males and 44 females with the average age of (57.5±18.5) years. The score of Acute Physiology and Chronic Health Evaluation Ⅱ(APACHE Ⅱ) and the 28-day mortality were 23.6±8.6 and 46.8% (52/111), respectively. The univariate analysis showed that mitral regurgitation and the lung ultrasound aeration loss score (LUSS) of the death group were higher than those of the survival group (P=0.039 and P=0.020). Mitral regurgitation and LUSS were independent risk factors for the 28-day mortality (P=0.015 and P=0.020) by Logistic multivariate analysis. The 28-day survival rate of patients with mitral regurgitation (38.2%, 13/34) was significantly lower than that of the non-mitral regurgitation group (59.7%, 46/77) (P=0.039) by the survival analysis. Conclusions Mitral regurgitation is associated with a worse prognosis in patients with septic shock. -
Key words:
- septic shock /
- mitral regurgitation /
- ultrasonography /
- prognosis
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表 1 111例感染性休克患者一般临床资料
项目 死亡组 生存组 P 例数（n） 52 59 年龄（x ±s，岁） 61.4±16.2 54.0±20.0 0.030 性别（男/女n） 35/17 32/27 0.160 APACHE Ⅱ评分(（x ±s分） 26.94±7.93 20.66±8.12 ＜0.01 合并基础疾病[n(%)] 冠状动脉粥样硬化性心脏病 2(3.84) 0(0) 0.220 高血压 18(34.62) 15(25.42) 0.290 糖尿病 20(38.46) 4(6.78) 0.290 慢性阻塞性肺病 5(9.62) 2(3.39) 0.250 乳酸[M(Q), mmol/L] 4.30(2.20，8.70) 2.40(1.70，3.50) ＜0.01 心率(x±s, 次/min) 119.90±22.60 115.95±23.61 0.370 血压(x±s, mm Hg） 78.97±16.62 80.55±14.58 0.600 带呼吸机时间[M(Q), h] 171.41(97.85, 383.75) 199.00(112.60, 408.00) 0.041 氧合指数 160.58(94.98, 214.31) 177.40(133.14, 254.85) 0.090 肌酐[M(Q), μmol/L] 111.00(63.50，178.00) 104.00(58.00，169.00) 0.440 感染部位(n） 肺部 39 40 0.043 腹部 12 8 0.193 泌尿系 5 4 0.732 血液 11 9 0.892 ICU住院时间(d) 13.00(5.00, 21.00) 32.00(19.00, 56.00) ＜0.01 总住院时间(d) 18.50(6.75, 31.50) 18.00(11.00, 38.00) ＜0.01 APACHE Ⅱ：急性生理与慢性健康状况评分Ⅱ 
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表 2 111例感染性休克患者28 d病死率与瓣膜疾病的单因素分析
参数 r值 P 95% CI 二尖瓣反流 0.874 0.039 1.047~5.487 二尖瓣前向血流加速 0.445 0.295 0.678~3.595 三尖瓣反流 0.668 0.087 0.907~4.193 三尖瓣前向血流加速 0.668 0.365 0.451~8.749 主动脉瓣反流 -0.032 0.958 0.304~3.092 主动脉瓣前向血流加速 -0.839 0.329 0.080~2.328 二尖瓣口血流频谱E峰/二尖瓣瓣环组织多普勒Ea峰 0.063 0.369 0.929~1.220 肺部超声失充气评分 0.109 0.020 1.041~1.194
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表 3 111例感染性休克患者28 d死亡率与瓣膜疾病的多因素分析
参数 r值 P 95% CI 二尖瓣反流 1.621 0.015 1.371~18.68 二尖瓣前向血流加速 -0.263 0.672 0.228~2.59 三尖瓣反流 -0.075 0.257 0.146~1.671 三尖瓣前向血流加速 1.272 0.248 0.416~30.611 主动脉瓣反流 0.984 0.315 0.392~18.254 主动脉瓣前向血流加速 -1.236 0.355 0.021~30.611 二尖瓣口血流频谱E峰/二尖瓣瓣环组织多普勒Ea峰 0.04 0.963 0.859~1.173 肺部超声失充气评分 0.105 0.020 1.017~1.213
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