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Evaluating Value of Modified Critical Care Ultrasonic Examination Protocol for the Patients Unplanned Admission to the ICU
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摘要:
目的 探讨改良重症超声快速管理(modified critical care ultrasonic examination，M-CCUE)方案对非计划入ICU患者的评估价值，并分析其是否会影响医疗行为及预后判断。 方法 回顾性收集并分析2015年12月至2016年6月北京协和医院重症医学科非计划收治患者的相关临床资料，包括血流动力学指标、器官及组织灌注指标和预后评价指标。所有入选患者在入室30 min内完成初始M-CCUE评估，根据M-CCUE评分系统予以评分(M-CCUE score，MCS)。分析MCS与预后的相关性及对治疗策略的影响。 结果 共计272例符合入选和排除标准的非计划入ICU患者纳入本研究，其中仅3例(1.1%，3/272)患者在M-CCUE评估方案中未发现异常，139例(51.1%，139/272)因评估结果改变了药物治疗方案，81例(29.8%，81/272)进行了有创检查或治疗。MCS与患者28 d死亡率(r=0.432，P=0.020)、48 h死亡率(r=0.594，P=0.008)、机械通气时间(r=0.454，P=0.040)、ICU住院时间(r=0.563，P=0.003)均呈正相关。多因素回归分析显示，年龄、急性生理与慢性健康状况评分Ⅱ(acute physiology and chronic health evaluation Ⅱ，APACHE Ⅱ)、MCS和序贯性器官衰竭评分(sequential organ failure assessment，SOFA)是28 d死亡的独立危险因素，同时年龄、MCS和SOFA是48 h死亡的独立危险因素。 结论 M-CCUE能够实现早期床旁心肺功能评估，其量化评估结果可改进临床治疗方案，预测患者预后。 Abstract:Objective The purpose of this study was to investigate the evaluating value of the modified critical care ultrasonic examination (M-CCUE) protocol for those patients unplanned admission to the ICU and to analyze whether it could influence the management decision and predict the outcome. Methods The clinical data of patients unplanned admission to the department of critical care medicine of Peking Union Medical College Hospital from December 2015 to June 2016 were collected and analyzed retrospectively, including the hemodynamic index, organ and tissue perfusion index, and prognosis evaluating index. All the enrolled patients received the M-CCUE within 30 minutes after admission to our department and were scored according to the M-CCUE scoring system (MCS). The correlation between MCS and the prognosis and its effect on the management decision were analyzed. Results A total of 272 patients who met the inclusion and exclusion criteria were enrolled in this study. Only 3 patients (1.1%, 3/272)did not show any anomaly in M-CCUE; the management decision of 138 patients (50.7%, 138/272), was adjusted; 81 patients (29.8%, 81/272) underwent additional invasive diagnostic procedures or treatment. The univariate analysis revealed that MCS correlated positively with the 28-day mortality (r=0.432, P=0.020), 48-hour mortality (r=0.594, P=0.008), ventilator time (r=0.454, P=0.040), and length of ICU stay (r=0.563, P=0.003). The multivariate analysis demonstrated that age, acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ), MCS, and sequential organ failure assessment score were the independent risk factors for the 28-day mortality, while age, MCS, and sequential organ failure assessment score were the independent risk factors for the 48-hour mortality. Conclusions M-CCUE protocol can achieve the early bedside cardiopulmonary function assessment; its quantitative assessment results are associated with the prognosis and might improve the clinical management decision. -
Key words:
- critical ultrasound /
- uplanned admission /
- evaluation /
- prognosis
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表 1 M-CCUE评分标准
超声部分 超声表现正常 超声表写异常 左肺 0分 1分/项 上蓝点 A B/C/P M点 A B/C/P 膈肌点 A B/C/P PLAPS点 A B/C/P 后蓝点 A B/C/P 得分 右肺 0分 1分/项 上蓝点 A B/C/P M点 A B/C/P 膈肌点 A B/C/P PLAPS点 A B/C/P 后蓝点 A B/C/P 得分 明显心脏异常 0分 2分/项 大量心包积液 否 是 心包堵塞 否 是 新的瓣膜毁损 否 是 得分 右心功能 0分 1分/项 2分/项 室间隔形态 正常运动 室间隔抖动 矛盾运动 右室室壁增厚 否 是 - 右心室/左心室比例 ＜0.6 0.6~1.0 ＞1.0 三尖瓣瓣环收缩期位移(cm) ＞1.8 ≤1.8 - 得分 左室功能 左室收缩功能 0分 0.5分/项 1分/项 1.5分/项 2分/项 LVEF (%) 51~57 ＞70 30~50 11~29 ＜10 二尖瓣瓣环收缩期位移(cm) ＞1.2 - ≤1.2 左室舒张功能 0分 - 1分/项 - - LVEF＜50% 否 - 是 - - 左室室壁增厚 否 - 是 - - 左房增大 否 - 是 - - 得分 容量状态 0分 2分/项 下腔静脉直径(cm) 1.5~2.0(机械通气) ＜1.5或2.0(机械通气) 1.0~2.0(非机械通气) ＜1.0或2.0(非机械通气) 下腔静脉直径呼吸变异度(%) ＜18(机械通气) ≥18(机械通气) ＜50(非机械通气) ≥50(非机械通气) 得分 总评分 M-CCUE:同图 1 
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表 2 非计划入ICU患者入室后30 min内血流动力学参数
参数 结果 心率(x ±s, 次/分) 110±3 2 平均动脉压(x±s, mm Hg) 62 ±21 氧合指数(x±s) 176± 46 机械通气/非机械通气(n) 221/51 呼气末正压(x±s, cm H2o) 10± 6 机械通气时间[M(Q), d] 4.2(0.9, 24) ICU住院时间[M(Q), d] 11(5, 19) 住院时间[M(Q), d] 24(10, 28) 血管活性药物使用时间[M(Q), h] 67(31, 197) 28d死亡率(%) 17.6(48/272) 48h死亡率(%) 13.6(36/272)
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表 3 非计划入ICU患者病情评分与预后的相关性
评分项目 28d死亡率 48h死亡率 机械通气时间(d) ICU住院时间(d) r值 p值 r值 p值 r值 p值 r值 p值 MCS 0.432 0.020 0.594 0.008 0.445 0.040 0.563 0.003 APACHE 0.465 0.010 0.175 0.132 0.198 0.170 0.745 ＜0.001 SOFA 0.523 0.005 0.342 0.030 0.542 0.030 0.416 0.084 MCS:改良重症超声快速管理方案评分; APACHE Ⅱ :急性生理与慢性健康状况评分Ⅱ; SOFA:序贯性器官衰竭评分
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表 4 MCS与非计划入ICU患者预后相关性
分组 MCS 例数 28死亡率(%) ICU住院时间(d) 机械通气时间(d) 低危组 0~10 67 11.9 7.6 5.2 中危组 11~20 125 16.0 12.4 7.3 高危组 21~32 80 25.0 19.3 14.2 p值 0.006 0.024 0.035 MCS:同表 3
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表 5 非计划入ICU患者28 d和48 h死亡风险单因素分析
风险因素 28d死亡 48h死亡 OR值 P值 OR值 P值 MCS 1.450 0.017 1.967 0.003 APACHE Ⅱ 1.087 0.023 - - SOFA 1.836 < 0.001 2.013 0.012 年龄 1.031 0.042 1.125 0.037 氧合指数 2.013 0.028 1.783 0.026 平均动脉压 1.131 0.073 0.946 0.040 心率 0.764 0.132 1.097 0.310 性别 1.183 0.0231 0.853 0.425 机械通气时间 1.473 0.076 1.218 0.079 ICU住院时间 0.624 0.213 0.873 0.058 MCS、APACHE Ⅱ、SOFA:同表 3
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表 6 非计划入ICU患者28 d和48 h死亡独立危险因素分析
风险因素 28d死亡 48h死亡 OR值 P值 95% CI OR值 P值 95% CI MCS 1.543 0.013 1.243~1.678 1.967 < 0.001 1.243~2.678 APACHE Ⅱ 1.087 0.030 1.023~1.196 - - - SOFA 1.836 0.002 1.212~2.013 1.021 0.042 1.001~1.130 年龄 1.031 0.021 1.002~1.217 1.125 0.020 1.002~1.310 MCS、APACHE Ⅱ、SOFA:同表 3
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