pSOFA评分联合C-反应蛋白、降钙素原在脓毒症患儿预后评估中的作用

doi:10.3969/j.issn.1004-583X.2022.07.006

摘要/Abstract

摘要：

目的通过探讨儿童序贯器官功能障碍(pediatric sequential organ failure assessment,pSOFA)评分联合C反应蛋白(C-reactive protein,CRP)、降钙素原(procalcitonin,PCT)等感染相关生物标志物在脓毒症患儿预后评估中的作用。方法采用回顾性观察性研究方法,收集并分析2018年8月至2019年8月在我院儿童重症监护病房(pediatric intensive care unit,PICU)住院并诊断为脓毒症的289例患儿的临床资料。根据28天生存结局分为生存组和死亡组。比较两组患儿在PICU入院后24小时内各种生理和实验室数据的差异,采用二元逻辑回归分析影响脓毒症患儿预后的高危因素,绘制受试者工作特征(receiver operating characteristic,ROC)曲线,采用ROC曲线下面积(area under ROC curve,AUC)评价pSOFA评分联合CRP、PCT在脓毒症患儿早期诊断和预后评价中的作用。结果共有289例儿童被纳入研究,生存组254例(87.9%),死亡组35例(12.1%);两组儿童在是否持续泵入血管活性药物、机械通气时间、格拉斯哥昏迷评分、胃肠功能、血清PCT浓度间比较差异有统计学意义(均 $P$ <0.05);二元逻辑回归显示:pSOFA评分和是否持续泵入血管活性药物是脓毒症患儿预后不良的高危因素( $P$ <0.05);CRP和PCT预测脓毒症儿童死亡的AUC分别为0.547(95% $C I$ :0.488-0.606)、0.667(95% $C I$ :0.609-0.721);pSOFA+CRP、pSOFA+PCT和pSOFA评分预测脓毒症儿童死亡的AUC均为0.947(95% $C I$ :0.914-0.970),差异无统计学意义( $P$ >0.05)。结论 pSOFA评分对脓毒症患儿的预后评估具有重要价值,但pSOFA评分联合CRP、PCT并不能提高脓毒症患儿的预后评价能力。

关键词: 脓毒症, 儿童, pSOFA评分, C反应蛋白, 降钙素原, 预后

Abstract:

Objective To evaluat pediatric sequential organ failureassessment (pSOFA) score combined with C-reactive protein (CRP), procalcitonin (PCT), and other infection-related biomarkers of the prognostic assessment in sepsis children. Methods A retrospective observational study was applied to collect the clinical data of 289 sepsis children (2018.8-2019.8) admitted to Pediatric Intensive Care Unit (PICU) of the Hospital. The children were divided into the survival group and death group according to 28-day survival outcomes. The differences in intergroup physiological and laboratory data in pediatric intensive care unit (PICU) within 24 hours of admission were compared, binary logistic regression was applied to analyze high-risk factors impacting the prognosis of sepsis children, the receiver operating characteristic (ROC) curve and the area under ROC curve (AUC) were drawn to assess the effects of the pSOFA scores combined with CRP and PCT in the early diagnosis and prognosis of children with sepsis. Results A total of 289 children including 254 (87.9%) in the survival group and 35 (12.1%) in the death group were included in the study. The comparative differences of children in terms of availability of constantly pumped vasoactive drugs, duration of mechanical ventilation, Glasgow coma scores, gastrointestinal functions, and serum PCT concentration were statistically significant (all P<0.05). Binary logistic regression showed that pSOFA scores and availability of continuously pumped vasoactive drugs were high-risk factors for poor prognosis in children with sepsis (P<0.05); AUCs for CRP and PCT to predict death in children with sepsis was 0.547(95%CI: 0.488-0.606) and 0.667(95%CI: 0.609-0.721), respectively. The AUC of pSOFA+CRP, pSOFA+PCT and pSOFA scores for predicting death of children with sepsis was 0.947 without exception (95%CI: 0.914-0.970), and the differences weren't statistically significant (P>0.05). Conclusion pSOFA scores deliver important value for prognostic evaluation of sepsis children, while pSOFA score combined with CRP and PCT fail to improve the prognostic evaluation of children with sepsis.

Key words: sepsis, pediatrics, pSOFA score, C-reactive protein, procalcitonin, prognosis

中图分类号:

R631

周彬, 曾词正, 黄宇戈, 钟娩玲, 吴家园. pSOFA评分联合C-反应蛋白、降钙素原在脓毒症患儿预后评估中的作用[J]. 临床荟萃, 2022, 37(7): 616-622.

Zhou Bin, Zeng Cizheng, Huang Yuge, Zhong Mianling, Wu Jiayuan. Effect of pSOFA score combined with C-reactive protein and procalcitonin in prognosis assessment of sepsis children[J]. Clinical Focus, 2022, 37(7): 616-622.

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链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2022.07.006

https://huicui.hebmu.edu.cn/CN/Y2022/V37/I7/616

图/表 8

图1 研究对象纳入流程图

表1 两组住院期间临床资料比较

项目	存活组	死亡组	χ²/ $Z$ 值	$P$ 值
例数	254	35
男/女	165/89	23/12	0.008	0.930
年龄[月, $M$ (P25,P75)]	5.5[2.0,22.3]	17.0[6.0,53.0]	3.388	0.001
PICU住院时间(d, $x -$ ±s)	6.6±7.2	8.4±13.4	-1.142	0.215
总住院时间(d, $x -$ ±s)	12.8±9.7	9.0±16.3	1.352	0.185
机械通气时间(d, $x -$ ±s)	1.1±4.9	4.0±4.7	-3.448	0.001
持续泵入血管活性药物[例(%)]	57(22.4)	32(91.4)	68.695	0.000
胃肠功能(正常/肠麻痹/肠出血)[例(%)]	250(98.4)/3(1.2)/1(0.4)	27(77.1)/8(22.9)/0	23.463	0.000
格拉斯哥昏迷评分[分,M(P25,P75)]	13[13,13]	5[3,10]	-9.948	0.000
CRP[mg/L, $M$ (P25,P75)]	6.9[2.9,20.8]	8.1[3.7,72.7]	0.904	0.366
PCT[ng/L, $M$ (P25,P75)]	0.3[0.1,1.7]	1.6[0.4,20.5]	3.196	0.001
pSOFA(分, $x -$ ±s)	3.0±2.4	10.6±3.9	-11.137	0.000

表1 两组住院期间临床资料比较

项目	存活组	死亡组	χ²/ $Z$ 值	$P$ 值
例数	254	35
男/女	165/89	23/12	0.008	0.930
年龄[月, $M$ (P25,P75)]	5.5[2.0,22.3]	17.0[6.0,53.0]	3.388	0.001
PICU住院时间(d, $x -$ ±s)	6.6±7.2	8.4±13.4	-1.142	0.215
总住院时间(d, $x -$ ±s)	12.8±9.7	9.0±16.3	1.352	0.185
机械通气时间(d, $x -$ ±s)	1.1±4.9	4.0±4.7	-3.448	0.001
持续泵入血管活性药物[例(%)]	57(22.4)	32(91.4)	68.695	0.000
胃肠功能(正常/肠麻痹/肠出血)[例(%)]	250(98.4)/3(1.2)/1(0.4)	27(77.1)/8(22.9)/0	23.463	0.000
格拉斯哥昏迷评分[分,M(P25,P75)]	13[13,13]	5[3,10]	-9.948	0.000
CRP[mg/L, $M$ (P25,P75)]	6.9[2.9,20.8]	8.1[3.7,72.7]	0.904	0.366
PCT[ng/L, $M$ (P25,P75)]	0.3[0.1,1.7]	1.6[0.4,20.5]	3.196	0.001
pSOFA(分, $x -$ ±s)	3.0±2.4	10.6±3.9	-11.137	0.000

表2 影响脓毒症患儿预后的高危因素的二元logistic回归分析结果

影响因素	回归系数	标准误	Wald χ²值	$O R$ 值	95% $C I$	$P$ 值
年龄	0.015	0.009	2.938	1.015	0.998-1.033	0.087
机械通气时间	-0.070	0.047	2.267	0.932	0.851-1.021	0.132
是否持续静脉泵入血管活性药物	-1.756	0.804	4.772	0.173	0.036-0.835	0.029
格拉斯哥昏迷评分	-0.186	0.097	3.718	0.830	0.687-1.003	0.054
胃肠功能	0.371	1.972	0.106	1.372	0.204-9.216	0.745
CRP	0.007	0.005	1.686	1.007	0.997-1.017	0.194
PCT	-0.015	0.013	1.477	0.985	0.961-1.009	0.224
pSOFA评分	0.371	0.105	12.394	1.449	1.179-1.782	0.000

表2 影响脓毒症患儿预后的高危因素的二元logistic回归分析结果

影响因素	回归系数	标准误	Wald χ²值	$O R$ 值	95% $C I$	$P$ 值
年龄	0.015	0.009	2.938	1.015	0.998-1.033	0.087
机械通气时间	-0.070	0.047	2.267	0.932	0.851-1.021	0.132
是否持续静脉泵入血管活性药物	-1.756	0.804	4.772	0.173	0.036-0.835	0.029
格拉斯哥昏迷评分	-0.186	0.097	3.718	0.830	0.687-1.003	0.054
胃肠功能	0.371	1.972	0.106	1.372	0.204-9.216	0.745
CRP	0.007	0.005	1.686	1.007	0.997-1.017	0.194
PCT	-0.015	0.013	1.477	0.985	0.961-1.009	0.224
pSOFA评分	0.371	0.105	12.394	1.449	1.179-1.782	0.000

表3 CRP、PCT与pSOFA评分联合诊断对重症监护室脓毒症患儿死亡的预测能力

评分系统	AUC	95% $C I$	最佳截断值	敏感度 (%)	特异度 (%)	阳性预测值(%)	阴性预测值(%)	$Z$ 值	$P$ 值
CRP	0.547	0.488-0.606	>91.5	22.86	90.94	2.52	0.85	0.839	0.4016
PCT	0.667	0.609-0.721	>0.891	68.57	67.32	2.10	0.47	2.953	0.0031
pSOFA	0.947	0.914-0.970	>5	85.71	88.19	7.26	0.16	28.149	<0.0001
pSOFA+CRP	0.947	0.914-0.970	>0.071	85.71	88.19	7.26	0.16	28.149	<0.0001
pSOFA+PCT	0.947	0.914-0.970	>0.071	85.71	88.19	7.26	0.16	28.149	<0.0001

表3 CRP、PCT与pSOFA评分联合诊断对重症监护室脓毒症患儿死亡的预测能力

评分系统	AUC	95% $C I$	最佳截断值	敏感度 (%)	特异度 (%)	阳性预测值(%)	阴性预测值(%)	$Z$ 值	$P$ 值
CRP	0.547	0.488-0.606	>91.5	22.86	90.94	2.52	0.85	0.839	0.4016
PCT	0.667	0.609-0.721	>0.891	68.57	67.32	2.10	0.47	2.953	0.0031
pSOFA	0.947	0.914-0.970	>5	85.71	88.19	7.26	0.16	28.149	<0.0001
pSOFA+CRP	0.947	0.914-0.970	>0.071	85.71	88.19	7.26	0.16	28.149	<0.0001
pSOFA+PCT	0.947	0.914-0.970	>0.071	85.71	88.19	7.26	0.16	28.149	<0.0001

图2 CRP、PCT与pSOFA评分对重症监护室脓毒症患儿死亡的预测能力

图3 CRP、PCT与pSOFA评分联合诊断对重症监护室脓毒症患儿死亡的预测能力

表4 CRP、PCT、pSOFA评分、pSOFA+CRP和pSOFA+PCT对患儿脓毒症严重程度的预测能力

评分系统	AUC	95% $C I$	最佳截断值	敏感度 (%)	特异度 (%)	阳性预测值(%)	阴性预测值(%)	$Z$ 值	$P$ 值
CRP	0.601	0.538-0.662	>19.3	48.84	76.67	2.09	0.67	1.831	0.0671
PCT	0.684	0.623-0.741	>1.01	62.79	76.19	2.64	0.49	3.660	0.0003
pSOFA	0.904	0.861-0.937	>4	74.42	90.48	7.81	0.28	16.53	<0.0001
pSOFA+CRP	0.911	0.869-0.943	>0.2861	79.07	90.48	8.30	0.23	15.451	<0.0001
pSOFA+PCT	0.913	0.872-0.945	>0.2342	79.07	89.52	7.55	0.23	16.340	<0.0001

表4 CRP、PCT、pSOFA评分、pSOFA+CRP和pSOFA+PCT对患儿脓毒症严重程度的预测能力

评分系统	AUC	95% $C I$	最佳截断值	敏感度 (%)	特异度 (%)	阳性预测值(%)	阴性预测值(%)	$Z$ 值	$P$ 值
CRP	0.601	0.538-0.662	>19.3	48.84	76.67	2.09	0.67	1.831	0.0671
PCT	0.684	0.623-0.741	>1.01	62.79	76.19	2.64	0.49	3.660	0.0003
pSOFA	0.904	0.861-0.937	>4	74.42	90.48	7.81	0.28	16.53	<0.0001
pSOFA+CRP	0.911	0.869-0.943	>0.2861	79.07	90.48	8.30	0.23	15.451	<0.0001
pSOFA+PCT	0.913	0.872-0.945	>0.2342	79.07	89.52	7.55	0.23	16.340	<0.0001

图4 CRP、PCT、pSOFA评分、pSOFA+CRP和pSOFA+PCT对患儿脓毒症严重程度的预测能力

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