目的 探究血栓弹力图(thromboelastography,TEG)指标与重症医学科(ICU)脓毒症患者住院病死率的关系.方法 采用回顾性观察性队列研究方法,对广州医科大学附属第二医院重症医学科2019年6月至2023年6月间诊断为脓毒症,并就诊当天进行TEG的185例患者临床资料进行分析.根据脓毒症患者住院转归分为生存组(n=112)和死亡组(n=73),分析基线特征及TEG指标,采用多因素Cox回归评估TEG指标与脓毒症患者住院病死率之间的相关性.用受试者工作特征曲线(ROC)分析TEG指标对脓毒症患者住院病死率的预测价值,并根据最佳截取值分组绘制住院病死率Kaplan-Meier生存曲线.对各分类变量分层进行敏感性分析.结果 共纳入185例ICU脓毒症患者中,死亡73例,住院病死率39.5％.两组脓毒症患者R值、K值、α角、氧合指数、总胆红素(TBIL)、乳酸、活化部分凝血活酶时间(APTT)、急性生理学和慢性健康状况评价Ⅱ(APACHE Ⅱ)评分、序贯器官衰竭评估(SOFA)评分差异均有统计学意义(P＜0.05).多因素Cox回归分析显示,K值每增加1分钟,脓毒症患者住院病死率将增加21％[HR=1.21,95％置信区间(95％CI)为1.1～1.33,P＜0.001];最大振幅(MA值)每增加1 mm,脓毒症患者住院病死率将减少4％[HR=0.96,95％CI 0.93～0.98,P＜0.001].K值和MA值预测脓毒症患者住院病死率的 ROC 曲线下面积(AUC)为 0.834(95％CI0.760～0.887)和 0.648(95％CI0.552～0.719).K值最佳截取值为2.15时,敏感度为0.685,特异度为0.857,阳性预测值为0.758,阴性预测值为0.807;MA值最佳截取值为55.45 mm时,敏感度为0.397,特异度为0.866,阳性预测值为0.660,阴性预测值为0.688.根据K值与MA值最佳截取值将患者分为低K值组(＜2.15 min)和高 K 值组(≥2.15 min)、低 MA 值组(＜55.45 mm)和高 MA 值组(≥ 55.45 mm).K-M生存曲线显示,高K值组住院累积存活率显著低于低K值组(Log-rank检验:P＜0.0001);高MA值组住院累积存活率显著高于低MA值组(P＜0.0001).多因素Cox回归分析显示,考虑到年龄、性别、主要诊断、合并症、乳酸、D-二聚体、α角、MA值、APACHE Ⅱ评分和SOFA评分因素影响,高K值组住院病死率是低K值组的3.56倍(HR=3.56,95％CI为1.83～6.92,P＜0.001).对所有分类变量进行分层分析显示,K值、MA值与脓毒症住院病死率的关系保持一致.结论 脓毒症患者TEG中K值、MA值与住院病死率密切相关;TEG K值超过2.15 min、MA值低于55.45 mm时,脓毒症患者死亡风险大幅增加.
The relationship between thromboelastography indexes and in-hospital mortality among sepsis patients in ICU
Objective To investigate the correlation between thromboelastography(TEG)indexes and in-hospital mortality among sepsis patients in intensive care unit(ICU).Methods A retrospective observational cohort study was conducted,the clinical data of 185 sepsis patients underwent TEG on admission in Intensive Care Unit of the Second Affiliated Hospital of Guangzhou Medical University between June 2019 and June 2023 were analyzed.According to the hospital outcomes(survival or death),the patients were divided into survival group(n=112)and death group(n=73)and their baseline characteristics and TEG indexes were analyzed.Multivariate Cox regression analysis was employed to assess the relationship between TEG indexes and in-hospital mortality in sepsis patients.The predictive value of TEG indexes for in-hospital mortality rate in sepsis patients was analyzed by using receiver operating characteristic(ROC)curve,and Kaplan-Meier survival curves of in-hospital mortality were drawn based on the optimal cut-off values for grouping.Additionally,sensitivity analysis stratified each categorical variable.Results The study included 185 sepsis patients in the ICU,and found that 73 cases(39.5％)died in hospital.Significant differences were found in various factors between two groups,including the value of reaction time(R value),blood coagulation time(K value),α angle,oxygenation index,total bilirubin(TBIL),lactic acid,activated partial thromboplastin time(APTT),acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ)and sequential organ failure assessment(SOFA)(P＜0.05).Multivariate Cox regression analysis revealed for every 1-minute increase in K value,the in-hospital mortality rate of sepsis patients increased by 21％(HR=1.21,95％CI 1.1-1.33,P＜0.001),while for every 1-mm increase in maximum amplitude(MA)value,the in-hospital mortality rate of sepsis patients decreased by 4％(HR=0.96,95％CI 0.93-0.98,P＜0.001).Additionally,ROC curve analysis demonstrated that the AUC of K value and MA value for predicting in-hospital mortality in sepsis patients was 0.834(95％CI 0.760-0.887)and 0.648(95％CI 0.552-0.719),respectively.With an optimal cut-off value of 2.15 min for K value,the sensitivity was 0.685,the specificity was 0.857,the positive predictive value was 0.758,and the negative predictive value was 0.807.Furthermore,at an optimal cut-off value of 55.45 mm for MA,the sensitivity was 0.397,the specificity was 0.866,the positive predictive value was 0.660,and the negative predictive value was 0.688.The patients were categorized into groups based on the optimal cut-off values of K value and MA value:low K value group(＜2.15 min)and high K value group(≥2.15 min),low MA value group(＜55.45 mm)and high MA value group(≥55.45 mm),respectively.According to Kaplan-Meier survival curves,the cumulative hospitalization survival rates in high K value group were significantly lower than those in low K value group(Log-rank test:P＜0.0001).The cumulative hospitalization survival rates of high MA value group were significantly higher than those of low MA value group(P＜0.0001).Multivariate Cox regression analysis revealed that the high K value group had a 3.56 times higher risk of in-hospital mortality compared to those in the low K value group after adjusting for the variables such as age,sex,main diagnosis,comorbidities,lactic acid,D-dimer,α angle,MA value,APACHEⅡ score and SOFA score(HR=3.56,95％CI 1.83-6.92,P＜0.001).Stratified analysis of categorical variables indicated the relationship of K value and MA value with in-hospital mortality rate remained consistent.Conclusions In the patients with sepsis in ICU,there is a strong correlation of K value and MA value in TEG with in-hospital mortality rate.Sepsis patients with K value exceeding 2.15 min and MA value less than 55.45 mm had a significantly higher risk of mortality.
万方数据
维普
