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牛津急性疾病严重程度评分鉴别快速序贯器官功能衰竭评分阴性脓毒症患者的临床价值
陈钦桂
谢锐杰
陈燕珠
曾勉
作者及单位信息
·
DOI： 10.3760/cma.j.issn.1001-0939.2018.09.010
Clinical value of Oxford acute severity of illness score in identifying quick sequential organ failure assessment-negative patients with sepsis
Chen Qingui
Xie Ruijie
Chen Yanzhu
Zeng Mian
Authors Info & Affiliations
Chen Qingui
Department of Medical Intensive Care Unit, First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
Xie Ruijie
Chen Yanzhu
Zeng Mian
·
DOI： 10.3760/cma.j.issn.1001-0939.2018.09.010
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摘要

目的评价牛津急性疾病严重程度评分(OASIS)对快速序贯器官功能衰竭评分(qSOFA)阴性(qSOFA<2)脓毒症患者的鉴别价值。

方法从存储了美国贝斯以色列迪康医学中心重症监护室2001年至2012年住院患者医疗信息的监护室医学信息数据集(MIMIC-Ⅲ)中选取qSOFA阴性的脓毒症患者，同时筛选qSOFA<2、无可疑感染且SOFA<2的其他患者作为对照，并构建倾向性评分匹配队列以减少选择偏倚，运用ROC曲线分析OASIS鉴别qSOFA阴性脓毒症患者的价值并确定其阈值，进一步运用多因素Cox回归、logistic回归分析基于该阈值的OASIS水平与研究对象临床结局的关联。

结果2 273例qSOFA阴性脓毒症患者与3 342例作为对照的非脓毒症患者纳入最终分析，其中1 677对患者成功匹配。受试者工作特征曲线(ROC曲线)分析结果显示，OASIS鉴别qSOFA阴性脓毒症患者的曲线下面积为0.753(95% CI为0.741～0.765)，Youden指数法确定的阈值为26.5，相应的敏感度为67.2%，特异度为70.8%。多因素回归分析显示，OASIS>26分别是患者28 d死亡(风险比为2.80，95% CI为2.15～3.65， P<0.01)、ICU内死亡(比值比为4.69，95% CI为2.60～8.49， P<0.01)以及院内死亡(比值比为4.48，95% CI为3.13～6.42， P<0.01)的独立危险因素。对匹配队列的分析结果亦类似。

结论OASIS对qSOFA阴性脓毒症患者具有较高的鉴别能力。

脓毒症;危重病;牛津急性疾病严重程度评分;快速序贯器官功能衰竭评分
ABSTRACT

ObjectiveThe quick sequential organ failure assessment (qSOFA) score has been proposed as part of diagnostic criteria for sepsis, but there might be an underestimation of the incidence of qSOFA-negative sepsis according to a few recent studies. The purpose of this study was to evaluate the value of Oxford acute severity of illness score (OASIS) in identifying qSOFA-negative (qSOFA<2) patients with sepsis.

MethodsSepsis patients with negative qSOFA scores were selected from the Medical Information Mart for Intensive Care Ⅲ(MIMIC-Ⅲ), a database comprising de-identified health-related data from patients staying in the critical care units of Beth Israel Deaconess Medical Center between 2001 and 2012. Non-infectious patients with both qSOFA and SOFA scores less than 2 were enrolled as controls. Propensity score matching (PSM) analysis was used to reduce the effects of selection bias. Receiver operating characteristic (ROC) curve analysis was performed to assess the value of OASIS in discriminating qSOFA-negative patients with sepsis and to determine its optimal cut-off. Associations of OASIS with 28-day mortality after intensive care unit (ICU) admission, ICU mortality, and hospital mortality were further examined using multivariate Cox regression and multivariate logistic regression analysis.

Results2 273 qSOFA-negative patients with sepsis and 3 342 non-sepsis controls were included finally with a PSM cohort consisted of 1 677 sepsis patients and 1 677 controls. Results of ROC analysis showed that the area under ROC curve was 0.753 [95% confidence interval ( CI) 0.741-0.765] and the optimal OASIS threshold according to the Youden index was 26.5 and yielded a 67.2% sensitivity and 70.8% specificity. Multivariate regression analysis indicated that OASIS>26 was an independent risk factor for 28-day mortality (hazard ratio 2.80, 95% CI 2.15-3.65, P<0.01), ICU mortality (odds ratio 4.69, 95% CI 2.60-8.49, P<0.01), and hospital mortality (odds ratio 4.48, 95% CI 3.13-6.42, P<0.01). Analysis of the PSM cohort presented consistent results.

ConclusionsOASIS had a good discriminative value to differentiate qSOFA-negative patients with sepsis from those without sepsis.

Sepsis;Critical illness;Oxford acute severity of illness score;Quick sequential organ failure assessment
Zeng Mian, Email: mocdef.3ab614002naimgnez
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引用本文

陈钦桂,谢锐杰,陈燕珠,等. 牛津急性疾病严重程度评分鉴别快速序贯器官功能衰竭评分阴性脓毒症患者的临床价值[J]. 中华结核和呼吸杂志,2018,41(9)：701-708.

DOI:10.3760/cma.j.issn.1001-0939.2018.09.010

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除非特别声明，本刊刊出的所有文章不代表中华医学会和本刊编委会的观点。

脓毒症3.0定义最大的变化是以器官衰竭为核心，将脓毒症定义为机体对感染的失控反应所导致的威胁生命的器官衰竭，并推荐以序贯器官衰竭评分(sequential organ failure assessment，SOFA)≥2作为判断器官衰竭的标准 [ 1 ]。脓毒症3.0定义起草工作组还同时推荐了快速序贯器官功能衰竭评分(quick SOFA，qSOFA)这一简便工具用于脓毒症患者的早期识别。qSOFA评分的计算仅涉及收缩压、呼吸频率与精神状态3个参数，简便的条目设计以及与预后指标密切的关联，使其特别适用于急诊室等重症监护室(ICU)之外的场合 [ 2 ]。然而，与其他条目众多的评分系统相比，qSOFA的简便性是以牺牲其敏感性为代价的 [ 3 ]。事实上，临床上的确存在qSOFA<2的脓毒症患者，有学者将其称为"qSOFA阴性"(qSOFA-negative)脓毒症，并已有零星的研究报道。Nakayama等 [ 4 ]观察到14.1%的脓毒症患者在进入ICU时qSOFA<2，且该部分患者的院内病死率与进入ICU时qSOFA≥2的脓毒症患者并无显著差异。考虑到及早识别并给予集束化治疗对于改善脓毒症预后的重要意义 [ 5 ]，如何从qSOFA阴性的就诊人群中快速、准确地鉴别出可疑脓毒症患者，这一临床问题的解决将对脓毒症的诊疗实践产生重要影响。
牛津急性疾病严重程度评分(Oxford acute severity of illness score，OASIS)是由Johnson等 [ 6 ]建立的疾病严重程度评分系统，其计算仅涉及10个参数，且不依赖于任何实验室检验指标。本研究主要探索OASIS用于鉴别qSOFA阴性脓毒症患者的临床价值，以期为优化或改进脓毒症的诊断程序提供一定的研究证据与启示。
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备注信息
A
曾勉，Email： mocdef.3ab614002naimgnez
B
国家自然科学基金 (81670066)
广东省科技计划 (2016A020216009)
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