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目的探讨严重脓毒症与脓毒性休克死亡危险因素,分层分析影响不同生存期患者预后的因素。方法回顾性分析2013年1月至2014年12月108例严重脓毒症与脓毒性休克患者临床资料,通过多因素Cox回归模型明确死亡的独立危险因素。结果总死亡率为53.7%,生存期<30 d,30 d~89 d,90 d~365 d患者死亡率分别为27.8%、24.4%与15.3%。急性生理与慢性健康评分(APACHE-Ⅱ评分)、查尔森合并症指数(CCI)与降钙素原变化率(△PCT)是影响死亡率的独立预后因素,HR(95%CI)分别为1.105(1.066~1.146)、1.390(1.210~1.596)与0.996(0.995~0.997)。分层分析,生存期<30 d者,预后因素为APACHE-Ⅱ评分(HR=1.104,95%CI:1.052~1.158)、CCI(HR=1.462,95%CI:1.204~1.775)、△PCT(HR=0.992,95%CI:0.989~0.995)与ICU住院时间(HR=0.893,95%CI:0.841~0.949);生存期30 d~89 d者,预后因素为APACHE-Ⅱ评分(HR=1.102,95%CI:1.026~1.183)与△PCT(HR=0.996,95%CI:0.994~0.998)。生存期90 d~365 d者,仅CCI(HR=1.689,95%CI:1.065~2.679)影响预后。结论 APACHE-Ⅱ评分、CCI与△PCT为影响严重脓毒症与脓毒性休克患者死亡率的独立预后因素。但对于不同生存期的死亡患者,其预后因素稍有不同,需进一步开展多中心大样本的前瞻性队列研究证实。
Objective To investigate the risk factors of death from severe sepsis and septic shock and to analyze the factors affecting the prognosis of patients with different survival stages. Methods The clinical data of 108 patients with severe sepsis and septic shock from January 2013 to December 2014 were retrospectively analyzed. The independent risk factors of death were determined by multivariate Cox regression model. Results The overall mortality rate was 53.7%. The survival rates were less than 30 days and 30 days to 89 days. The mortality rates were 27.8%, 24.4% and 15.3% respectively after 90 days to 365 days. The acute physiology and chronic health score (APACHE-Ⅱ), Charlsson’s comorbidity index (CCI) and procalcitonin (△ PCT) were the independent prognostic factors of mortality. HR (95% CI) 1.105 (1.066-1.1414), 1.390 (1.210-1.596) and 0.996 (0.995-0.997). Stratified analysis showed that the prognostic factors were APACHE-Ⅱscore (HR = 1.104, 95% CI: 1.052-1.158), CCI (HR = 1.462, 95% CI: 1.204-1.775) (HR = 0.992, 95% CI: 0.989-0.995) and hospital stay (HR = 0.893,95% CI: 0.841-0.949). The prognosis was APACHE-II score with a survival time of 30 d to 89 d , 95% CI: 1.026-1.183) and delta PCT (HR = 0.996, 95% CI: 0.994-0.998). Survival of 90 d ~ 365 d, only CCI (HR = 1.689, 95% CI: 1.065 ~ 2.679) affect the prognosis. Conclusion APACHE-Ⅱ score, CCI and △ PCT are independent prognostic factors affecting mortality in patients with severe sepsis and septic shock. However, prognostic factors are slightly different among patients with different life-span deaths, and further prospective cohort studies of multicenter large samples are needed.