脓毒症患者DIC预警系统构建与临床研究

张涛; 万亚楠; 王逸平; 钟斐; 孙杰; 韩振; 万健

doi:10.13201/j.issn.1009-5918.2021.08.001

脓毒症患者DIC预警系统构建与临床研究

- 1. 上海市浦东新区人民医院急诊与危重症医学科(上海, 201200);
- 2. 南通大学附属医院重症医学科
基金项目:
上海市医学重点专科建设项目(No:ZK2019C08)

上海市浦东新区卫生系统领先人才培养项目(No:PWRl2018-08)

详细信息

通讯作者: 万健,E-mail:drjian@yeah.net

中图分类号: R459.7

收稿日期: 2021-05-17

Construction of early warning system for DIC in patients with sepsis and clinical study

- 1. Department of Emergency and Critical Care Medicine, Shanghai Pudong New District People's Hospital, Shanghai, 201200, China;
- 2. Department of Critical Medicine, Affiliated Hospital of Nantong University

More Information

Corresponding author: WAN Jian, E-mail: drjian@yeah.net

Received Date: 17 May 2021

摘要

摘要: 目的:构建脓毒症患者弥散性血管内凝血(DIC)自动筛查预警系统,并对脓毒症患者进行筛查;将由预警系统筛查出的DIC的患者与由中国弥散性血管内凝血诊断积分系统(CDSS)诊断出的DIC患者进行比较,探讨DIC预警系统与CDSS诊断标准对脓毒症患者病死率预测的价值。方法:依托ISTH DIC及SIC DIC诊断标准在重症医学科Do Care重症监护临床信息系统V5.0中构建出DIC预警系统,收集2019年1月1日-2020年5月31日期间入住南通大学附属医院重症医学科并被诊断为脓毒症的患者共100例作为研究对象,记录患者的一般情况,包括年龄、性别、体重等,抽取入科当天和后续4 d(第2~5天)的外周血,检测并记录入组患者5 d的血乳酸、血小板计数、D-二聚体、纤维蛋白原浓度、纤维蛋白原降解产物、凝血酶原时间、国际标准化比率、部分凝血活酶时间等实验室检查指标,以及SOFA评分、APACHEⅡ评分和患者28 d生存状态。同时对入组患者每天由DIC预警系统及CDSS诊断标准进行积分,记录每天新增的DIC患者。运用多因素logistic回归及受试者工作曲线(ROC)来评估两种DIC诊断方法对ICU患者28 d生存率的预测效果;同时分析第1天两种诊断标准对ICU生存率方面的预测价值。最后通过Kaplan-Meier曲线分析比较两组患者28 d生存率的差异。结果:两种诊断标准在第1天预测ICU患者28 d病死率的多因素logistic回归分析表明:预警系统在患者入院第1天对患者28 d病死率的预测有显著的价值(优势比为3.831、P=0.019、95%的置信区间1.255~11.656),而CDSS评分标准则差异无统计学意义。且预警系统的特异度(82.6%vs.52.2%)、阳性预测值(58.6%vs. 40.0%)及精确度(74.0%vs. 58.0%)均更高,同时,Kaplan-Meier生存曲线表明预警系统在第1天预测患者的28 d病死率方面差异有统计学意义(P=0.007),而CDSS评分标准则差异无统计学意义(P=0.271)。结论:(1)构建的脓毒症患者DIC预警系统,可早期筛查出DIC患者,以实现对脓毒症合并DIC患者的早期诊断。(2)构建的DIC预警系统在早期预测ICU患者28 d生存率方面更有优势。
- 脓毒症 /
- DIC预警系统 /
- 中国弥散性血管内凝血诊断积分系统 /
- 弥散性血管内凝血
Abstract: Objective: Establish an automatic screening and early warning system for diffuse intravascular coagulation(DIC) in sepsis patients and conduct automatic screening for sepsis patients; and compare the patients with DIC screened by the early warning system with the patients with DIC diagnosed by the Chinese DIC Scoring System(CDSS), and. To explore the evaluation of DIC early warning system and CDSS diagnostic criteria on the prediction of the mortality of sepsis.Methods: Relying on the ISTH DIC and SIC DIC diagnostic criteria, a DIC early warning system was constructed in the Do Care Intensive Care Clinical Information System V5.0 of the Department of Intensive Care Medicine, and the collection was collected from January 1, 2019 to May 31, 2020 in Critical Care Medicine, Affiliated Hospital of Nantong University A total of 100 patients who were diagnosed as sepsis were used as research subjects. The general information of the patients, including age, gender, weight, etc., was recorded the first day and the following 4 days(days 2-5) peripheral blood, record the five-day blood lactic acid, platelet count, D-dimer, fibrinogen concentration, fibrinogen degradation products, prothrombin time, international standardized ratio, partial thromboplastin time and other experiments of the enrolled patients laboratory examination indicators, as well as SOFA score, APACHE Ⅱ score, and 28-day survival status. At the same time, the enrolled patients were scored by the DIC early warning system and CDSS diagnostic criteria every day, and the DIC patients diagnosed every day were recorded. Multivariate logistic regression and receiver operating curve(ROC) were used to evaluate the predictive effect of the two DIC diagnostic methods on the 28-day survival rate of ICU patients; at the same time, the predictive value of the two diagnostic criteria on the first day of the ICU survival rate was analyzed. Finally, the Kaplan-Meier survival analysis method was used to evaluate the predictive value of the two diagnostic methods in the early(first day) 28-day mortality of patients.Results: The multivaiate logistic regression analysis of the two diagnostic criteria for predicting the 28-day mortality of ICU patients on the first day showed that the early warning system has significant value in predicting the 28-day mortality of patients on the first day(odds ratio is 3.831, P=0.019, 95% confidence interval 1.255-11.656), while the CDSS scoring standard is not statistically significant. And the specificity(82.6% vs. 52.2%), positive predictive value(58.6% vs. 40.0%) and accuracy(74.0% vs. 58.0%) of the early warning system are higher. At the same time, the Kaplan-Meier survival curve analysis also shows that the early warning system is statistically significant in predicting the 28-day mortality of patients on the first day(P=0.007), while the CDSS scoring standard is not statistically significant(P=0.271).Conclusion:(1)The constructed DIC early warning system for sepsis patients can screen out DIC patients early to realize the early diagnosis of sepsis patients with DIC.(2)The constructed DIC early warning system has advantages in early prediction of the 28-day survival rate of ICU patients.
- sepsis /
- DIC early warning system /
- Chinese DIC Scoring System /
- disseminated intravascular coagulation

HTML全文

参考文献(23)

[1]	王世伟,朱长清.脓毒症诊治中微循环检测的应用进展[J].临床急诊杂志,2019,20(8):599-602.
[2]	郭伟,李平,陈翠,等.脓毒症诱导T细胞功能紊乱及免疫治疗进展[J].临床急诊杂志,2020,21(9):758-762.
[3]	Mayeux PR,Macmillan-Crow LA.Pharmacological targets in the renal peritubular microenvironment:Implications for therapy for sepsis-induced acute kidney injury[J].Pharmacol Therapeutics,2012,134(2):139-155.
[4]	Gando S,Kameue T,Nanzaki S,et al.Disseminated intravascular coagulation is a frequent complication of systemic inflammatory response syndrome[J].Thromb Haemost 1996,75:224-228.
[5]	Bone RC.Toward a theory regarding the pathogenesis of the systemic inflammatory response syndrome:what we do and do not know about cytokine regulation[J].Crit Care Med,1996,24(1):163-172.
[6]	Hack CE.Tissue factor pathway of coagulation in sepsis[J].Crit Care Med,2000,28(9 Suppl):S25-30.
[7]	中华医学会血液学分会血栓与止血学组.弥散性血管内凝血诊断中国专家共识(2017年版)[J].中国血液病杂志,2017,38(5):361-363.
[8]	Iba T,Levy JH,Warkentin TE,et al.Diagnosis and management of sepsis-induced coagulopathy and disseminated intravascular coagulation[J].J Thromb Haemost,2019,17(11):1989-1994.
[9]	Iba T,Nisio MD,Levy JH,et al.New criteria for sepsis-induced coagulopathy(SIC)following the revised sepsis defi- nition:a retrospective analysis of a nationwide survey[J].BMJ Open,2017,7(9):e017046.
[10]	Ding R,Wang Z,Lin Y,et al.Comparison of a new criteria for sepsis-induced coagulopathy and International Society on Thrombosis and Haemostasis disseminated intravascular coagulation score in critically ill patients with sepsis 3.0:a retrospective study[J].Blood Coagul Fibrinolysis,2018,29(6):551-558.
[11]	Yamakawa K,Yoshimura J,Ito T,et al.External Validation of the Two Newly Proposed Criteria for Assessing Coagulopathy in sepsis[J].Thromb Haemost,2019,119(2):203-212.
[12]	Levi M,Toh CH,Thachil J,et al.Guidelines for the diagno osis and management of disseminated intravascular coagulation.Britis Committee for Standards in Haema tology[J].Br J Haematol,2009,145(1):24-33.
[13]	Gando S,Wada H,Asakura H,et al.Evaluation of new Japanese diagnostic criteria for disseminated intravascular coagulation in critically ill patients[J].Clin Appl Thromb Hemost, 2005,11(1):71-76.
[14]	Gando S,Iba T,Eguchi Y,et al.A multicenter,prospective validation of disseminated intravascular coagulation diagnostic criteria for critically ill patients:comparing current criteria[J].Crit Care Med,2006,34(10):625-631.
[15]	Hayakawa M,Gando S,Hoshino H.A prospective comparative study of three sets of criteria for disseminated intravascular coagulation:ISTH criteria vs Japanese criteria[J].Clin Appl Thromb Hemost,2007,13(1):65-72.
[16]	Singer M,Deutschman CS,Seymour CW,et al.The Third International Consensus Definitions for Sepsis and Septic Shock[J].JAMA,2016,315(8):801-810.
[17]	Chen XY,Zhang Y,Zhang D,et al.Evaluation of ISTH,JAAM and CDICS for predicting organ dysfunction and mortality in septic shock[J].Chinese J Crit Care Med,2019.
[18]	Liboni KC,Li N,Scumpia PO,et al.Glutamine modulates LPS induced IL-8 production through 1kB/N-kB in human fetal and a dult intestinal epithelium[J].J Nutr,2005,135(2):245-251.
[19]	Bagshaw SM,George C,Bellomo R,et alEarl acute kidney jury and sepsisa multicentre evaluation[J].Cnt Care,2008,12(2):47.
[20]	Rodelo JR,De la Rosa G,Valencia ML,et al.D-Dimer is a significant prognostic factor in patients with suspected infection and sepsis[J]Am J Emerg Med,2012,30(9):1991.
[21]	Gando S,Iba T,Eguchi Y,et al.A multicenter,prospective validation of disseminated intravascular coagulation diagnostic criteria for critically ill patients:comparing current criteria[J].Crit Care Med,2006,34(11):625-631.
[22]	Gando S,Saitoh D,Ogura H,et al.Natural history of disseminated intravascular coagulation diagnosed based on the newly established diagnostic criteria for critically ill patients:results of a multicenter,prospective survey[J].Crit Care Med,2008,36(2):145-150.
[23]	Yu M,Nardella A,Pechet L.Screening tests of disseminated intravascular coagulation:guidelines for rapid and specific laboratory diagnosis[J].Crit Care Med,2000,28(21):1777-1780.