脓毒性休克患者左心室舒张功能不全相关因素分析及其预后影响

doi:10.3877/cma.j.issn.1674-6880.2017.02.005

中华危重症医学杂志(电子版) ›› 2017, Vol. 10 ›› Issue (02) : 92 -97. doi: 10.3877/cma.j.issn.1674-6880.2017.02.005

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论著

脓毒性休克患者左心室舒张功能不全相关因素分析及其预后影响

呼邦传¹^,^†(

), 王宇佳¹, 葛伟东², 李锋之², 孙仁华¹

^1. 310014　杭州，浙江省人民医院重症医学科
^2. 310014　杭州，浙江省人民医院超声科

收稿日期:2016-10-26 出版日期:2017-04-01
通信作者: 呼邦传
基金资助:
浙江省公益性技术应用研究项目(2014C37023); 浙江省自然科学基金项目(LY17H15000); 浙江省医药卫生平台骨干项目(2013RCB001)

Analysis on correlation factors of left ventricular diastolic dysfunction and its association with mortality in the patients with septic shock

Bangchuan Hu¹^,^†(), Yujia Wang¹, Weidong Ge², Fengzhi Li², Renhua Sun¹

^1. Department of Intensive Care Unit, Zhejiang Provincial People’s Hospital, Hangzhou 310014, China
^2. Department of Ultrasonography, Zhejiang Provincial People’s Hospital, Hangzhou 310014, China

Received:2016-10-26 Published:2017-04-01
Corresponding author: Bangchuan Hu
About author:
Corresponding author: Hu Bangchuan, Email: hubangchuanicu@163.com

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引用本文：

呼邦传, 王宇佳, 葛伟东, 李锋之, 孙仁华. 脓毒性休克患者左心室舒张功能不全相关因素分析及其预后影响[J/OL]. 中华危重症医学杂志(电子版), 2017, 10(02): 92-97.

Bangchuan Hu, Yujia Wang, Weidong Ge, Fengzhi Li, Renhua Sun. Analysis on correlation factors of left ventricular diastolic dysfunction and its association with mortality in the patients with septic shock[J/OL]. Chinese Journal of Critical Care Medicine(Electronic Edition), 2017, 10(02): 92-97.

目的

探讨影响脓毒性休克患者左心室舒张功能不全（LVDD）的相关因素及其对临床预后影响。

方法

选取2014年6月至2015年12月浙江省人民医院ICU收治的127例脓毒性休克患者，按照舒张功能分为LVDD组（49例）和对照组（78例），对照组为左心室舒张功能正常患者。对两组患者的一般资料进行比较。于入ICU 24 h内行超声心动图检查，结合二尖瓣环舒张早期运动速度峰值（E’）和二尖瓣舒张早期血流速峰值/二尖瓣环舒张早期运动速度峰值比率（E/E’）作为评价脓毒性休克患者LVDD的指标。运用Pearson简单相关分析探讨影响脓毒性休克患者LVDD的相关因素，采用多元Logistic回归分析脓毒性休克患者死亡的危险因素。

结果

两组患者在年龄[（63 ± 14）岁vs.（58 ± 18）岁]、入ICU时收缩压[（90 ± 18）mmHg vs.（99 ± 18）mmHg]、冠状动脉粥样硬化性心脏病（CHD）（15/49 vs. 12/78）、血肌酐[（188 ± 96）μmol/L vs.（116 ± 92）μmol/L]、急性病生理学与长期健康状况评价（APACHE）Ⅱ评分[（21 ± 5）分vs.（17 ± 6）分]、血浆脑利钠肽（BNP）[（178 ± 84）pg/mL vs.（355 ± 128）pg/mL]、左室收缩末期内径（LVESD）[（34 ± 8）mm vs.（31 ± 5）mm]、室间隔厚度（IVST）[（10.1 ± 1.9）mm vs.（9.4 ± 1.4）mm]、左室后壁厚度（PWT）[（10.2 ± 1.5）mm vs.（9.6 ± 1.2）mm]、左室侧壁二尖瓣环收缩期运动速度峰值（S’）[（9.0 ± 3.0）cm/s vs.（11.4 ± 3.6）cm/s]、E’[（7.3 ± 2.3）cm/s vs.（12.3 ± 3.6）cm/s]及E/E’[（11.6 ± 4.0）vs.（6.8 ± 2.6）]方面比较，差异均有统计学意义（P均< 0.05）。相关分析显示：年龄、高血压、CHD、血浆BNP和APACHEⅡ评分与E/E’呈正相关（r = 0.302、0.289、0.277、0.418、0.290，P均< 0.05）；而入ICU收缩压和左室射血分数（LVEF）与E/E’呈负相关（r = -0.239、-0.284，P均< 0.05）。多元Logistic回归分析统计结果显示：年龄[OR = 1.040，95%CI（1.020，1.071）]、血乳酸[OR = 1.492，95%CI（1.176，1.732）]、血浆BNP [OR = 2.051，95% CI（1.232，2.964）]、E/E’ [OR = 1.362，95% CI（1.122，1.534）]和APACHEⅡ评分[OR = 2.370，95%CI（1.131，3.674）]是预测脓毒性休克患者死亡的独立危险因素（P均< 0.05）。

结论

年龄、入ICU收缩压、高血压、冠状动脉粥样硬化性心脏病、血浆BNP、APACHEⅡ评分和LVEF与脓毒性休克患者LVDD存在相关；而年龄、血乳酸、血浆BNP、E/E’和APACHEⅡ评分是脓毒性休克患者死亡的独立危险因素。

关键词: 脓毒性休克, 左心室舒张功能不全, B型脑利钠肽, 预后

Objective

To study the determinants of left ventricular diastolic dysfunction (LVDD) and investigate its association with mortality in patients with septic shock.

Methods

Totally 127 patients with septic shock in Zhejiang Provincial People’s Hospital recruited from June 2014 to December 2015 were divided into the LVDD group (49 cases) and control group as patients with normal left ventricular diastolic function (78 cases). General data of the two groups were compared. According to diastolic function underwent trans-thoracic echocardiography examination within 24 h after admission to ICU, LVDD was assessed as the conbination early diastolic mitral annulus velocity (E’) with the ratio of early diastolic mitral inflow velocity to early diastolic mitral annulus velocity (E/E’). The related factors of LVDD in patients with septic shock were analyzed by Pearson simple correlation, and the risk factors associated with mortality in patients with septic shock were evaluated by multivariate Logistic regression.

Results

Compared with the normal group, the age [(63 ± 14) years vs. (58 ± 18) years], systolic blood pressure admitted to ICU [(90 ± 18) mmHg vs. (99 ± 18) mmHg], coronary atherosclerotic heart disease (CHD) (15/49 vs. 12/78), serum creatinine [(188 ± 96) μmol/L vs. (116 ± 92) μmol/L], acute physiology and chronic health evaluation (APACHE) Ⅱ scores [(21 ± 5) vs. (17 ± 6)], plasma brain natriuretic peptide (BNP) [(178 ± 84) pg/mL vs. (355 ± 128) pg/mL], left ventricular end systolic diamete (LVESD) [(34 ± 8) mm vs. (31 ± 5) mm], interventricular septal thickness (IVST) [(10.1 ± 1.9) mm vs. (9.4 ± 1.4) mm], left ventricular posterior wall thickness (PWT) [(10.2 ± 1.5) mm vs. (9.6 ± 1.2) mm], mitral annular systolic velocity peak (S’) [(9.0 ± 3.0) cm/s vs. (11.4 ± 3.6) cm/s], E’[(7.3 ± 2.3) cm/s vs. (12.3 ± 3.6) cm/s] and E/E’[(11.6 ± 4.0) vs. (6.8 ± 2.6)] of these two groups were significantly different (all P < 0.05). Correlation analysis showed that E/E’ had a positive correlation with age, hypertension, CHD, plasma BNP and APACHEⅡ score (r = 0.302, 0.289, 0.277, 0.418, 0.290; all P < 0.05). However, the systolic blood pressure admitted to ICU and left ventricular eject fraction (LVEF) had negative correlations with those parameters (r = -0.239, -0.284; all P < 0.05). Multivariate Logistic regression analysis found that age [OR = 1.040, 95% CI (1.020, 1.071)], blood lactic acid [OR = 1.492, 95% CI (1.176, 1.732)], plasma BNP [OR = 2.051, 95% CI (1.232, 2.964)], E/E’ [OR = 1.362, 95% CI (1.122, 1.534)] and APACHE Ⅱ score [OR = 2.370, 95% CI (1.131, 3.674)] were the independent risk factors associated with mortality in patients with septic shock (all P < 0.05).

Conclusions

Age, systolic blood pressure admitted to ICU, hypertension, CHD, plasma BNP, APACHEⅡ score and LVEF were significantly related to LVDD. However, age, blood lactic acid, plasma BNP, E/E’and APACHE Ⅱ score were the independent risk factors associated with mortality in patients with septic shock.

Key words: Septic shock, Left ventricular diastolic dysfunction, B-type brain natriuretic peptide, Prognosis

表1 两组脓毒性休克患者一般资料比较（ ± s）

组别	例数	入ICU收缩压（mmHg）	入ICU舒张压（mmHg）	血糖（mmol/L）	白蛋白（g/L）	血乳酸（mmol/L）
LVDD组	49	90 ± 18	57 ± 16	9.2 ± 1.6	32 ± 4	2.9 ± 1.3
对照组	78	99 ± 18	60 ± 14	9.0 ± 1.4	32 ± 6	2.8 ± 1.8
t/χ²值	?	2.633	1.269	0.441	0.132	0.247
P值	?	0.024	0.197	0.632	0.922	0.787
组别	例数	血肌酐（μmol/L）	APACHEⅡ评分（分）	肌钙蛋白I（ng/mL）	血浆BNP（pg/mL）	血管活性药物使用（例，%）
LVDD组	49	188 ± 96	21 ± 5	0.7 ± 1.6	355 ± 128	45（91.8%）
对照组	78	116 ± 92	17 ± 6	0.5 ± 1.6	178 ± 84	69（88.5%）
t/χ²值	?	3.819	4.558	0.653	5.848	0.371
P值	?	< 0.001	< 0.001	0.523	< 0.001	0.542

表1 两组脓毒性休克患者一般资料比较（ ± s）

组别	例数	入ICU收缩压（mmHg）	入ICU舒张压（mmHg）	血糖（mmol/L）	白蛋白（g/L）	血乳酸（mmol/L）
LVDD组	49	90 ± 18	57 ± 16	9.2 ± 1.6	32 ± 4	2.9 ± 1.3
对照组	78	99 ± 18	60 ± 14	9.0 ± 1.4	32 ± 6	2.8 ± 1.8
t/χ²值	?	2.633	1.269	0.441	0.132	0.247
P值	?	0.024	0.197	0.632	0.922	0.787
组别	例数	血肌酐（μmol/L）	APACHEⅡ评分（分）	肌钙蛋白I（ng/mL）	血浆BNP（pg/mL）	血管活性药物使用（例，%）
LVDD组	49	188 ± 96	21 ± 5	0.7 ± 1.6	355 ± 128	45（91.8%）
对照组	78	116 ± 92	17 ± 6	0.5 ± 1.6	178 ± 84	69（88.5%）
t/χ²值	?	3.819	4.558	0.653	5.848	0.371
P值	?	< 0.001	< 0.001	0.523	< 0.001	0.542

表2 两组脓毒性休克患者心脏超声资料比较（ ± s）

组别	例数	LVEDD（mm）	LVESD（mm）	IVST（mm）	PWT（mm）	LVEF（分）	E（m/s）
LVDD组	49	50 ± 7	34 ± 8	10.1 ± 1.9	10.2 ± 1.5	53 ± 14	0.85 ± 0.30
对照组	78	49 ± 6	31 ± 5	9.4 ± 1.4	9.6 ± 1.2	55 ± 10	0.84 ± 0.22
t/χ²值	?	1.123	2.459	2.782	2.374	0.830	0.292
P值	?	0.276	0.032	0.025	0.037	0.326	0.734
组别	例数	A（m/s）	E/A	DT（m/s）	S’（cm/s）	E’（cm/s）	E/E’
LVDD组	49	0.84 ± 0.32	1.1 ± 0.6	134 ± 57	9.0 ± 3.0	7.3 ± 2.3	11.6 ± 4.0
对照组	78	0.77 ± 0.21	1.1 ± 0.4	146 ± 54	11.4 ± 3.6	12.3 ± 3.6	6.8 ± 2.6
t/χ²值	?	1.353	0.618	0.865	3.948	6.786	5.320
P值	?	0.201	0.553	0.302	< 0.001	< 0.001	< 0.001

表2 两组脓毒性休克患者心脏超声资料比较（ ± s）

组别	例数	LVEDD（mm）	LVESD（mm）	IVST（mm）	PWT（mm）	LVEF（分）	E（m/s）
LVDD组	49	50 ± 7	34 ± 8	10.1 ± 1.9	10.2 ± 1.5	53 ± 14	0.85 ± 0.30
对照组	78	49 ± 6	31 ± 5	9.4 ± 1.4	9.6 ± 1.2	55 ± 10	0.84 ± 0.22
t/χ²值	?	1.123	2.459	2.782	2.374	0.830	0.292
P值	?	0.276	0.032	0.025	0.037	0.326	0.734
组别	例数	A（m/s）	E/A	DT（m/s）	S’（cm/s）	E’（cm/s）	E/E’
LVDD组	49	0.84 ± 0.32	1.1 ± 0.6	134 ± 57	9.0 ± 3.0	7.3 ± 2.3	11.6 ± 4.0
对照组	78	0.77 ± 0.21	1.1 ± 0.4	146 ± 54	11.4 ± 3.6	12.3 ± 3.6	6.8 ± 2.6
t/χ²值	?	1.353	0.618	0.865	3.948	6.786	5.320
P值	?	0.201	0.553	0.302	< 0.001	< 0.001	< 0.001

表3 Logistic回归评价脓毒性休克死亡危险因素

指标	回归系数	标准误	OR值	95%CI	Wald值	P值
年龄（岁）	0.041	0.030	1.040	1.020 ~ 1.071	5.631	0.022
血乳酸（mmol/L）	0.202	0.123	1.492	1.176 ~ 1.732	4.894	0.032
血浆BNP（ng/L）	0.289	0.103	2.051	1.232 ~ 2.964	8.569	0.007
E/E’	0.151	0.053	1.362	1.122 ~ 1.534	3.980	0.043
APACHEⅡ评分（分）	0.318	0.116	2.370	1.131 ~ 3.674	10.52	0.001

表3 Logistic回归评价脓毒性休克死亡危险因素

指标	回归系数	标准误	OR值	95%CI	Wald值	P值
年龄（岁）	0.041	0.030	1.040	1.020 ~ 1.071	5.631	0.022
血乳酸（mmol/L）	0.202	0.123	1.492	1.176 ~ 1.732	4.894	0.032
血浆BNP（ng/L）	0.289	0.103	2.051	1.232 ~ 2.964	8.569	0.007
E/E’	0.151	0.053	1.362	1.122 ~ 1.534	3.980	0.043
APACHEⅡ评分（分）	0.318	0.116	2.370	1.131 ~ 3.674	10.52	0.001

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Analysis on correlation factors of left ventricular diastolic dysfunction and its association with mortality in the patients with septic shock

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Analysis on correlation factors of left ventricular diastolic dysfunction and its association with mortality in the patients with septic shock