Lindegaard指数预测早期脓毒症相关性脑病的临床价值

doi:10.3969/j.issn.1006-7795.2023.06.009

摘要/Abstract

摘要： 目的探讨脑血管痉挛指数（Lindegaard index，LR)预测早期脓毒症相关性脑病（sepsis-associated encephalopathy，SAE)的临床价值。方法选取2021年11月至2022年3月首都医科大学附属北京朝阳医院急诊监护室脓毒症患者，收集入院患者24 h内一般临床资料，以重症加强护理病房谵妄评估量表（confusion assessment method for the intensive care unit， CAM-ICU)及格拉斯哥昏迷评分（Glasgow coma score，GCS)作为临床诊断SAE金标准，在确诊脓毒症后3 d内出现CAM-ICU阳性或持续性GCS≤14诊断为SAE。对比分析SAE组与非SAE组入院第1天及第3天大脑中动脉(middle cerebral artery，MCA)收缩期峰值流速（systolic velocity，Vs)、舒张末期流速（diastolic velocity，Vd)、平均流速（mean velocity，Vm)、搏动指数（pulsatility index，PI)、阻力指数（resistant index，RI)、LR等超声血流动力学参数，采用Logistic回归分析脓毒症早期发生SAE的危险因素，绘制受试者工作特征（receiver operating characteristic，ROC)曲线。结果 37例脓毒症患者纳入本研究，SAE组17例，非SAE组20例。SAE组入院24 h内急性生理与慢性健康状况评分Ⅱ（acute physiology and chronic health evaluation Ⅱ，APACHE Ⅱ)、GCS评分、血乳酸、脑血管痉挛发生率及28 d病死率均明显高于非SAE组（P<0.05)。第1天(D1)SAE组VsD1、VdD1、VmD1及LRD1均明显高于非SAE组（P<0.05)。第3天(D3)SAE组与非SAE组各项血流动力学指标差异均无统计学意义。SAE组组内第3天VsD3、VdD3、VmD3及LRD3均较第1天明显下降（P<0.05)；SAE组ΔLR(LRD1-LRD3)显著高于非SAE组（P<0.05)。Logistic回归分析显示入院24 h APACHE Ⅱ评分、LRD1及ΔLR是SAE的危险因素，ROC分析显示APACHE Ⅱ评分、LRD1、ΔLR及APACHE Ⅱ评分联合ΔLR预测早期SAE的曲线下面积（area under the curve，AUC)分别是0.94、0.86、0.77、0.96，P均<0.05。LRD1诊断SAE的界值为2.6，灵敏度为76.47%，特异度为95.00%。APACHE Ⅱ联合ΔLR对SAE的诊断效能最好（AUC=0.96,95%CI：0.85 ～ 0.99，P<0.05)，灵敏度为88.24%，特异度为95.00%。结论脓毒症患者入院24 h APACHE Ⅱ评分、LRD1及ΔLR均可预测早期SAE的发生，APACHE Ⅱ与ΔLR联合可进一步提高对早期SAE的预测效能。床旁超声动态评估脓毒症患者脑血流及LR对早期SAE的诊断具有较高临床价值。

Abstract: Objective To investigate the clinical value of Lindegaard index (LR) in early diagnosis of sepsis-associated encephalopathy (SAE). Methods A retrospective analysis was performed on sepsis patients admitted to the Emergency Department of Beijing Chaoyang Hospital, Capital Medical University, from November 2021 to March 2022. Clinical data were collected during 24 h after admission. Within three days after the diagnosis of sepsis, the SAE was diagnosed with diagnostic gold standard: the positive confusion assessment method for the intensive care unit (CAM-ICU) evaluation or persistent Glasgow coma score (GCS) ≤ 14.Patients were divided into the SAE group and the non-SAE group. The differences in ultrasound parameters of the middle cerebral artery (MCA) including systolic velocity (Vs), diastolic velocity (Vd), mean velocity (Vm), pulsatility index (PI), resistant index (RI), LR on the first and third day of admission were analyzed between the two groups. Logistic regression was used to analyze the risk factors of early SAE in patients with sepsis. The receiver operating characteristic (ROC) curve was plotted to assess the predictive value of each risk factor for SAE. Results Thirty-seven patients with sepsis were included in this study, with 17 in the SAE group and 20 in the non-SAE group. The 28-day mortality and acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score, GCS, blood lactate, incidence of cerebral vasospasm within 24 h of admission were significantly higher in the SAE group than those in the non-SAE group (P<0.05). On the first day (D1), VsD1, VdD1, VmD1, and LRD1 in the SAE group were significantly higher than those in the non-SAE group (P<0.05). There were no significant differences in those ultrasound parameters between the SAE group and the non-SAE group on the third day. On the third day (D3), VsD3, VdD3, VmD3, and LRD3 in the SAE group were significantly lower compared to the first day (P<0.05). ΔLR (LRD1－LRD3) in the SAE group was significantly higher than that in the non-SAE group (P<0.05). Logistic regression analysis showed that the APACHE Ⅱ score within 24 h of admission, LRD1 and ΔLR were risk factors for SAE. ROC analysis showed that the area under the curve (AUC) of APACHE Ⅱ score within 24 h of admission, LRD1, ΔLR and APACHE Ⅱ score combined with ΔLR predicting SAE were 0.94, 0.86, 0.77 and 0.96 respectively, with P<0.05. The cut-off value of LRD1 for diagnosing SAE was 2.6, the sensitivity was 76.47%, and the specificity was 95.00%. The APACHE Ⅱ combined with ΔLR had the best diagnostic efficacy for SAE (AUC=0.96,95% CI： 0.85－0.99, P<0.05), with a sensitivity of 88.24% and a specificity of 95.00%. Conclusion The APACHE Ⅱ score within 24 h of admission, LRD1, ΔLR are all valuable in predicting the occurrence of early SAE. The APACHE Ⅱ score combined with ΔLR demonstrates the best diagnostic significance of SAE. The bedside ultrasound can dynamically obtain LR in patients with sepsis, which has great predictive value of early SAE.

Key words: sepsis, sepsis-associated encephalopathy, bedside ultrasound, Lindegaard index

中图分类号:

R445

宋倩, 周倩, 孙宏, 李硕, 梅雪, 郭瑞君, 葛辉玉. Lindegaard指数预测早期脓毒症相关性脑病的临床价值[J]. 首都医科大学学报, 2023, 44(6): 959-965.

Song Qian, Zhou Qian, Sun Hong, Li Shuo, Mei Xue, Guo Ruijun, Ge Huiyu. Clinical value of Lindegaard in the early diagnosis of sepsis-associated encephalopathy[J]. Journal of Capital Medical University, 2023, 44(6): 959-965.

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