Abstract：
OBJECTIVE: To observe the clinical characteristics and prognosis of patients with acute respiratory distress syndrome (ARDS) in sepsis combined with acute gastrointestinal injury (AGI) of different grades, and to further explore the risk factors associated with the poor prognosis of patients.
METHODS: The clinical data of patients with septic ARDS admitted to the intensive care unit (ICU) of Tianjin First Central Hospital from March to October 2023 were collected. According to the 2012 European Association of Critical Care Medicine AGI definition and grading criteria, the patients were categorized into AGI grade 0- IV groups. The clinical characteristics and 28-day clinical outcomes of the patients were observed; the risk factors related to the prognosis of patients with septic ARDS combined with AGI were analyzed by using univariate and multivariate Logistic regression; and the receiver operator characteristic curve (ROC curve) and calibration curves were plotted to evaluate the predictive value of each risk factor on the prognosis of patients with septic ARDS combined with AGI.
RESULTS: A total of 92 patients with septic ARDS were enrolled, including 7 patients in the AGI 0 group, 20 patients in the AGI I group, 38 patients in the AGI II group, 23 patients in the AGI III group, and 4 patients in the AGI IV group. The incidence of AGI was 92.39%. With the increase of AGI grade, the ARDS grade increased, and acute physiology and chronic health evaluation II (APACHE II), sequential organ failure assessment (SOFA), intra-abdominal pressure (IAP), white blood cell count (WBC), neutrophil count (NEU), lymphocyte count (LYM), lymphocyte percentage (LYM%), and 28-day mortality all showed a significant increasing trend, while the oxygenation index (PaO2/FiO2) showed a significant decreasing trend (all P < 0.05). Pearson correlation analysis showed that APACHE II score, SOFA score, and ARDS classification were positively correlated with patients\' AGI grade (Pearson correlation index was 0.386, 0.473, and 0.372, respectively, all P < 0.001), and PaO2/FiO2 was negatively correlated with patients\' AGI grade (Pearson correlation index was -0.425, P < 0.001). Among the patients with septic ARDS combined with AGI, there were 68 survivors and 17 deaths at 28 days. The differences in APACHE II score, SOFA score, ARDS grade, AGI grade, PaO2/FiO2, IAP, AGI 7-day worst value, length of ICU stay, and total length of hospital stay between the survival and death groups were statistically significant. Univariate Logistic regression analysis showed that SOFA score [odds ratio (OR) = 1.350, 95% confidence interval (95%CI) was 1.071-1.702, P = 0.011], PaO2/FiO2 (OR = 0.964, 95%CI was 0.933-0.996, P = 0.027) and AGI 7-day worst value (OR = 2.103, 95%CI was 1.194-3.702, P = 0.010) were the risk factors for 28-day mortality in patients with septic ARDS combined with AGI. Multivariate Logistic regression analysis showed that SOFA score (OR = 1.384, 95%CI was 1.153-1.661, P < 0.001), PaO2/FiO2 (OR = 0.983, 95%CI was 0.968-0.999, P = 0.035) and AGI 7-day worst value (OR = 1.992, 95%CI was 1.141-3.478, P = 0.015) were the independent risk factors for 28-day mortality in patients with septic ARDS combined with AGI. ROC curve analysis showed that SOFA score, PaO2/FiO2 and AGI 7-day worst value had predictive value for the 28-day prognosis of patients with septic ARDS combined with AGI. The area under the ROC curve (AUC) was 0.824 (95%CI was 0.697-0.950), 0.760 (95%CI was 0.642-0.877) and 0.721 (95%CI was 0.586-0.857), respectively, all P < 0.01; when the best cut-off values of the above metrics were 5.50 points, 163.45 mmHg (1 mmHg≈0.133 kPa), and 2.50 grade, the sensitivities were 94.1%, 94.1%, 31.9%, respectively, and the specificities were 80.9%, 67.6%, 88.2%, respectively.
CONCLUSIONS: The incidence of AGI in patients with septic ARDS is about 90%, and the higher the AGI grade, the worse the prognosis of the patients. SOFA score, PaO2/FiO2 and AGI 7-day worst value have a certain predictive value for the prognosis of patients with septic ARDS combined with AGI, among which, the larger the SOFA score and AGI 7-day worst value, and the smaller the PaO2/FiO2, the higher the patients\' mortality.
METHODS: The clinical data of patients with septic ARDS admitted to the intensive care unit (ICU) of Tianjin First Central Hospital from March to October 2023 were collected. According to the 2012 European Association of Critical Care Medicine AGI definition and grading criteria, the patients were categorized into AGI grade 0- IV groups. The clinical characteristics and 28-day clinical outcomes of the patients were observed; the risk factors related to the prognosis of patients with septic ARDS combined with AGI were analyzed by using univariate and multivariate Logistic regression; and the receiver operator characteristic curve (ROC curve) and calibration curves were plotted to evaluate the predictive value of each risk factor on the prognosis of patients with septic ARDS combined with AGI.
RESULTS: A total of 92 patients with septic ARDS were enrolled, including 7 patients in the AGI 0 group, 20 patients in the AGI I group, 38 patients in the AGI II group, 23 patients in the AGI III group, and 4 patients in the AGI IV group. The incidence of AGI was 92.39%. With the increase of AGI grade, the ARDS grade increased, and acute physiology and chronic health evaluation II (APACHE II), sequential organ failure assessment (SOFA), intra-abdominal pressure (IAP), white blood cell count (WBC), neutrophil count (NEU), lymphocyte count (LYM), lymphocyte percentage (LYM%), and 28-day mortality all showed a significant increasing trend, while the oxygenation index (PaO2/FiO2) showed a significant decreasing trend (all P < 0.05). Pearson correlation analysis showed that APACHE II score, SOFA score, and ARDS classification were positively correlated with patients\' AGI grade (Pearson correlation index was 0.386, 0.473, and 0.372, respectively, all P < 0.001), and PaO2/FiO2 was negatively correlated with patients\' AGI grade (Pearson correlation index was -0.425, P < 0.001). Among the patients with septic ARDS combined with AGI, there were 68 survivors and 17 deaths at 28 days. The differences in APACHE II score, SOFA score, ARDS grade, AGI grade, PaO2/FiO2, IAP, AGI 7-day worst value, length of ICU stay, and total length of hospital stay between the survival and death groups were statistically significant. Univariate Logistic regression analysis showed that SOFA score [odds ratio (OR) = 1.350, 95% confidence interval (95%CI) was 1.071-1.702, P = 0.011], PaO2/FiO2 (OR = 0.964, 95%CI was 0.933-0.996, P = 0.027) and AGI 7-day worst value (OR = 2.103, 95%CI was 1.194-3.702, P = 0.010) were the risk factors for 28-day mortality in patients with septic ARDS combined with AGI. Multivariate Logistic regression analysis showed that SOFA score (OR = 1.384, 95%CI was 1.153-1.661, P < 0.001), PaO2/FiO2 (OR = 0.983, 95%CI was 0.968-0.999, P = 0.035) and AGI 7-day worst value (OR = 1.992, 95%CI was 1.141-3.478, P = 0.015) were the independent risk factors for 28-day mortality in patients with septic ARDS combined with AGI. ROC curve analysis showed that SOFA score, PaO2/FiO2 and AGI 7-day worst value had predictive value for the 28-day prognosis of patients with septic ARDS combined with AGI. The area under the ROC curve (AUC) was 0.824 (95%CI was 0.697-0.950), 0.760 (95%CI was 0.642-0.877) and 0.721 (95%CI was 0.586-0.857), respectively, all P < 0.01; when the best cut-off values of the above metrics were 5.50 points, 163.45 mmHg (1 mmHg≈0.133 kPa), and 2.50 grade, the sensitivities were 94.1%, 94.1%, 31.9%, respectively, and the specificities were 80.9%, 67.6%, 88.2%, respectively.
CONCLUSIONS: The incidence of AGI in patients with septic ARDS is about 90%, and the higher the AGI grade, the worse the prognosis of the patients. SOFA score, PaO2/FiO2 and AGI 7-day worst value have a certain predictive value for the prognosis of patients with septic ARDS combined with AGI, among which, the larger the SOFA score and AGI 7-day worst value, and the smaller the PaO2/FiO2, the higher the patients\' mortality.
摘要：
目的：观察脓毒症合并不同程度急性胃肠道损伤(AGI)的急性呼吸窘迫综合征(ARDS)患者的临床特点及预后。并进一步探讨与患者不良预后相关的危险因素。
方法：收集2023年3-10月天津市第一中心医院重症监护病房(ICU)收治的感染性ARDS患者的临床资料。根据2012年欧洲重症监护医学协会AGI定义和分级标准，将患者分为AGI级0-IV组.观察患者的临床特征和28d临床结局；采用单因素和多因素Logistic回归分析与脓毒症ARDS合并AGI患者预后相关的危险因素；绘制受试者操作特征曲线(ROC曲线)和校正曲线，评价各危险因素对脓毒症ARDS合并AGI患者预后的预测价值。
结果：共纳入92例脓毒症ARDS患者，包括AGI0组的7名患者，AGII组20名患者，AGIⅡ组38例，AGIIII组23例，AGIIV组4例。AGI的发生率为92.39%。随着AGI等级的提高,ARDS等级增加，和急性生理学和慢性健康评估II(APACHEII)，序贯器官衰竭评估（SOFA），腹内压(IAP),白细胞计数(WBC),中性粒细胞计数（NEU），淋巴细胞计数（LYM），淋巴细胞百分比（LYM%），28天死亡率均呈显著上升趋势,氧合指数(PaO2/FiO2)呈显著下降趋势(均P<0.05)。Pearson相关分析显示,APACHEⅡ评分,SOFA得分,ARDS分级与患者AGI分级呈正相关(Pearson相关指数分别为0.386、0.473和0.372,所有P<0.001)，PaO2/FiO2与患者的AGI分级呈负相关（Pearson相关指数为-0.425，P<0.001）。脓毒症ARDS合并AGI患者中,28天有68名幸存者和17人死亡。APACHEⅡ评分的差异,SOFA得分,ARDS等级,AGI等级,PaO2/FiO2,IAP,AGI7天最差值，ICU住院时间,生存组和死亡组之间的总住院时间有统计学意义。单因素Logistic回归分析显示,SOFA评分[比值比(OR)=1.350,95%置信区间(95CI)为1.071~1.702,P=0.011],PaO2/FiO2(OR=0.964,95CI为0.933~0.996,P=0.027)和AGI7天最强值(OR=2.103,95CI为1.194~3.702,P=0.010)是脓毒症ARDS合并AGI患者28天死亡的危险因素。多因素Logistic回归分析显示SOFA评分(OR=1.384,95CI为1.153~1.661,P<0.001),PaO2/FiO2（OR=0.983，95CI为0.968-0.999，P=0.035）和AGI7天最差值（OR=1.992，95CI为1.141-3.478，P=0.015）是脓毒症ARDS合并AGI患者28天死亡的独立危险因素。ROC曲线分析显示,SOFA评分,PaO2/FiO2和AGI7天最差值对脓毒症ARDS合并AGI患者28天预后具有预测价值。ROC曲线下面积(AUC)为0.824(95CI为0.697-0.950),0.760（95CI为0.642-0.877）和0.721（95CI为0.586-0.857），分别,所有P<0.01；当上述指标的最佳临界值为5.50分时，163.45mmHg（1mmHg≈0.133kPa），和2.50级，敏感性为94.1%，94.1%,31.9%,分别,特异性为80.9%，67.6%,88.2%,分别。
结论：感染性ARDS患者的AGI发生率约为90％，AGI等级越高,患者的预后越差。SOFA得分,PaO2/FiO2和AGI7天最差值对脓毒症ARDS合并AGI患者的预后有一定的预测价值,其中,SOFA评分和AGI7天最坏值越大，PaO2/FiO2越小，患者死亡率越高。
方法：收集2023年3-10月天津市第一中心医院重症监护病房(ICU)收治的感染性ARDS患者的临床资料。根据2012年欧洲重症监护医学协会AGI定义和分级标准，将患者分为AGI级0-IV组.观察患者的临床特征和28d临床结局；采用单因素和多因素Logistic回归分析与脓毒症ARDS合并AGI患者预后相关的危险因素；绘制受试者操作特征曲线(ROC曲线)和校正曲线，评价各危险因素对脓毒症ARDS合并AGI患者预后的预测价值。
结果：共纳入92例脓毒症ARDS患者，包括AGI0组的7名患者，AGII组20名患者，AGIⅡ组38例，AGIIII组23例，AGIIV组4例。AGI的发生率为92.39%。随着AGI等级的提高,ARDS等级增加，和急性生理学和慢性健康评估II(APACHEII)，序贯器官衰竭评估（SOFA），腹内压(IAP),白细胞计数(WBC),中性粒细胞计数（NEU），淋巴细胞计数（LYM），淋巴细胞百分比（LYM%），28天死亡率均呈显著上升趋势,氧合指数(PaO2/FiO2)呈显著下降趋势(均P<0.05)。Pearson相关分析显示,APACHEⅡ评分,SOFA得分,ARDS分级与患者AGI分级呈正相关(Pearson相关指数分别为0.386、0.473和0.372,所有P<0.001)，PaO2/FiO2与患者的AGI分级呈负相关（Pearson相关指数为-0.425，P<0.001）。脓毒症ARDS合并AGI患者中,28天有68名幸存者和17人死亡。APACHEⅡ评分的差异,SOFA得分,ARDS等级,AGI等级,PaO2/FiO2,IAP,AGI7天最差值，ICU住院时间,生存组和死亡组之间的总住院时间有统计学意义。单因素Logistic回归分析显示,SOFA评分[比值比(OR)=1.350,95%置信区间(95CI)为1.071~1.702,P=0.011],PaO2/FiO2(OR=0.964,95CI为0.933~0.996,P=0.027)和AGI7天最强值(OR=2.103,95CI为1.194~3.702,P=0.010)是脓毒症ARDS合并AGI患者28天死亡的危险因素。多因素Logistic回归分析显示SOFA评分(OR=1.384,95CI为1.153~1.661,P<0.001),PaO2/FiO2（OR=0.983，95CI为0.968-0.999，P=0.035）和AGI7天最差值（OR=1.992，95CI为1.141-3.478，P=0.015）是脓毒症ARDS合并AGI患者28天死亡的独立危险因素。ROC曲线分析显示,SOFA评分,PaO2/FiO2和AGI7天最差值对脓毒症ARDS合并AGI患者28天预后具有预测价值。ROC曲线下面积(AUC)为0.824(95CI为0.697-0.950),0.760（95CI为0.642-0.877）和0.721（95CI为0.586-0.857），分别,所有P<0.01；当上述指标的最佳临界值为5.50分时，163.45mmHg（1mmHg≈0.133kPa），和2.50级，敏感性为94.1%，94.1%,31.9%,分别,特异性为80.9%，67.6%,88.2%,分别。
结论：感染性ARDS患者的AGI发生率约为90％，AGI等级越高,患者的预后越差。SOFA得分,PaO2/FiO2和AGI7天最差值对脓毒症ARDS合并AGI患者的预后有一定的预测价值,其中,SOFA评分和AGI7天最坏值越大，PaO2/FiO2越小，患者死亡率越高。
