国际麻醉学与复苏杂志   2024, Issue (12): 0-0
    
脓毒症外科患者术后心肌损伤的影响因素及预测模型构建
郭仁楠, 唐雯, 刘艳1()
1.新疆维吾尔自治区人民医院
Influential factors and prediction modeling for postoperative myocardial injury in surgical patients with sepsis
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摘要:

目的 探讨脓毒症患者外科术后并发脓毒症心肌损伤(SIMD)的危险因素,据此构建脓毒症患者外科术后SIMD发生的列线图模型。 方法 回顾性分析2021年1月至12月就诊于新疆维吾尔自治区人民医院明确诊断脓毒症并外科手术引流后转入重症医学科的128例患者,收集患者一般资料及实验室指标,根据治疗期间是否出现SIMD将研究对象分为心肌损伤组(47例)和对照组(81例)。采用多因素logistic回归分析确定脓毒症患者外科术后发生SIMD的独立危险因素,在此基础上构建列线图预测模型,并对列线图预测模型的临床适用性进行分析及内部验证。 结果 心肌损伤组年龄、血小板(PLT)、天冬氨酸转氨酶(AST)、乳酸(Lac)、B型利钠肽(BNP)、肌钙蛋白T(cTnT)、肌酸激酶同工酶(CK‑MB)、脓毒症相关性器官功能衰竭评价(SOFA)、急性生理学与慢性健康状况评价Ⅱ(APACHEⅡ)、病死率等高于对照组(均P<0.05),外科干预时间长于对照组(P<0.05)。将具有统计学意义的变量作为自变量、心肌损伤发生与否作为因变量进行单因素logistic回归分析,BNP、CK‑MB、SOFA及外科干预时间延迟是SIMD的独立危险因素(均P<0.05)。利用上述4个预测指标构建列线图预测模型,当预测阈值在0.02~0.83时,预测模型的净收益率比全干预和不干预要高,提示列线图模型具有较好的临床适用性。列线图内部验证前后的曲线下面积(AUC)值分别为0.895[95%置信区间(CI) 0.838~0.952]、0.891(95%CI 0.826~0.941),敏感度分别为0.852和0.812,特异度分别为0.830和0.803,提示模型的区分能力较好。 结论 依据脓毒症患者外科术后并发SIMD独立危险因素构建的个性化SIMD发生风险预测模型具备临床实用性,可有效预测脓毒症患者外科术后并发SIMD的发生风险,有助于早期识别高危人群,改善预后。

关键词: 脓毒症; 术后; 心肌损伤; 列线图; 预测模型
Abstract:

Objective To investigate risk factors for postoperative sepsis‑induced myocardial dysfunction (SIMD) in patients with sepsis and to construct a nomogram model predicting SIMD occurrence in postoperative sepsis patients. Methods Retrospective analysis was conducted on 128 patients who were diagnosed with sepsis and underwent surgical drainage before transfer to Department of Critical Care Medicine, the People's Hospital of Xinjiang Uygur Autonomous Region from January to December 2021. Their demographics and laboratory data were collected. Based on whether SIMD occurred during treatment, the patients were divided into two groups: a myocardial injury group (n=47) and a control group (n=81). Multivariate logistic regression analysis was conducted to identify independent risk factors for postoperative SIMD in sepsis patients, based on which a predictive nomogram model was constructed. The clinical applicability of the nomogram model was analyzed and internally validated. Results The myocardial injury group showed increases in age, platelet (PLT), aspartate aminotransferase (AST), lactate (Lac), B‑type natriuretic peptide (BNP), cardiac troponin T (cTnT), creatine kinase‑MB (CK‑MB), Sepsis‑related Organ Failure Assessment (SOFA) score, Acute Physiology and Chronic Health Evaluation Ⅱ (APACHEⅡ) score and mortality rate compared with the control group (all P<0.05), as well as extended surgical intervention time compared with the control group (P<0.05). Univariate logistic regression analysis was conducted, using statistically significant variables as independent variables, and the occurrence of myocardial injury as the dependent variable, and BNP, CK‑MB, SOFA score, and delayed surgical intervention time were identified as independent risk factors for SIMD (all P<0.05). Using these four predictors, a nomogram prediction model was established. When the prediction threshold was 0.02‒0.83, the net benefit rate of the prediction model was higher than that of both full intervention and no intervention, suggesting good clinical applicability of the nomogram. The area under the curve (AUC) values before and after internal validation were 0.895 [95% confidence interval (CI) 0.838, 0.952] and 0.891 (95%CI 0.826, 0.941), with sensitivities of 0.852 and 0.812, and specificities of 0.830 and 0.803, indicating good discriminative ability of the model. Conclusions The individualized risk prediction model for SIMD based on independent risk factors for postoperative SIMD in sepsis patients has clinical applicability. It effectively predicts the risk of postoperative SIMD in sepsis patients, facilitates early identification of high‑risk individuals, and may improve outcomes.

Key words: Sepsis; Postoperative; Myocardial injury; Nomogram; Prediction model