体温高峰与重症监护室内脓毒症患者预后的相关性

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摘要目的：探讨体温变化与脓毒症患者预后之间的关系，分析体温是否能影响脓毒症患者的预后。方法：回顾性分析2013年1月至2017年5月在衢州市人民医院重症监护室内治疗的176例脓毒症患者临床资料，将患者按入ICU后24 h内体温最高峰值（MAXICU）分为4组：≤37.4 ℃组、37.5～38.4 ℃组、38.5～39.4 ℃组、≥39.5 ℃组。记录患者的一般临床资料；采用Kaplan-Meier法计算4组脓毒症患者入ICU后
28 d内的病死率，log-rank检验比较4组患者的病死率；应用Cox比例风险模型分析脓毒症入ICU后28 d内死亡的相关危险因素，最后进行多分类哑变量检验。结果：4组患者总的28 d病死例数为80例，病死率为45.4%。≤37.4 ℃组、37.5～38.4 ℃组、38.5～39.4 ℃组、≥39.5 ℃组中位生存时间分别为28、13、28、28 d，其病死例数分别为16、39、17、8例。Kaplan-Meier生存曲线分析显示，各体温组患者入ICU后28 d内病死率之间的差异具有统计学意义（log-rank χ2=16.377，P=0.001）。log-rank法进行两两比较，38.5～39.4℃组与37.5～38.4℃组的生存分布差异有统计学意义（P＜0.001）；≥39.5 ℃组与37.5～38.4 ℃组的生存分布差异有统计学意义（P=0.013），而≤37.4组与37.5～38.4 ℃组间差异无统计学意义（P＞0.05）。以患者入ICU后最高体温（分为≤37.4 ℃组、37.5～38.4 ℃组、38.5～39.4 ℃组、≥39.5 ℃组）、急性生理与慢性健康（APACHE II）评分、使用血制品情况、国际标准化比值（INR）、PaCO2、年龄、性别为自变量，以患者入ICU后28 d病死为因变量作单因素、多因素Cox回归分析。单因素COX回归分析显示入ICU后最高体温（HR=0.722，95%CI=0.562～0.927，P=0.011）、APACHE II评分（HR=1.057，95%CI=1.031～1.084，P＜0.001）、使用血制品（HR=1.650，95%CI=1.061～2.566，P=0.026）、INR水平（HR=2.179，95%CI=1.054～4.509，P= 0.036）、PaCO2水平（HR=0.978，95%CI=0.961～0.995，P=0.01）是脓毒症患者入ICU后28 d内病死的危险因素。多因素COX回归分析显示，体温仍是影响患者入ICU后28 d内病死的独立危险因素（P=0.045）。进一步对入ICU后最高体温进行多分类哑变量检验，以37.5～38.4 ℃组为参照组（哑变量），发现MAXICU=38.5～39.4 ℃是脓毒症患者入ICU后28 d内病死风险的保护因素，其病死风险是参照组的41.2%（95%CI=0.221～0.771，P=0.005）；而MAXICU=36.5～37.4 ℃、MAXICU≥39.5 ℃与患者入ICU后28 d内病死风险之间无相关性
（HR=0.930，95%CI=0.448～1.930，P=0.846；HR=0.560，95%CI=0.237～1.232，P=0.186）。结论：MAXIC= 38.5～39.4 ℃可能能够减少ICU内脓毒症患者的病死率。

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关键词 ：体温, 脓毒症, 预后, Cox回归

Abstract：Objective: To explore the correlation between temperature and prognosis in sepsis patients. Methods: The clinical data of 176 cases of sepsis patients admitted to intensive care unit of Quzhou People’ Hospital during January 2013 to May 2017 were retrospectively analyzed. They were divided into 4 groups according to the highest body temperature (MAXICU) recorded during ICU stay: ≤37.4 ℃ group, 37.5-38.4 ℃ group, 38.5-39.4 ℃ group, ≥39.5 ℃ group and all their clinical data were recorded. The relationship between the temperature in each group and 28-mortality was analyzed by Cox regression; the survival rates was calculated using the Kaplan-Meier method and the differences in each group were assessed by log-rank test. Multivariate Cox proportional hazard regression analysis was used to analyze the risk factors of 28-mortality in patients with sepsis. Finally, multivariate dummy variable test was performed. Results: Of the four groups, the 28-day death occurred in 80 cases, with a mortality rate of 45.4%. The median survival time of ≤37.4 ℃ group, 37.5-38.4 ℃ group, 38.5-39.4 ℃ group and 38.5-39.4 ℃ group was 28 days, 13 days, 28 days and 28 days respectively, which involved 16 cases, 39 cases, 17 cases and 8 cases of respectively. Kaplan-Meier survival curve analysis showed the mortality rate between the four groups within 28 days after entering into ICU was statistically different (χ2 log-rank=16.377, P=0.001). Log-rank method was used to compare between groups. The survival distribution was statistically different between 38.5-39.4 ℃ group and 37.5-38.4 ℃ group (P<0.001). Significant difference also existed between ≥39.5 ℃ group and 37.5-38.4 ℃ group (P=0.013), but there’s no statistical difference between ≤37.4 ℃ group and 37.5-38.4 ℃ group (P>0.05) in the survival distribution. The maximum temperature taken in ICU (37.5-38.4 ℃ group, ≤37.4 ℃ group, 38.5-39.4 ℃ group, ≥39.5 ℃ group), acute physiology and chronic health evaluation (APACHE II) score, the use of blood products, international normalized ratio level (INR), PaCO2, age, gender were used as the independent variables and the 28-day mortality after patients entered ICU as the dependent variable to perform the single factor Cox regression and multi-factor Cox regression. Single factor Cox regression analysis showed that the maximum body temperature after entering ICU (HR=0.722, 95%CI=0.562-0.927, P=0.011), APACHE II score (HR=1.057, 95%CI=1.031-1.084, P<0.001), use of blood products (HR= 1.650, 95%CI=1.061-2.566, P=0.026), the level of INR (HR=2.179, 95%CI=1.054-4.509, P=0.036), PaCO2 level (HR=0.978, 95%CI=0.961-0.995, P=0.01) were the risk factors of the death in sepsis patients within 28 days after ICU. Multivariate COX regression analysis showed that the body temperature was still the independent risk factor that affected the patient’s death within 28 days after entering the ICU (P=0.045). Further multivariate dummy variable test for temperature was performed. The 37.5-38.4 ℃ group was taken as the control group (dummy variable), the MAXICU=38.5-39.4 ℃ was the independent protective factor of the 28-day mortality for the septic patients in ICU, the 28-day mortality risk was 41.2% as much as the control group (95%CI=0.221-0.771, P=0.005), but there was no obvious correlation between MAXICU=36.5-37.4 ℃, MAXICU≥39.5 ℃ and the 28-day mortality in ICU (HR=0.930, 95%CI=0.448-1.930, P=0.846; HR=0.560, 95%CI=0.237-1.323, P=0.186). Conclusion: MAXICU=38.5-39.4 ℃ may reduce the mortality of septic patients in ICU.

Key words： temperature sepsis prognosis Cox regression

基金资助:浙江省医药卫生科技计划项目（2017KY699）。

作者简介: 毛小强（1984-），男，浙江江山人，主治医师，在职硕士生。

链接本文:

https://xb.wmu.edu.cn/CN/ 或 https://xb.wmu.edu.cn/CN/Y2018/V48/I8/582

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