标题：ICU重症肺炎并休克患者发生急性呼吸窘迫综合征预警指标研究

      作者：王灵，杨勇灵，张郑平，周建林，刘凯凤，王振华，李雪峰，谢群松    凯里市黔东南苗族侗族自治州人民医院重症医学科，贵州 凯里 556000

      卷次： 2019年30卷19期

      【摘要】 目的 探索重症监护病房(ICU)肺炎伴休克患者发生急性呼吸窘迫综合征(ARDS)的预警指标。方法 选取黔东南苗族侗族自治州人民医院2016年6月至2019年4月入住 ICU的社区获得性肺炎致休克患者102例，在入住 ICU时检查体温、收缩血压(SBP)、呼吸频率(RR)，检验白细胞计数(WBC)、中性粒细胞百分比(N%)、C反应蛋白(CRP)、降钙素原(PCT)、乳酸(Lac)、6 h乳酸(6 h-Lac)、中心静脉血氧饱和度(ScvO2)、肺泡动脉氧分压差[P(A-a)O2]、二氧化碳分压(PCO2)、碱剩余(BE)、D-二聚体(D-dimer)、肌酐(Cr)、白蛋白(Alb)、乳酸脱氢酶(LDH)，计算乳酸清除率(LCR)、氧合指数(OI)及急性生理与慢性健康评分系统Ⅱ (APACHEⅡ)评分。以入住 ICU 7 d内是否发生ARDS将患者分为ARDS组(A组，48例)及非ARDS组(B组，54例)，比较两组患者的性别、年龄、合并症及上述指标的差异，分析发生ARDS的独立危险因素，绘制受试者工作特征曲线(ROC)分析其独立危险因素对发生ARDS的预测能力。结果 两组患者的性别、年龄、合并COPD、体温、SBP、RR、N%、CRP、Lac、PCO2、BE、Cr、Alb、LDH、APACHEⅡ评分比较差异均无统计学意义(P>0.05)；A组患者的WBC、PCT、LCR、ScvO2及OI低于B组，6 h-Lac、P(A-a)O2及D-dimer高于B组，差异均有统计学意义(P<0.05)；Logistic回归分析结果显示 P(A-a)O2为ARDS的独立危险因素(P<0.01)；P(A-a)O2预测肺炎患者的受试者工作特征曲线下面积(AUC)为0.928 (0.867，0.989)，截断值为147.00，敏感性为95.80%，特异性为90.60%。结论 P(A-a)O2是判断 ICU肺炎合并休克患者发生ARDS的较好预测指标。
      【关键词】 重症肺炎；急性呼吸窘迫综合征；休克；白细胞；降钙素原；D-二聚体；乳酸清除率；中心静脉血氧饱和度；肺泡动脉氧分压差；氧合指数
      【中图分类号】 R563.1 【文献标识码】 A 【文章编号】 1003—6350（2019）19—2449—04

Predicting indexes of acute respiratory distress syndrome in patients with severe pneumonia and shock inIntensive Care Unit.
WANG Ling, YANG Yong-ling, ZHANG Zheng-ping, ZHOU Jian-lin, LIU Kai-feng, WANGZhen-hua, LI Xue-feng, XIE Qun-song. Intensive Care Unit, the People's Hospital of Qiandongnan Miao and DongAutonomous Prefecture, Kaili 556000, Guizhou, CHINA
【Abstract】 Objective To study the predicting indexes of acute respiratory distress syndrome (ARDS) in pa-tients with pneumonia and shock in Intensive Care Unit (ICU). Methods The patients with community-acquired pneu-monia and shock who were admitted to ICU in the People's Hospital of Qiandongnan Miao and Dong Autonomous Pre-fecture from June 2016 to April 2019 were selected. When they were admitted to ICU, their temperature, systolic bloodpressure (SBP), and respiratory rate (RR) were examined. The white blood cell count (WBC), neutrophil percentage(N%), C-reactive protein (CRP), procalcitonin (PCT), lactic acid (Lac), lactic acid of 6 hours (6 h-Lac), central venousblood oxygen saturation (ScvO2), alveolar-arterial oxygen tension difference (P(A-a)O2), partial pressure of carbon diox-ide (PCO2), base excess (BE), D-dimer, creatinine (Cr), albumin(Alb), and lactate dehydrogenase (LDH) were detected.The lactate clearance rate (LCR), oxygen index (OI), and acute physiology and chronic health evaluation system Ⅱ(APACHEⅡ) score were calculated. According to whether ARDS occurred within 7 days of ICU admission, the patientswere divided into ARDS group (group A, 48 cases) and non-ARDS group (group B, 54 cases). The gender, age, complica-tions, and above-mentioned indicators were compared between the two groups. The independent risk factors for ARDSwere analyzed, and the working characteristic curve of subjects (ROC) was drawn to analyze the forecasting ability of in-dependent risk factors for ARDS. Results The two groups showed no statistically significant difference in gender, age,chronic obstructive pulmonary disease (COPD), body temperature, SBP, RR, N%, CRP, Lac, PCO2, BE, Cr, Alb, LDH,APACHEⅡ (P>0.05). WBC, PCT, LCR, ScvO2, and OI in group A were significantly lower than those in group B, while6 h-lac, P(A-a)O2, and D-dimer in group A were significantly higher than those in group B (P<0.05). Logistic regressionanalysis showed that P(A-a)O2 was an independent risk factor for ARDS. The area under the curve (AUC) of P(A-a)O2 forpredicting pneumonia was 0.928 (0.867, 0.989), and truncated value, sensitivity, specificity were 147.00, 95.80%, 90.60%,respectively. Conclusion P(A-a)O2 is a good predictor of ARDS in patients with pneumonia and shock in ICU.
      【Key words】 Severe pneumonia; Acute respiratory distress syndrome (ARDS); Shock; White blood cells; Procal-citonin; D-dimer; Lactate clearance rate; Central venous oxygen saturation; Alveolar-arterial oxygen tension difference(P(A-a)O2); Oxygenation index