Early changes in organ function predict eventual survival in severe sepis
Early changes in organ function predict eventual survival in severe sepis
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DOI：
10.1097/01.ccm.0000182798.39709.84
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发表时间：
2005-10-01
影响因子：
8.8
通讯作者：
Williams, MD
中科院分区：
文献类型：
--
作者：
Levy, MM;Macias, WL;Williams, MD
目的：早期发现和治疗严重脓毒症可显著降低病死率。我们假设基于早期的风险预测模型（基线至研究第1天）对标准治疗的反应应与28天生存率显著相关。设计：分析两项安慰剂对照严重脓毒症试验的器官功能障碍数据（PROWESS和分泌型磷脂酶A2抑制剂试验）。设置：研究实验室。患者：合并了两项随机、双盲脓毒症试验的安慰剂组（n = 1036）。这些患者符合严重脓毒症的标准，并接受支持性标准重症监护和液体复苏。干预措施：无。测量和主要结果：连续器官衰竭评估（SOFA）评分计算每天使用最异常的生理或实验室变量。将基线和基线后SOFA评分分类为改善、不变或恶化，用于器官功能障碍变化与28天死亡率相关的回归分析。从基线到第1天，心血管（p = 0.0010）、肾（p <0.0001）或呼吸（p = 0.0469）功能的改善与生存率显著相关。第1天开始前，与呼吸、心血管或肾功能改善与恶化相关的比值比（95%置信区间）分别为0.56（0.35-0.91）、0.33（0.18-0.59）和0.30（0.17-0.52）。第2天和第3天开始前心血管功能的持续改善与生存率的进一步改善相关（p <0.0001），改善患者与恶化患者相比的优势比为0.15（0.08-0.39）和0.11（0.04-0.31）。没有其他器官系统保留在模型中，并改善超过第1天，在任何其他器官功能没有增加到模型的predictive power.Conclusions：这些分析表明，严重脓毒症患者的结果是密切相关的早期（基线到第1天在这里）改善，或缺乏，在器官功能。此外，随后几天的临床改善可能对生存的可能性几乎没有额外的影响。
Objective: Early identification and treatment of severe sepsis can significantly reduce mortality rate. We hypothesized that a risk prediction model based on early (baseline to day 1 of study) response to standard care should be significantly related to 28-day survival.Design: Analysis of organ dysfunction data from two placebo-controlled severe sepsis trials (PROWESS and secretory phospholipase A2 inhibitor trials).Setting: Research laboratory.Patients: The placebo arms of two randomized, double-blind sepsis trials were combined (n = 1036). These patients met criteria for severe sepsis and received supportive standard intensive care and fluid resuscitation.Interventions: None.Measurements and Main Results: Sequential Organ Failure Assessment (SOFA) scores were calculated daily using the most aberrant physiologic or laboratory variables. Baseline and postbaseline SOFA scores categorized as improved, unchanged, or worsened were used in regression analyses correlating organ dysfunction changes with 28-day mortality. Improvement in cardiovascular (p = .0010), renal (p < .0001), or respiratory (p = .0469) function from baseline to day 1 was significantly related to survival. Odds ratios (95% confidence intervals) associated with improved vs. worsened respiratory, cardiovascular, or renal function before start of day 1 were 0.56 (0.35-0.91), 0.33 (0.18-0.59), and 0.30 (0.17-0.52), respectively. Continued improvement in cardiovascular function before start of day 2 and start of day 3 was associated with further improvement in survival (p < .0001), with odds ratios of 0.15 (0.08-0.39) and 0.11 (0.04-0.31) for patients who improved compared with those who worsened. No other organ system was retained in the model, and improvement beyond day 1 in any other organ function did not add to the model's predictive power.Conclusions: These analyses suggest that outcomes for patients with severe sepsis are closely related to early (baseline to day 1 here) improvement, or lack thereof, in organ function. Also, clinical improvement on subsequent days may have little additional impact on the likelihood of survival.