| Background and ObjectiveSeptic shock,a severe subtype of sepsis,had been the focus of severe medical research for many years due to its critical condition,high fatality rate and heavy economic burden.After years of exploration and research,people had gained a deeper and more comprehensive understanding of sepsis and septic shock.In 2016,based on decades of research results and clinical observation,the severe medical community redefined sepsis and septic shock,and the resuscitation and cluster therapy guidelines for septic shock had been updated several times.Over the past decade,several aspects of ICU patient management had changed,including wider use of small tidal ventilation strategies,lower blood transfusion thresholds,reduced use of sedation drugs and early exercise,and quicker early identification and intervention of patients with septic shock.Advances in these therapeutic concepts had improved the prognosis of septic shock to a certain extent,so although the reported incidence of sepsis and severity of sepsis were increasing,the mortality rate of sepsis and septic shock was decreasing gradually.But even so,the mortality rate of septic shock was still higher than diseases that threaten human health such as heart failure,breast cancer,colon cancer and AIDS.At the same time,it was often accompanied by high treatment costs,which brought great economic burden to families and society.At present,the epidemiological data of septic shock were mainly concentrated in the economically developed countries,while the epidemiological investigation of septic shock in economically underdeveloped countries was less,but it was also increasing in recent years.There was a significant regional difference in the incidence and mortality of septic shock,which was closely related to the level of local economic development,medical and health investment and the number of beds in ICU.Two previous national epidemiological surveys of severe sepsis and septic shock in China also reported dramatically different morbidity and mortality.The China Critical Care Clinical Trials Group(CCCCTG)reported that the mortality rate of standard sepsis in China was 66.5 per 100,000 person-times,higher than that in some developed countries,according to the data of 605 disease observation points nationwide.The mortality rate of sepsis had obvious regional differences,which were related to local economic development level,education level and disposable income.As a populous province in China,the epidemiological investigation of sepsis in Henan Province was of great practical significance.In addition,due to the extremely high mortality rate of septic shock,it was necessary to carry out risk grade,prognosis evaluation,optimal treatment,severity and prognosis scoring system in order to timely detect high-risk patients.Currently,the commonly used scoring systems in the clinic were the acute physiological and chronic health scoring system(APACHE II score)and the sequential organ failure scoring system(SOFA score).These two scoring systems had advantages and disadvantages in the evaluation of infectious shock condition and prognosis.In this study,we attempted to combine the two scoring systems to establish a new prediction model of septic shock mortality and validate it,and compared with SOFA score and APACHE II score to evaluate the predictive power of the new model.The study was divided into two parts.1.Epidemiological characteristics of septic shock in The FirstAffiliated Hospital of Zhengzhou University.MethodsCollected the patients who diagnosed septic shock or sepsis shock in the hospital from July 01,2013 to June 30,2017 in The First Affiliated Hospital of Zhengzhou University.According to the information of hospitalization,all the patients above were manually reviewed,the patients younger than 15 years old were excluded,the patients who were not admitted to ICU were excluded,and the patients who did not meet the diagnostic criteria of septic shock in sepsis 3.0 were excluded.The rest of the patients who met the inclusion criteria were included,and the relevant hospitalization information of these patients were collected and analyzed.ResultsA total of 535 patients who met the inclusion criteria were selected,and the incidence of ICU was 6.6%.There were statistically significant differences between the death patients and the survival patients in ICU time of hospitalization(median 3:5,P=0.004),APACHE II score(median 23:16,P<0.001),mechanical ventilation(319: 95,P < 0.001),total organ failure(median 4:3,P < 0.001),CRRT treatment(81:25,P < 0.001),concurrent ARDS(27: 5,P < 0.001).The most common infection site was lung infection,accounting for 78.4%(n=421),followed by abdominal infection,accounting for 39.3%(n=210),and 278 patients with multi-site infection(infection site≥2).The most common pathogenic bacteria was escherichia coli,which was present in 29.7%(n=30)of patients,followed by acinetobacter baumannii,klebsiella pneumoniae,staphylococcus aureus and pseudomonas aeruginosa,accounting for 22.8%(n=23),19.8%(n=20),17.8%(n=18)and 9.9%(n=20)respectively.The total number of death patients was 325,and 243 patients died in the hospital.The hospital mortality rate was 45.4%,and the total 28-day mortality rate was 60.7%.The APACHE II score,SOFA score within 24 hours after diagnosis,and blood D-dimer levels were independent risk factors for hospitalized patients.2.Establishment of prognostic model of septic shock.MethodsThe data of SOFA score and APACHE II score of the subjects included in the first part of the study were collected,and ROC curve analysis was carried out for the two scoring systems to calculate the optimal cutoff value,sensitivity,specificity,positive predictive value,negative predictive value,yoden index and area under the curve to draw the corresponding ROC curve.The SOFA score and the APACHE II score were substituted into the logistic regression to obtain a new equation for predicting the risk of septic shock death,and ROC curve was plotted after analysis.The consistency test of the equation and the two scoring systems was conducted in real cases,and the test effectiveness of the three was compared.ResultsAccording to logstic regression method,the equation of the joint model was ln(p/1-p)= APACHE II*0.133+SOFA*0.062-3.618.Based on this,we established the death risk prediction model of SOFA score combined with APACHE II score.The area under ROC curve was larger,and the prediction effect was better.The consistency test was performed in 100 real cases with good consistency.SOFA score alone or APACHE II score alone could also be used to predict the prognosis of septic shock patients,but the consistency of the score was general.The predictive power of the combined model was higher than APAHE II score and higher than SOFA score.ConclusionThis study showed that the inpatient mortality rate of septic shock in The First Affiliated Hospital of Zhengzhou University was high with a high mortality rate of 28 days,which was closely related to the overall economic and health development level and development imbalance in Henan Province.APACHE II score,SOFA score,and D-dimer were independent risk factors for death in septic shock patients.The septic shock situation in Henan Province was severe,causing a huge disease burden and seriously endangering people’s health.In the future work,multi-center prospective epidemiological investigation should be carried out to further clarify the incidence and mortality of sepsis in Henan Province.To promote the balanced development of health care in Henan Province as much as possible,promote the standardization of treatment methods and vigorously promote the awareness and compliance of the guidelines for sepsis,and reduce the mortality of septic shock in Henan Province.A new predictive model of septic shock death was established by combining the SOFA score and the APACHE II score,which was more effective than any single model.The model with high predictive efficacy and ease of promotion would help identify high-risk patients,implement risk grading,judge prognosis,and optimize treatment. |
