摘要:目的 分析重症医学科(ICU)创伤患者并发脓毒症的危险因素,建立一种预测创伤患者发生脓毒症的新评分系统,为临床提供一种简便有效的脓毒症预警方法.方法 回顾性分析2012年1月至2017年12月陆军军医大学陆军特色医学中心及遵义医学院附属医院ICU收治的591例创伤患者的临床资料,按临床预后分为脓毒症组(n=382)和非脓毒症组(n=209).收集所有入住ICU创伤患者的基本临床资料,并分析两组间性别、年龄、基础疾病及入ICU 24 h内生命体征、相关危重症评分、血培养结果及实验室生化检查情况的差异.采用单因素Logistic回归分析对导致脓毒症的相关因素进行初筛,将其中P<0.12的指标纳入多因素Logistic回归分析,筛选创伤患者并发脓毒症的危险因素,并予以赋值,其总分即为脓毒症预警评分;绘制受试者工作特征曲线(ROC),评价脓毒症预警评分对ICU创伤患者并发脓毒症的预测价值.结果 ICU创伤患者脓毒症发生率为64.6%(382/591),ICU病死率为10.5%(40/382);车祸伤是创伤患者入住ICU最为常见的原因.与未并发脓毒症患者相比,创伤并发脓毒症患者格拉斯哥昏迷评分(GCS)、既往史比例、红细胞计数(RBC)、血小板计数(PLT)、白蛋白(Alb)水平更低,体温、脉搏、急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、序贯器官衰竭评分(SOFA)、损伤严重度评分(ISS)、新损伤严重度评分(NISS)、吸入氧浓度(FiO2)、血钠、活化部分凝血活酶时间(APTT)、凝血酶原时间(PT)、降钙素原(PCT)、C-反应蛋白(CRP)水平更高,输血、中心静脉置管、机械通气、休克、多器官功能障碍综合征(MODS)、开放伤和多发伤比例更高,机械通气时间、ICU住院时间和总住院时间更长,差异均有统计学意义.发生脓毒症的创伤患者大多存在多发伤,其多个部位损伤患者比例明显高于未并发脓毒症者,且创伤患者多为头面颈部损伤.Logistic单因素和多因素逐步回归分析结果显示,脉搏>100次/min〔优势比(OR)=1.617,95%可信区间(95%CI)=0.992~2.635,P=0.044〕、APTT>36 s (OR=2.164,95%CI=1.056~4.435,P=0.035)、休克(OR=1.798,95%CI=1.056~3.059,P=0.031)、机械通气(OR=5.144,95%CI=2.302~11.498,P<0.001)、 APACHEⅡ >21 分(OR=3.348,95%CI=1.724~6.502, P<0.001)和NISS>25分(OR=3.332,95%CI=1.154~9.624,P=0.026)为ICU创伤患者并发脓毒症的危险因素,根据β值进行赋值,分别为 0.5、1.0、0.5、1.5、1.5、1.5分,并以这6个指标作为脓毒症预警评分建立的基础.ROC曲线分析显示,脓毒症预警评分预测创伤患者并发脓毒症的ROC曲线下面积(AUC)为 0.782,明显高于APACHEⅡ(AUC=0.672)、APTT(AUC=0.574)和NISS(AUC=0.515),差异均有统计学意义(均P<0.01);当脓毒症预警评分的截断值为4.0分时,其敏感度为71.7%,特异度为61.9%.结论 严密监测并稳定创伤患者入住ICU 24 h内的生命体征,减少不合理的有创机械通气时间等,有望降低创伤患者脓毒症发生率;脓毒症预警评分由脉搏、APTT、休克、机械通气、APACHEⅡ和NISS这6个因素组成,合理运用脓毒症预警评分可以更加简洁有效地评估创伤患者的预后,其预测效果优于单独应用APACHEⅡ、APTT和NISS.%Objective To analyze the risk factors of patients with trauma in intensive care unit (ICU), a new warning scoring system is established for predicting the incidence of sepsis in traumatic patients; and to provide a new simple method of clinical score, which could provide a reference for clinical prevention and treatment of sepsis. Methods The clinical data of 591 patients with trauma in the ICU of the Army Specialized Medical Center of Army Medical University and Affiliated Hospital of Zunyi Medical University from January 2012 to December 2017 were retrospectively analyzed. The patients were divided into sepsis group (n = 382) and non-sepsis group (n = 209) according to their clinical outcome. The basic clinical data of all ICU trauma patients were collected, and the differences in gender, age, underlying diseases, and vital signs, critical illness scores, blood culture results and laboratory biochemical examinations within 24 hours of ICU admission between the two groups were analyzed. Univariate Logistic regression analysis was used to screen the related factors leading to sepsis. The indexes with P < 0.12 analyzed by univariate Logistic regression analysis were included in multivariate Logistic regression analysis. The risk factors of sepsis in traumatic patients were screened and assigned, and the total score was sepsis early warning score. The receiver operating characteristic (ROC) curve was plotted to evaluate the predictive value of the warning score of sepsis in patients with trauma. Results The incidence of sepsis in ICU trauma patients was 64.6% (382/591), and the ICU mortality was 10.5% (40/382). The traffic accident was a common cause of ICU trauma patients. Compared with non-sepsis patients, Glasgow coma score (GCS), proportion of past history, red blood cell (RBC), platelet (PLT), albumin (Alb) were lower in patients with sepsis, and body temperature, pulse, acute physiology and chronic health evaluation Ⅱ (APACHEⅡ), sequential organ failure assessment (SOFA), injury severity score (ISS), new injury severity score (NISS), fraction of inspired oxygen (FiO2), blood sodium, activated partial thromboplastin time (APTT), prothrombin time (PT), procalcitonin (PCT), C-reactive protein (CRP) levels were higher, blood transfusion, central venous catheterization, mechanical ventilation, shock, multiple organ dysfunction syndrome (MODS), open injury and multiple injuries were more common, the duration of mechanical ventilation, ICU days and total hospital days were longer, and all the differences were statistically significant. Most of the traumatic patients with sepsis were undergone with multiple trauma. Compared with non-sepsis patients, the proportion of multiple position trauma was significantly higher than patients without sepsis. And most traumatic patients were insulted in head, face and neck. The risk factors were screened by univariate and multivariate Logistic stepwise regression analysis, the indexes into the regression model were pulse > 100 bpm [odds ratio (OR) = 1.617, 95% confidence interval (95%CI) = 0.992-2.635, P = 0.044], APTT > 36 s (OR = 2.164, 95%CI =1.056-4.435, P = 0.035), shock (OR = 1.798, 95%CI = 1.056-3.059, P = 0.031), mechanical ventilation (OR = 5.144, 95%CI = 2.302-11.498, P < 0.001), APACHEⅡ > 21 (OR = 3.348, 95%CI = 1.724-6.502, P < 0.001), NISS > 25 (OR = 3.332, 95%CI = 1.154-9.624, P = 0.026), assigning scores were 0.5, 1.0, 0.5, 1.5, 1.5, 1.5, respectively, which were included in the new warning score of sepsis. ROC curve analysis showed that the area under ROC curve (AUC) of warning score for predicting sepsis in patients with trauma was 0.782, which was significantly higher than the APACHEⅡ(AUC = 0.672), APTT (AUC = 0.574) and NISS (AUC = 0.515) with significant difference (all P < 0.01). When the cut-off value of sepsis warning score was 4.0, the sensitivity and specificity were 71.7% and 61.9%, respectively. Conclusions Close monitoring and stabilization of vital signs of traumatic patients within 24 hours of ICU admission and reduction of unreasonable invasive mechanical ventilation time are expected to reduce the incidence of sepsis in traumatic patients. New warning score of sepsis consisted of six factors: pulse, APTT, shock, mechanical ventilation, APACHEⅡ and NISS. Rational use of warning score of sepsis would help us to assess the prognosis of traumatic patients more easily and effectively, and the predicted effect is much better than APACHEⅡ, APTT and NISS.