常用风险评估系统在心脏手术后风险评估中的应用  

Application of Common Risk Evaluation Systems for Patients after Cardiac Surgery

作　　者：毛斌[1] 阎晓蕾[1] 陈英[1] 张建群[1] 

机构地区：[1]首都医科大学附属北京安贞医院心脏外科,北京100029

出　　处：《中国胸心血管外科临床杂志》2010年第2期114-118,共5页Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

摘　　要：目的比较多器官衰竭评分系统(MODS)、序贯器官衰竭评分系统(SOFA)、急性生理及慢性健康评分系统(APACHE)Ⅱ、APACHEⅢ对患者心脏手术后风险评估的价值,为重症患者的治疗及预测预后提供依据。方法自2007年10月至2008年4月,北京安贞医院心脏外科监护室收治18岁以上心脏手术后患者共1 935例,男1 050例,女885例;年龄18～86岁,平均年龄53.96岁。病种包括冠心病、心瓣膜病、先天性心脏病、动脉瘤、心房颤动、心包疾病、肺动脉栓塞等。采用MODS、SOFA、APACHEⅡ、APACHEⅢ系统进行评分,分别计算各评分系统的手术当天分值、3 d内最大分值、最大分值、第3 d与第1 d的差值,再计算各评分系统不同时段的ROC曲线下面积,并进行Hosmer-Lemeshow拟合优度检验。结果围术期死亡47例,死亡率2.43%,主要死于循环功能、呼吸功能、肾功能、肝功能衰竭和神经系统病变。MODS评分系统的手术当天分值、最大MODS值、手术3 d内最大MODS值和手术后第3 d与第1 d的MODS分值差ROC曲线下面积分别为0.747,0.901,0.892,0.786;χ2值分别为4.712,5.905,5.384,13.215。SOFA系统ROC曲线下面积分别为0.736,0.891,0.880,0.798;χ2值分别为8.673,3.189,3.111,14.225。APACHEⅡ系统ROC曲线下面积分别为0.699,0.848,0.827,0.562;χ2值分别为15.688,10.132,8.061,42.253。APACHEⅢ系统ROC曲线下面积分别为0.721,0.872,0.869,0.587;χ2值分别为13.608,11.196,19.310,47.576。MODS和SOFA评分系统的ROC曲线下面积均大于APACHEⅡ或APACHEⅢ评分系统的相应值(P<0.05);APACHEⅡ评分系统的ROC曲线下面积均小于APACHEⅢ评分系统的相应值(P<0.05)。结论MODS、SOFA、APACHEⅡ、APACHEⅢ系统都可用于心脏外科手术后患者的风险评估,但MODS和SOFA系统对死亡的风险评估优于APACHEⅡ、APACHEⅢ系统。在心脏外科中,可以用简单的MODS和SOFA系统替代复杂的APACHEⅡ、APACHEⅢ系统。Objective To compare the multiple organ dysfunction score（MODS）,the sequential organ failure assessment（SOFA）,the acute physiology,age,and chronic health evaluation systemⅡ（APACHEⅡ）,the acute physiology,age,and chronic health evaluation systemⅢ（APACHEⅢ） in evaluating risks for patients after cardiac surgery,in order to provide better treatment and prediction of prognosis after cardiac operation.Methods A prospective study was carried out on 1 935 cardiac postoperative patients,including 1 050 males and 885 females,enrolled in cardiac postoperative intensive care unit of Anzhen hospital between October 2007 and April 2008.The age of the patients ranged from 18 to 86 years with the mean age of 53.96 years.The patients underwent the surgery because of various cardiac diseases including coronary heart disease,valve disease,congenital heart disease,aortic aneurysm,pericardial disease,atrial fibrillation,and pulmonary embolism.We used MODS,SOFA,APACHEⅡ,and APACHEⅢrespectively to calculate the value of the first day after operation,the maximum value during the first three days,the maximum value,and the change of the value between the third day and the first day for every patient,and then we compared the calibration and discrimination of these different systems using Hosmer-Lemeshow goodness-of-fit analysis and Receiver Operating Characteristic（ROC） curve.Results There were 47 peri-operative deaths because of circulating system failure,respiration failure,kidney failure,liver failure or nervous system diseases.The death rate was 2.43%.In discrimination analysis,the area under the curve（AUC） in ROC of the first day value after operation,the maximum value,the maximum value during the first three days,and the change of value between the third day and the first day for MODS were respectively 0.747,0.901,0.892,and 0.786;for SOFA were respectively 0.736,0.891,0.880,and 0.798;for APACHEⅡwere respectively 0.699,0.848,0,827,and 0.562;for APACHE Ⅲwere respectively 0.721,0.872,0.869,and 0.587

关 键 词：多器官衰竭评分系统 序贯器官衰竭评分系统 急性生理及慢性健康评分系统 

分 类 号：R654.2[医药卫生—外科学]