连续性肾脏替代治疗非计划下机风险预测模型的构建与外部验证  

Construction and external validation of a risk prediction model for unplanned interruption during continuous renal replacement therapy

作　　者：许红妍 任奇[1] 祝利红 林娟[1] 陈上仲 胡才宝[1] 沈延飞 蔡国龙[1] Xu Hongyan;Ren Qi;Zhu Lihong;Lin Juan;Chen Shangzhong;Hu Caibao;Shen Yanfei;Cai Guolong(Department of Critical Care Medicine,Zhejiang Hospital,Hangzhou 310030,Zhejiang,China)

机构地区：[1]浙江医院重症医学科,浙江杭州310030

出　　处：《中华危重病急救医学》2024年第5期520-526,共7页Chinese Critical Care Medicine

基　　金：浙江省医药卫生科技计划项目(2022KY487)。

摘　　要：目的筛选连续性肾脏替代治疗(CRRT)非计划下机的独立影响因素并构建相应的风险预测模型,验证该模型的临床应用效果。方法回顾性纳入2021年1月至2022年8月于浙江医院重症监护病房(ICU)接受CRRT治疗的成人危重症患者用于模型构建,根据是否发生非计划下机分为两组,比较两组患者CRRT非计划下机的潜在影响因素,通过二元Logistic回归筛选CRRT非计划下机的独立影响因素并构建风险预测模型,分别进行Hosmer-Lemeshow检验及绘制受试者工作特征曲线(ROC曲线)以评估该模型的拟合优度及预测效能。将风险预测模型嵌入医院ICU多功能重症电子病历系统,前瞻性选择2022年11月至2023年10月于浙江医院ICU接受CRRT治疗的成人危重症患者,验证该模型的临床应用效果。结果①模型构建及内部验证:回顾性选择331例患者,其中计划下机组238例,非计划下机组93例。与计划下机组相比,非计划下机组患者男性比例更低(80.6%比91.6%),合并慢性疾病的比例更高(60.2%比41.6%),血液净化导管功能不佳者比例更高(31.2%比6.3%),CRRT启动前血小板计数(PLT)更高〔×10^(9)/L:137(101,187)比109(74,160)〕,血流速更低〔mL/min:120(120,150)比150(140,180)〕,应用前置换者比例更高(37.6%比23.5%),滤过分数更高〔23.0%(17.5%,32.9%)比19.1%(15.7%,22.6%)〕,血泵停止次数更多〔次:19(14,21)比9(6,13)〕,差异均有统计学意义(均P<0.05)。二元Logistic回归分析结果显示,合并慢性疾病〔优势比(OR)=3.063,95%可信区间(95%CI)为1.200~7.819〕、血液净化导管功能(OR=4.429,95%CI为1.270~15.451)、血流速(OR=0.928,95%CI为0.900~0.957)和血泵停止次数(OR=1.339,95%CI为1.231~1.457)是CRRT非计划下机的独立影响因素(均P<0.05),并以该4个独立影响因素构建风险预测模型。ROC曲线分析显示,该模型预测的曲线下面积(AUC)为0.952(95%CI为0.930~0.973,P=0.0030),敏感度为88.2%,特异度为89.9%,约登指数最大值为1.781Objective To identify the independent factors of unplanned interruption during continuous renal replacement therapy(CRRT)and construct a risk prediction model,and to verify the clinical application effectiveness of the model.Methods A retrospective study was conducted on critically ill adult patients who received CRRT treatment in the intensive care unit(ICU)of Zhejiang Hospital from January 2021 to August 2022 for model construction.According to whether unplanned weaning occurred,the patients were divided into two groups.The potential influencing factors of unplanned CRRT weaning in the two groups were compared.The independent influencing factors of unplanned CRRT weaning were screened by binary Logistic regression and a risk prediction model was constructed.The goodness of fit of the model was verified by a Hosmer-Lemeshow test and its predictive validity was evaluated by receiver operator characteristic curve(ROC curve).Then embed the risk prediction model into the hospital's ICU multifunctional electronic medical record system for severe illness,critically ill patients with CRRT admitted to the ICU of Zhejiang Hospital from November 2022 to October 2023 were prospectively analyzed to verify the model's clinical application effect.Results①Model construction and internal validation:a total of 331 critically ill patients with CRRT were included to be retrospectively analyzed.Among them,there were 238 patients in planned interruption group and 93 patients in unplanned interruption group.Compared with the planned interruption group,the unplanned interruption group was shown as a lower proportion of males(80.6%vs.91.6%)and a higher proportion of chronic diseases(60.2%vs.41.6%),poor blood purification catheter function(31.2%vs.6.3%),as a higher platelet count(PLT)before CRRT initiation[×10_(9)/L:137(101,187)vs.109(74,160)],lower level of blood flow rate[mL/min:120(120,150)vs.150(140,180)],higher proportion of using pre-dilution(37.6%vs.23.5%),higher filtration fraction[23.0%(17.5%,32.9%)vs.19.1%(15.7%,22.6%)],and

关 键 词：连续性肾脏替代治疗 非计划下机 多因素分析 风险预测模型 护理 

分 类 号：R459.5[医药卫生—治疗学]