Dong Jiahui, Wang Lingling, Xiong Richeng, Liu Xing, Guo Zhenhui, Sun Weifeng, Chen Rui
Department of Medical Intensive Care Unit, General Hospital of Southern Theatre Command; Guangzhou Key Laboratory of Geriatric Infection and Organ Function Support, Branch of National Clinical Research Center for Geriatric Diseases (Chinese PLA General Hospital), Guangzhou 510010, Guangdong, China.
Guangzhou University of Chinese Medicine, Guangzhou 510006, Guangdong, China. Corresponding author: Chen Rui, Email:
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. 2021 Mar;33(3):257-262. doi: 10.3760/cma.j.cn121430-20201027-00688.
To establish a 180-day mortality predictive score based on frailty syndrome in elderly sepsis patients [elderly sepsis score (ESS)].
A prospective study for sepsis patients aged 60 years and above who were admitted to a medical intensive care unit of the General Hospital of Southern Theatre Command from January 1st, 2018 to December 31st, 2018 was conducted. Univariate analysis was performed on 19 independent variables including gender, age, body mass index (BMI), tumor, charlson comorbidity index (CCI), activity of daily living (ADL), instrumental activity of daily living (IADL), mini-mental state examination (MMSE), geriatric depression scale (GDS), clinical frail scale (CFS), sequential organ failure assessment (SOFA), Glasgow coma scale (GCS), acute physiology and chronic health evaluation (APACHE II, APACHE IV), modified NUTRIC score (MNS), multiple drug resistance (MDR), mechanical ventilation (MV), continuous renal replacement therapy (CRRT) and palliative care. Continuous independent variables were converted into classified variables. Multivariate binary regression analysis of risk factors was conducted to screen independent risk factors which affecting 180-day mortality in elderly sepsis patients. Then a 180-daymortality predictive score was established, and the discrimination of the mortality of patients using CFS, SOFA, GCS, APACHE II, APACHE IV, MNS scores were compared.
A total of 257 patients were enrolled, with a 180-day mortality of 60.7%. Univariate analysis showed that age, tumor, CCI, ADL, IADL, MMSE, CFS, SOFA, GCS, APACHE II, APACHE IV, MNS, MDR, MV, CRRT, palliative care were risk factors of 180-day mortality in elderly sepsis patients [age: odds ratio (OR) = 1.027, 95% confidence interval (95%CI) was 1.005-1.050, P = 0.018; tumor: OR =2.001, 95%CI was 1.022-3.920, P = 0.043; CCI: OR = 1.193, 95%CI was 1.064-1.339, P = 0.003; ADL: OR = 0.851, 95%CI was 0.772-0.940, P = 0.001; IADL: OR = 0.894, 95%CI was 0.826-0.967, P = 0.005; MMSE: OR = 0.962, 95%CI was 0.937-0.988, P = 0.004; CFS: OR = 1.303, 95%CI was 1.089-1.558, P = 0.004; SOFA: OR = 1.112, 95%CI was 1.038-1.191, P = 0.003; GCS: OR = 0.918, 95%CI was 0.863-0.977, P = 0.007; APACHE II: OR = 1.098, 95%CI was 1.053-1.145, P < 0.001; APACHE IV: OR = 1.032, 95%CI was 1.020-1.044, P < 0.001; MNS: OR = 1.315, 95%CI was 1.159-1.493, P < 0.001; MDR: OR = 2.029, 95%CI was 1.197-3.437, P = 0.009; MV: OR = 6.408, 95%CI was 3.480-11.798, P < 0.001, CRRT: OR = 2.744, 95%CI was 1.529-4.923, P = 0.001, palliative care: OR = 5.760, 95%CI was 2.177-15.245, P < 0.001]. By binary regression analysis, CFS stratification (OR = 1.934, 95%CI was 1.267-2.953, P = 0.002), MV (OR = 4.531, 95%CI was 2.376-8.644, P < 0.001), CRRT (OR = 2.471, 95%CI was 1.285-4.752, P = 0.007), palliative care (OR = 6.169, 95%CI was 2.173-17.515, P = 0.001) were independent risk factors of 180-day mortality in elderly patients with sepsis. The model of "ESS = 0.660×CFS stratification+1.511×MV+0.905×CRRT+1.820×palliative care" was established. Receiver operating characteristic curve (ROC curve) analysis showed that the area under the ROC curve (AUC) for predicting 180-day mortality by ESS was 0.785 (95%CI was 0.730-0.834, P < 0.001). When the best cut-off value was 2.2 points, its sensitivity was 78.9%, specificity was 70.3%, the positive predictive value was 80.4%, and the negative predictive value was 68.3%. Simplified ESS was defined as "0.5×CFS stratification+1.5×MV+1×CRRT+2×palliative care". ROC curve analysis showed that AUC for predicting 180-day mortality by simplified ESS was 0.784 (95%CI was 0.729-0.833, P < 0.001). When the best cut-off value was 2.0 points, sensitivity was 76.9%, specificity was 70.3%, the positive predictive value was 80.0%, and the negative predictive value was 66.4%. Compared with CFS, SOFA, GCS, APACHE II, APACHE IV and MNS, ESS had a significant difference in discriminating 180-day mortality in elderly patients with sepsis (AUC was 0.785 vs. 0.607, 0.607, 0.600, 0.664, 0.702, 0.657, 95%CI: 0.730-0.734 vs. 0.537-0.678, 0.537-0.677, 0.529-0.671, 0.598-0.730, 0.638-0.766, 0.590-0.725, all P < 0.05).
CFS, MV, CRRT, and palliative care are independent risk factors of 180-day mortality in elderly patients with sepsis. We established ESS based on these risk factors. The ESS model has good discrimination and can be used as a reference and assessment tool for prediction and treatment guidance in elderly patients with sepsis.
基于老年脓毒症患者的衰弱综合征建立一个180天死亡率预测评分系统[老年脓毒症评分（ESS）]。
对2018年1月1日至2018年12月31日入住南部战区总医院医学重症监护病房的60岁及以上脓毒症患者进行前瞻性研究。对性别、年龄、体重指数（BMI）、肿瘤、查尔森合并症指数（CCI）、日常生活活动能力（ADL）、工具性日常生活活动能力（IADL）、简易精神状态检查表（MMSE）、老年抑郁量表（GDS）、临床衰弱量表（CFS）、序贯器官衰竭评估（SOFA）、格拉斯哥昏迷量表（GCS）、急性生理与慢性健康状况评估（APACHE II、APACHE IV）、改良营养风险与感染评分（MNS）、多重耐药（MDR）、机械通气（MV）、持续肾脏替代治疗（CRRT）和姑息治疗等19个独立变量进行单因素分析。将连续型独立变量转换为分类变量。对危险因素进行多因素二元回归分析，筛选出影响老年脓毒症患者180天死亡率的独立危险因素。然后建立一个180天死亡率预测评分系统，并比较使用CFS、SOFA、GCS、APACHE II、APACHE IV、MNS评分对患者死亡率的判别能力。
共纳入257例患者，180天死亡率为60.7%。单因素分析显示，年龄、肿瘤、CCI、ADL、IADL、MMSE、CFS、SOFA、GCS、APACHE II、APACHE IV、MNS、MDR、MV、CRRT、姑息治疗是老年脓毒症患者180天死亡率的危险因素[年龄：比值比（OR）=1.027，95%置信区间（95%CI）为1.005 - 1.050，P = 0.018；肿瘤：OR = 2.001，95%CI为1.022 - 3.920，P = 0.043；CCI：OR = 1.193，95%CI为1.064 - 1.339，P = 0.003；ADL：OR = 0.851，95%CI为0.772 - 0.940，P = 0.001；IADL：OR = 0.894，95%CI为0.826 - 0.967，P = 0.005；MMSE：OR = 0.962，95%CI为0.937 - 0.988，P = 0.004；CFS：OR = 1.303，95%CI为1.089 - 1.558，P = 0.004；SOFA：OR = 1.112，95%CI为1.038 - 1.191，P = 0.003；GCS：OR = 0.918，95%CI为0.863 - 0.977，P = 0.007；APACHE II：OR = 1.098，95%CI为1.053 - 1.145，P < 0.001；APACHE IV：OR = 1.032，95%CI为1.020 - 1.044，P < 0.001；MNS：OR = 1.315，95%CI为1.159 - 1.493，P < 0.001；MDR：OR = 2.029，95%CI为1.197 - 3.437，P = 0.009；MV：OR = 6.408，95%CI为3.480 - 11.798，P < 0.001，CRRT：OR = 2.744，95%CI为1.529 - 4.923，P = 0.001，姑息治疗：OR = 5.760，95%CI为2.177 - 15.245，P < 0.001]。通过二元回归分析，CFS分层（OR = 1.934，95%CI为1.267 - 2.953，P = 0.002）、MV（OR = 4.531，95%CI为2.376 - 8.644，P < 0.001）、CRRT（OR = 2.471，95%CI为1.285 - 4.752，P = 0.007）、姑息治疗（OR = 6.169，95%CI为2.173 - 17.515，P = 0.001）是老年脓毒症患者180天死亡率的独立危险因素。建立了“ESS = 0.660×CFS分层 + 1.511×MV + 0.905×CRRT + 1.820×姑息治疗”模型。受试者工作特征曲线（ROC曲线）分析显示，ESS预测180天死亡率的ROC曲线下面积（AUC）为0.785（95%CI为0.730 - 0.834，P < 0.001）。当最佳截断值为2.2分时，其灵敏度为78.9%，特异度为70.3%，阳性预测值为80.4%，阴性预测值为68.3%。简化ESS定义为“0.5×CFS分层 + 1.5×MV + 1×CRRT + 2×姑息治疗”。ROC曲线分析显示，简化ESS预测180天死亡率的AUC为0.784（95%CI为0.729 - 0.833，P < 0.001）。当最佳截断值为2.0分时，灵敏度为76.9%，特异度为70.3%，阳性预测值为80.0%，阴性预测值为66.4%。与CFS、SOFA、GCS、APACHE II、APACHE IV和MNS相比，ESS在判别老年脓毒症患者180天死亡率方面有显著差异（AUC分别为0.785 vs. 0.607、0.607、0.600、0.664、0.702、0.657，95%CI：0.730 - 0.734 vs. 0.537 - 0.678、0.537 - 0.677、0.529 - 0.671、0.598 - 0.730、0.638 - 0.766、0.590 - 0.725，均P < 0.05）。
CFS、MV、CRRT和姑息治疗是老年脓毒症患者180天死亡率的独立危险因素。我们基于这些危险因素建立了ESS。ESS模型具有良好的判别能力，可作为老年脓毒症患者预测和治疗指导的参考及评估工具。
