平均气道压轨迹对机械通气脓毒症休克患者死亡率和急性肾损伤发生情况的影响：来自MIMIC-IV数据库的见解
Influence of the mean airway pressure trajectory on the mortality and AKI occurrence in septic shock patients with mechanical ventilation: insights from the MIMIC-IV database.
作者信息
Dong Yukang, Yang Changyan, Sun Run, Fu Jiangquan, Huang Rui, Yuan Jia, Wang Ying, Wang Jinni, Shen Feng
机构信息
Department of Intensive Care Unit, Guizhou Medical University Affiliated Hospital, Guiyang, China.
Department of Emergency, Guizhou Provincial People's Hospital, Guiyang, China.
出版信息
Front Med (Lausanne). 2025 Mar 5;12:1552336. doi: 10.3389/fmed.2025.1552336. eCollection 2025.
BACKGROUND
Mean airway pressure (Pmean) is a known prognostic marker for mortality and adverse outcomes in mechanically ventilated patients. However, most previous studies have relied on static measurements, leaving the impact of Pmean trajectory on clinical outcomes in septic shock patients unclear. This study aimed to investigate the effect of Pmean trajectory on survival rates and acute kidney injury (AKI) incidence in septic shock patients undergoing mechanical ventilation (MV).
METHODS
A retrospective cohort study was implemented utilizing sepsis patient data from the MIMIC-IV database. Group-based trajectory modeling (GBTM) was applied to identify distinct Pmean trajectory groups among septic shock patients. Cox proportional hazards and logistic regression models were utilized to analyze associations between Pmean trajectory and both mortality and AKI incidence. A causal mediation analysis evaluated the intermediary effect of cumulative fluid balance over the first 72 h post-ICU admission.
RESULTS
A total of 956 eligible patients were included. Based on model fitting criteria, five distinct Pmean trajectory groups were identified: group 1 (low-stable), group 2 (high-descend), group 3 (medium-ascend), group 4 (high-stable), and group 5 (higher-stable). Compared to the low-stable trajectory (group 1), trajectories in groups 3, 4, and 5 were associated with significantly higher 30-day mortality risks (HR = 1.40, 95% CI = 1.03-1.88; HR = 1.47, 95% CI = 1.01-2.13; HR = 2.54, 95% CI = 1.53-4.2, respectively), while group 2 exhibited similar mortality rates to group 1 (HR = 0.88, 95% CI = 0.60-1.30). Logistic regression analyses revealed that groups 3, 4, and 5 were also significant risk factors for AKI occurrence ( < 0.05), with group 1 as the reference. Mediation analysis revealed that 20.5% (95% CI = 0.106-0.40) of the Pmean trajectory effect on AKI occurrence was mediated through cumulative fluid balance.
CONCLUSION
Pmean trajectories were strongly associated with mortality and AKI incidence in septic shock patients receiving MV.
背景
平均气道压（Pmean）是机械通气患者死亡率和不良结局的已知预后标志物。然而，以往大多数研究依赖于静态测量，Pmean轨迹对脓毒性休克患者临床结局的影响尚不清楚。本研究旨在探讨Pmean轨迹对接受机械通气（MV）的脓毒性休克患者生存率和急性肾损伤（AKI）发生率的影响。
方法
利用MIMIC-IV数据库中的脓毒症患者数据进行一项回顾性队列研究。应用基于组的轨迹建模（GBTM）来识别脓毒性休克患者中不同的Pmean轨迹组。采用Cox比例风险模型和逻辑回归模型分析Pmean轨迹与死亡率和AKI发生率之间的关联。进行因果中介分析，以评估重症监护病房（ICU）入院后72小时内累积液体平衡的中介作用。
结果
共纳入956例符合条件的患者。根据模型拟合标准，识别出五个不同的Pmean轨迹组：第1组（低稳定）、第2组（高下降）、第3组（中上升）、第4组（高稳定）和第5组（更高稳定）。与低稳定轨迹组（第1组）相比，第3、4和5组的轨迹与30天死亡风险显著更高相关（HR分别为1.40，95%CI为1.03-1.88；HR为1.47，95%CI为1.01-2.13；HR为2.54，95%CI为1.53-4.2），而第2组的死亡率与第1组相似（HR为0.88，95%CI为0.60-1.30）。逻辑回归分析显示，以第1组为参照，第3、4和5组也是AKI发生的显著危险因素（P<0.05）。中介分析显示，Pmean轨迹对AKI发生的影响中有20.5%（95%CI为0.106-0.40）是通过累积液体平衡介导的。
结论
在接受MV的脓毒性休克患者中，Pmean轨迹与死亡率和AKI发生率密切相关。
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