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陈亚欧.连续肾脏替代治疗6小时后的高体温有助于更早识别危重症患者真菌感染[J].内科急危重症杂志,2025,31(2):154-159
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| DOI：10.11768/nkjwzzzz20250212 |
| 中文关键词: 连续肾脏代替治疗 发热 真菌感染 |
| 英文关键词: |
| 基金项目:苏州市卫生计生委科技项目（LCZX202112） |
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| 摘要点击次数: 240 |
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| 中文摘要: |
| 摘要 目的：探讨连续肾脏代替治疗（CRRT）6h后的高体温是否有助于更早识别危重症患者真菌感染。方法：回顾性分析142例重症监护病房住院患者的临床资料，包括患者性别、年龄、体重指数、主要诊断、28d生存状况、CRRT6h后的体温峰值（Tmax）。根据病历记录中Tmax前、后72h内是否有病原学诊断为真菌感染，分为真菌感染组（64例）和无真菌感染组（78例），比较Tmax前、后24h内最近一次急性生理学与慢性健康状况评估（APACHE II）评分、序贯器官衰竭评估（SOFA）评分及血红蛋白、白蛋白、白细胞计数、血肌酐、丙氨酸转氨酶、C反应蛋白、血乳酸水平。 比较Tmax前、后72h病原学特点及CRRT6h内降温措施使用情况。通过受试者工作特征曲线建立Tmax预测真菌感染模型并计算最佳预测值（Tp）。以Tmax为零点，记录真菌感染组接受抗真菌治疗的延迟时间，比较真实情况及以Tmax＞Tp即开始抗真菌治疗的理想情况，绘制Kaplan-Meier曲线。以单因素及多因素回归分析验证“合并真菌感染”是否是CRRT6h后高体温的独立危险因素。结果：2组丙氨酸转氨酶水平、CRRT6h后Tmax、病因分布及28d生存率比较，差异有统计学意义（P均＜0.05）。2组病原学特征、细菌种类及病毒感染、降温措施（包括物理降温、非甾体抗炎药降温、激素降温）比较，差异无统计学意义（P均＞0. 05）。Tmax对真菌感染有良好的预测价值（AUC 0.865，95%CI 0.802~0.927，P＜0.001）；计算最佳预测值Tp为38.55℃，敏感度65.6%,特异性94.9%。以Tmax为零点，Tmax＞Tp为标准开始抗真菌治疗可以明显缩短目标患者接受抗真菌药物治疗的延迟时间（P=0.001）。白色念珠菌阳性、热带念珠菌阳性及血流感染为CRRT6h后高体温（Tmax＞Tp）的独立危险因素。结论：真菌病原学阳性（念珠菌属）是CRRT6h后体温峰值（Tmax）＞Tp（38.55℃）的独立危险因素，以此为标准有助于更早识别危重症患者真菌感染。 |
| 英文摘要: |
| Abstract Objective: To investigate whether the high body temperature 6h after continuous renal replacement therapy (CRRT) can help identify patients with severe sepsis at an earlier stage. Methods: A total of 142 hospitalized patients in intensive care unit were collected. Gender, age, body mass index, main diagnosis, and survival status at 28 days were recorded, and peak temperature ( Tmax) after 6-h CRRT was observed. According to the case records, whether the disease was diagnosed as fungal infection in 72h before and after Tmax, the patients were divided into the fungal infection group (64 cases) and the non-fungal infection group (78 cases). The most recent acute physiology and chronic health evaluation (APACHE II score) , sequential organ failure assessment (SOFA), hemoglobin, albumin, white blood cell count, serum creatinine, alanine aminotransferase, C-reactive protein and blood lactic acid levels were compared before and after Tmax for 24h. The etiological characteristics before and after 72h of Tmax and the use of cooling measures within 6h of CRRT were compared. The Tmaxmodel for predicting fungal infection was established by receiver operating characteristic curve and the best predictive value (Tp) was calculated. Taking Tmax as zero point, the delay time of receiving antifungal therapy in the fungal infection group was recorded, the real situation was compared with the ideal situation of starting antifungal therapy with Tmax> Tp, and the Kaplan-Meier curve was drawn. Univariate and multivariate regression analyses were performed to verify whether "co-fungal infection" was an independent risk factor for hyperthermia after 6h of CRRT. Results: There were significant differences in alanine aminotransferase level, Tmax after 6h CRRT, etiological distribution and 28d survival rate between the two groups (all P< 0.05). There was no significant difference in etiological characteristics, bacterial species and viral infection, and cooling measures (including physical cooling, NSAID cooling and hormone cooling) between the two groups (all P> 0.05). Tmaxwas a good predictor of fungal infection (AUC 0.865, 95%CI 0.802-0.927, P< 0.001). The optimal predictive value Tp was 38.55℃, the sensitivity was 65.6%, and the specificity was 94.9%. Starting antifungal therapy with Tmax as zero and Tmax> Tp as the standard could significantly shorten the delay time of receiving antifungal drugs in target patients (P= 0.001). Candida albicans positivity, Candida tropicalis positivity and bloodstream infection were independent risk factors for hyperthermia ( Tmax> Tp) after 6h of CRRT. Conclusion: Positive fungal etiology (Candida) was an independent risk factor for peak body temperature ( Tmax) > Tp (38.55℃) after 6h of CRRT, which was helpful for earlier identification of fungal infection in critically ill patients. |
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