Combined APACH 栻 score and arterial blood lactate clearance rate to predict the prognosis of ARDS patients

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1 656 Asin Pcific Journl of Tropicl Medicine (2012) Contents lists vilble t ScienceDirect Asin Pcific Journl of Tropicl Medicine journl homepge: Document heding doi: Combined APACH 栻 score nd rteril blood lctte clernce rte to predict the prognosis of ARDS ptients Wen-Hui Wu 1*, Yun-Yun Niu 2*, Chng-Rn Zhng 2, Long-Bin Xio 1, Hui-Sho Ye 1, De-Mo Pn 2, Min Zeng 2 1 Deprtment of Gstrointestinl Surgery, the First Affilited Hospitl, Sun Yt-sen University, Gungzhou , Chin 2 Deprtment of MICU, the First Affilited Hospitl, Sun Yt-sen University, Gungzhou , Chin ARTICLE INFO Article history: Received 10 Mrch 2012 Received in revised form 15 My 2012 Accepted 15 July 2012 Avilble online 20 August 2012 Keywords: Acute respirtory distress syndrome APACHE 栻 score Arteril blood lctte clernce rte PO 2 /FiO 2 vlue Alveolr-rteril oxygen difference ABSTRACT Objective: To explore the esily pplicble indictors of prcticl vlue to evlute the prognosis of cute respirtory distress syndrome (ARDS). Methods: Blood nd biochemicl tests nd bloodgs nlyses were performed upon entry into the ICUs, 12 h, 24 h, 48 h nd 72 h fter tht in 72 ARDS ptients (who were dmitted to the ICUs of our hospitl from Jnury 2000 to December 2009). Then APACHE 栻 scores were chieved by combining relevnt physiologicl prmeters nd lbortory results. Results: There ws sttisticl difference between the deth group nd survivl group t different time points upon entering the ICUs in terms of APACHE 栻 score, lveolr-rteril oxygen difference nd rteril blood lctte clernce rte. PO 2 /FiO 2 vlues were recorded to be sttisticlly different between the deth group nd survivl group 24 h, 48 h nd 72 h, respectively fter entry into the ICUs. In ddition, registered liner regression existed between APACHE 栻 score, lveolr-rteril oxygen difference or PO 2 /FiO 2 vlue nd time. APACHE 栻 score 24 h nd 72 h fter entering ICUs predicted mortlity with n re under the ROC curve (AUC) stnding respectively t nd Arteril blood lctte clernce rte 12 h, 24 h, 48 h nd 72 h fter entering ICUs predicted mortlity with n re under the ROC curve (AUC) t 0.918, 0.918, nd 0.991, respectively. Conclusions: APACHE 栻 score pplied in combintion with rteril blood lctte clernce rte is of clinicl significnce in ssessing the prognosis of ARDS ptients. 1. Introduction In recent yers, studies on the prognosis of criticl diseses hve constituted n importnt re of criticl cre medicine. It hs helped improve medicl techniques nd service, nd hs gretly reduced medicl risks. Among them, the cute respirtory distress syndrome (ARDS), which ws described originlly in Lncet in 1967 by Ashbugh DG nd coworkers, hs remined focus nd difficulty in criticl cre medicine[1]. ARDS is life thretening respirtory filure due to lung injury from vriety of precipitnts. Pthologiclly, ARDS is chrcterized by *Corresponding uthor: Chng-Rn Zhng, Deprtment of MICU, the First Affilited Hospitl, Sun Yt-sen University, Gungzhou , Chin. E-mil: chngrnzhng@126.com Foundtion project: The study is sponsored by Gungdong Science nd Technology Project (No: 2009B ). diffuse lveolr dmge, lveolr cpillry lekge, nd protein rich pulmonry oedem leding to the clinicl mnifesttion of poor lung complince, severe hypoxemi, nd bilterl infiltrtes on the chest rdiogrph. It develops nd progresses rpidly, nd its prognosis is bd[2]. Through met-nlysis of clinicl study literture from 1967 to 1994 in the interntionl medicl community, the mortlity styed round 50% for ARDS ptients[3]. However, the ARDS cuses 30% to 70% totl mortlity, which ws ssocited with primry illness nd illness severity. Sepsis nd spirtion pneumoni hve been ssocited with higher motility, wheres ptients with lung injury resulting from mjor trum hve lower risk of deth. Direct lung injury hs lso been ssocited with greter mortlity[4]. Elderly ptients (over 65 yers old) with ARDS hve poor prognosis[5]. There were 16% ptients die only

2 Wen-Hui Wu et l./asin Pcific Journl of Tropicl Medicine (2012) of respirtory filure, while 49% ptients die of the multiple orgn dysfunction syndrome[6]. Most of ARDS survivors cn recover completely, but some of them hs lung-fibrogenesis residue[7]. ARDS cn ffect mny groups of ptients nd is ssocited with number of pulmonry nd/or extr pulmonry fctors, which cn impct ptient s prognosis[8]. Thus, it is necessry to build specific criterion or to find some biochemicl mrkers to predict ARDS prognosis. APACHE 栻 scoring system ws regrded s superior biochemicl mrker to evlute the outcomes of criticlly ill ptients nd ill severity[9-14]. Lctte clernce, surrogte for the mgnitude nd durtion of globl tissue hypoxi, is used dignosticlly, therpeuticlly nd prognosticlly. Recent severl studies hve identified tht rteril lctte clernce is significntly ssocited with septic shock severity[15-17], nd mesurement of serum rteril lctte clernce is helpful to evlute pressure of globl tissue perfusion nd to predict ptients prognosis in serving sepsis nd septic shock[18-20]. In the current study, we explored the esily pplicble biochemicl mrkers of prcticl vlue to evlute ARDS prognosis through observing cute physiologicl prmeters, APACHE 栻 score, lveolrrteril oxygen difference, PO 2 /FiO 2 nd rteril blood lctte clernce rte. 2. Mterils nd methods 2.1. Dignostic criteri The dignostic criteri for ARDS (formulted in 1999 by the chpter of Respirtory Diseses, Chinese Medicl Assocition): (i) high risk fctors for ARDS; (ii) cute onset with tchypne nd (or) respirtory distress; (iii) hypoxemi: PO 2 /FiO 2 200; (iv) chest X-ry: infiltrtion shdow observed in both lungs; (v) PAWP 18 mmhg or crdiogenic pulmonry edem being cliniclly excluded Subjects 72 ARDS ptients, who were dmitted to the ICUs of our hospitl from Jnury 2000 to December 2009, were registered s the study subjects, mong whom 49 died t the hospitl, 8 were dischrged ginst physicin dvice nd 15 witnessed improvement in their conditions. The 8 dischrges ginst medicl dvice were counted s subjects in the deth group of this study, so there were 57 cses in the deth group, which included 39 mles nd 18 femles with the verge ge stnding t 50.75±14.39, nd 15 in the survivl group, which ws comprised of 10 mles nd five femles with the verge ge t 49.53± Anlysis methods Blood nd biochemicl tests nd blood-gs nlyses were performed for ll subjects upon entry into the ICUs, 12 h, 24 h, 48 h nd 72 h fter tht. Besides, APACHE 栻 scores were chieved by combining relevnt physiologicl prmeters nd lbortory results Sttistics All dt chieved were expressed in the mnner of (±SD) for sttisticl nlysis by the ppliction of SPSS11.0, the softwre for running t-test, Kruskl-Wllis test, liner regression nlysis nd ROC nlysis. 3. Results 3.1. APACHE 栻 score The comprison of APACHE 栻 score (t-test) chieved t different time frmes between the two groups ws of sttisticl difference (Tble 1). In ddition, APACHE 栻 score rn in model of liner regression over time(liner regression nlysis, R 2 =0.85) in the deth group, mening tht APACHE 栻 score showed no noticeble improvement or even presented significntly incresing tendency over time in the deth group despite of ctive tretments (Figure 1). APACHE 栻 score y=0.06 7x R 2 = y= x R 2 = Time (hour) Survivl group Deth group Liner (Sirvivl group) Liner (Deth group) Figure 1. Liner regression drwn from APACHE 栻 score over time in the two groups Alveolr-rteril oxygen difference (A-O 2 ) The comprison of A-O 2 (t-test) chieved t different time frmes between the two groups ws of sttisticl difference (Tble 2). In ddition, A-O 2 vlue rn in model of liner regression over time (liner regression nlysis, R 2 =0.98) in the deth group, mening tht A-O 2 vlue showed no noticeble improvement or even presented significntly

3 658 Wen-Hui Wu et l./asin Pcific Journl of Tropicl Medicine (2012) incresing tendency over time in the deth group despite of ctive tretments PO 2 /FiO 2 vlue were nd 0.955, respectively t 24 h nd 72 h upon entry into the ICUs, which suggested tht it ws of noticeble significnce for the mortlity prediction of ARDS ptients (Figure 2). The comprison of PO 2 /FiO 2 vlue (t-test) chieved t the time points of 24 h, 48 h nd 72 h, respectively, between the two groups ws of sttisticl difference (Tble 3). In ddition, PO 2 /FiO 2 vlue rn in model of liner regression over time (liner regression nlysis, R 2 =0.95) in the deth group, mening tht PO 2 /FiO 2 showed no noticeble improvement or even presented significntly decresing tendency over time in the deth group despite of ctive tretments Arteril blood lctte clernce rte Sensitivity Source of the curve APACHE 0 APACHE 12 APACHE 24 APACHE 48 APACHE 72 The determintion of rteril blood lctte level ws strted only from the yer of 2007 t our hospitl, thus we hve only collected such dt bout 27 ptients, consisting of 22 in the deth group nd 5 in the survivl group. The comprison of rteril blood lctte clernce rte (Kruskl-Wllis test) chieved t ll the time frmes between the two groups ws of sttisticl significence (Tble 4) ROC Curve nlysis of APACHE 栻 score Ares under the ROC curve drwn from APACHE 栻 scores specificity Figure 2. ROC Curve nlysis of APACHE 栻 score ROC Curve nlysis of A-O2 nd PO 2 /FiO 2 Ares under the ROC curve of A-O 2 nd PO 2 /FiO 2 vlue fter ptients entering the ICUs rnged from to nd from to 0.351, respectively. Such results demonstrted tht A-O 2 nd PO 2 /FiO 2, s independent Tble 1 Comprison of APACHE 栻 score between the 2 groups. Group Time of dmission to hospitl 12 h 24 h 48 h 72 h Survivl group 依 依 依 依 依 4.65 Deth group 依 依 依 依 依 7.76 P<0.05 vs. deth group. Tble 2 Comprison of A-O 2 vlue between the 2 groups. Group Time of dmission to hospitl 12 h 24 h 48 h 72 h Survivl group 依 依 依 依 依 Deth group 依 依 依 依 依 P<0.05 vs. deth group. Tble 3 Comprison of PO 2 /FiO 2 between the 2 groups. Group Time of dmission to hospitl 12 h 24 h 48 h 72 h Survivl group 依 依 依 依 依 Deth group 依 依 依 依 依 P<0.05 vs. deth group. Tble 4 Comprison of rteril blood lctte clernce rte (%) between the 2 groups. Group 12 h 24 h 48 h 72 h Survivl group 依 依 依 依 Deth group 依 依 依 依 P<0.05 vs. deth group.

4 Wen-Hui Wu et l./asin Pcific Journl of Tropicl Medicine (2012) fctors, were neither of notble significnce for the mortlity prediction of ARDS ptients ROC Curve nlysis of rteril blood lctte clernce rte Ares under the ROC curve of rteril blood lctte clernce rte 12 h, 24 h, 48 h nd 72 h fter ptients entering the ICUs were 0.918, 0.918, nd 0.991, respectively. Such results demonstrted tht A-O 2 nd PO 2 /FiO 2 were of mrked significnce for the mortlity prediction of ARDS ptients (Figure 3). Sensitivity Source of the curve LAC 12 ALC 24 LAC 48 LCA specificity Figure 3. ROC Curve nlysis of rteril blood lctte clernce rte. 4. Discussion ARDS is minly chrcterized by lveolr-cpillry injury, which is the mnifesttion of cute respirtory filure[3,4,8]. The difficulty in its tretment lies in the refrctory hypoxemi. PO 2 /FiO 2 vlue, mjor indictor for the oxygenting cpbility of lung, hs become requisite for the dignosis of ARDS. However, PO 2 cnnot serve s n indictor of tissue cells demnd nd utiliztion of oxygen nd is subject to the influence of mny fctors like the concentrtion of the oxygen inhled, crdic output nd oxygen consumption, etc. A-O 2 represents the difference between the oxygen prtil pressure in the lung nd rteril blood, which is relted to rteriovenous ntomicl shunt, ventiltion/perfusion imblnce nd dysfunction of lveolrcpillry diffusion brriers, thus bering better embodiment of pulmonry ventiltion function[21]. The current study suggests tht the difference is of sttisticl significnce between the two groups in terms of A-O 2 t ll the five time points. No significntly difference could be found in PO 2 / FiO 2 vlue during the first 24 h upon ptients entry into the ICUs, which my be the result of high concentrtion of inhled oxygen nd unstble hemodynmic. It demonstrtes tht A-O 2 nd PO 2 /FiO 2, s independent fctors, is neither of notble vlue for the prognosis of ARDS ptients, indicting tht poor oxygention constitutes risk fctor of poor prognosis but not the only one. APACHE 栻 scoring system covers comprehensive multitude of fctors like respirtion, hert rte, blood pressure, consciousness, tissue perfusion nd primry illnesses. It hs been commonly pplied both t home nd brod in the severity nd prognosis ssessment of mny criticl illnesses[9-11]. A vriety of studies hve proven tht there exists the positive correltion between the APACHE 栻 sore nd ptients mortlity[11-14]. The results showed tht the difference between the two groups ws sttisticlly significnt t ll the five time points nd the score in the deth group presents positive correltion with time, which mens tht the score rises ccordingly over time. In ddition, the APACHE 栻 scores chieved respectively t 24h nd 72h fter entering the ICUs hve been discovered to be of notble significnce in ptients prognosis of mortlity (mesured by mens of res under ROC curve, AZ>0.9); the res under ROC curve drwn from APACHE 栻 scores were lso running round 0.9 t other time points we set. To sum up, APACHE 栻 score cn reflect ptients disese severity nd their response to tretments in timely nd ccurte mnner[21-23]. Furthermore, s ARDS tkes its course in ptients, lctte ccumultes in ptients blood strem[24]. This study lso shows us tht sttisticl difference cn be observed in terms of ptients rteril lctte clernce rte over time between the two groups nd the corresponding res under ROC curve (AZ) were ll higher thn 0.9, indicting tht this fctor cn be vlidly used to predict ptient s mortlity. As result, dynmic monitoring of blood lctte clernce rte cn be n ccurte reflection of tissue perfusion nd blood oxygention level fter tretment, nd thus it helps to mke n effective nd objective ssessment of ptients prognosis[18-20,25]. The prognosis cn be more ccurtely ssessed s long s dynmic monitoring of blood lctte clernce rte is performed in combintion with APACHE 栻 scoring. Conflict of interest sttement We declre tht we hve no conflict of interest. Acknowledgements The study is sponsored by Gungdong Science nd Technology Project (No: 2009B ).

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