Construction and validation of a nomogram prediction model for the progression to chronic critical illness in elderly patients with septic shock

doi:10.11958/20220519

Abstract

Abstract:

Objective To explore the related risk factors of the progression to chronic critical illness in elderly patients with septic shock, and to construct and verify a nomogram model to predict the risk of chronic critical illness based on the results. Methods A total of 252 patients with septic shock aged ≥ 65 years were enrolled in this study as the training set, and patients were divided into the chronic critical illness group (n=86) and the non-chronic critical illness group (n=166) according to whether they progressed to chronic critical illness. The data of general information, Charlson comorbidity index (CCI) score, sequential organ failure assessment (SOFA) score, intra-abdominal pressure (IAP), proportion of continuous renal replacement therapy (CRRT), mechanical ventilation (MV), serum levels of lactate (Lac) and procalcitonin (PCT) within 24 hours of entering EICU were analyzed in the two groups of patients. The independent risk factors for the progression of chronic critical illness in elderly patients with septic shock were identified by multivariate Logistic regression analysis, so as to establish a nomogram model based on the results to predict the risk of chronic critical illness. The calibration and discrimination of the model were evaluated by calibration curve and receiver operating characteristic (ROC) curve, respectively. The clinical practicability of the model was determined by decision curve analysis (DCA). In addition, 74 elderly patients with septic shock were selected as the verification set for external verification of the prediction model. Results The incidence of chronic critical illness in elderly patients with septic shock was 34.13% in the training set. Compared with the non-chronic critical illness group, the proportion of age≥75 years, CCI score≥3 points, MV, CRRT, SOFA score and IAP levels were higher in the chronic critical illness group (P<0.05). Multivariate Logistic regression analysis showed that CCI score≥3 points, elevated SOFA score, elevated IAP, MV and CRRT were independent risk factors for the progression to chronic critical illness in elderly patients with septic shock (P<0.05). The calibration curve showed that the nomogram prediction model constructed by the above five factors displayed good calibration in the training set and the verification set with the predicted probability closely to the actual probability. The ROC curve showed that the model displayed good discrimination in the training set and the verification set. The areas under the curve of predicting risks of chronic critical illness were 0.806 (95%CI: 0.750-0.862) and 0.802 (95%CI: 0.697-0.908), respectively. And the DCA curve demonstrated that the model had good clinical practicability. Conclusion The nomogram model based on CCI score, SOFA score, IAP, MV and CRRT shows good predicting performance in predicting the risk of progression to chronic critical illness in elderly patients with septic shock.

Key words: sepsis, nomograms, Logistic models, aged, risk assessment, chronic critical illness

CLC Number:

R515.3

Figures/Tables 6

References 17

[1]	KONG G, LIN K, HU Y. Using machine learning methods to predict in-hospital mortality of sepsis patients in the ICU[J]. BMC Med Inform Decis Mak, 2020, 20(1):251. doi:10.1186/s12911-020-01271-2.
[2]	李思澄, 吴婕, 于湘友, 等. 中国慢性危重症及外科相关慢性危重症的多中心横断面研究[J]. 中华胃肠外科杂志, 2019, 22(11):1027-1033.
	LI S C, WU J, YU X Y, et al. A multicenter cross-sectional study on chronic critical illness and surgery-related chronic critical illness in China[J]. Chin J Gastrointest Surg, 2019, 22(11):1027-1033. doi:10.3760/cma.j.issn.1671-0274.2019.11.005.
[3]	STORTZ J A, MURPHY T J, RAYMOND S L, et al. Evidence for persistent immune suppression in patients who develop chronic critical illness after sepsis[J]. Shock, 2018, 49(3):249-258. doi:10.1097/SHK.0000000000000981.
[4]	DARDEN D B, BRAKENRIDGE S C, EFRON P A, et al. Biomarker evidence of the persistent inflammation,immunosuppression and catabolism syndrome(PICS) in chronic critical illness(CCI)after surgical sepsis[J]. Ann Surg, 2021, 274(4):664-673. doi:10.1097/SLA.0000000000005067.
[5]	刘凯凤, 张镇, 张郑平, 等. 重症肺炎患者早期行机械通气的列线图预测模型构建及验证[J]. 天津医药, 2021, 49(3):320-324.
	LIU K F, ZHANG Z, ZHANG Z P, et al. Construction and verification of a prediction nomogram for early mechanical ventilation in patients with severe pneumonia[J]. Tianjin Med J, 2021, 49(3):320-324. doi:10.11958/20201075.
[6]	胡明, 杨云杰, 赵振华, 等. 预测输尿管结石进展为尿脓毒血症的列线图模型的外部验证[J]. 天津医药, 2019, 47(9):975-978.
	HU M, YANG Y J, ZHAO Z H, et al. External validation of nomogram for predicting the probability of urosepsis progressed from ureteral calculi[J]. Tianjin Med J, 2019, 47(9):975-978. doi:10.11958/20182210.
[7]	RHODES A, EVANS L E, ALHAZZANI W, et al. Surviving sepsis campaign:international guidelines for management of sepsis and septicshock:2016[J]. Intensive Care Med, 2017, 43(3):304-377. doi:10.1007/s00134-017-4683-6.
[8]	STORTZ J A, MIRA J C, RAYMOND S L, et al. Benchmarking clinical outcomes and the immunocatabolic phenotype of chronic critical illness after sepsis in surgical intensive care unit patients[J]. J Trauma Acute Care Surg, 2018, 84(2):342-349. doi:10.1097/TA.0000000000001758.
[9]	BRAKENRIDGE S C, EFRON P A, COX M C, et al. Current epidemiology of surgical sepsis:discordance between inpatient mortality and 1-year outcomes[J]. Ann Surg, 2019, 270(3):502-510. doi:10.1097/SLA.0000000000003458.
[10]	MARCHIONI A, TONELLI R, SDANGANELLI A, et al. Prevalence and development of chronic critical illness in acute patients admitted to a respiratory intensive care setting[J]. Pulmonology, 2020, 26(3):151-158. doi:10.1016/j.pulmoe.2019. 09.006.
[11]	EFRON P A, MOHR A M, BIHORAC A, et al. Persistent inflammation,immunosuppression,and catabolism and the development of chronic critical illness after surgery[J]. Surgery, 2018, 164(2):178-184. doi:10.1016/j.surg.2018.04.011.
[12]	张晓勤, 王茜, 罗晓秀, 等. 查尔森合并症指数及序贯器官衰竭评分联合降钙素原对脓毒症患者预后的评估价值[J]. 中华危重病急救医学, 2019, 31(11):1335-1339.
	ZHANG X Q, WANG Q, LUO X X, et al. Prognostic value of Charlson weighted index of comorbidities combined with sequential organ failure assessment score and procalcitonin in patients with sepsis[J]. Chin Crit Care Med, 2019, 31(11):1335-1339. doi:10.3760/cma.j.issn.2095-4352. 2019.11.005.
[13]	凤尔稳. 脓毒症高风险评分对脓毒症患者死亡风险的预测价值[J]. 天津医药, 2020, 48(8):773-776.
	FENG E W. The predictive values of high risk score of sepsis for mortality risks of septic patients[J]. Tianjin Med J, 2020, 48(8):773-776. doi:10.11958/20192876.
[14]	陈亮, 曹日进, 王金莉, 等. 脓毒症继发慢性重症患者临床特征分析[J]. 中华危重病急救医学, 2021, 33(12):1414-1417.
	CHEN L, CAO R J, WANG J L, et al. Analysis of clinical characteristics of patients with chronic critical illness after sepsis[J]. Chin Crit Care Med, 2021, 33(12):1414-1417. doi:10.3760/cma.j.cn121430-20210706-01014.
[15]	姚红林, 薛阳阳, 江方正, 等. 腹腔压力分级管理在慢重症病人肠内营养实施中的效果与评价[J]. 肠外与肠内营养, 2020, 27(2):100-103.
	YAO H L, XUE Y Y, JIANG F Z, et al. Effects of intra-abdominal pressure-directed management on enteral nutrition therapy for patients with chronic critical illness[J]. Parenteral & Enteral Nutrition, 2020, 27(2):100-103. doi:10.16151/j.1007-810x.2020.02.008.
[16]	OHBE H, MATSUI H, FUSHIMI K, et al. Epidemiology of chronic critical illness in Japan:a nationwide inpatient database study[J]. Crit Care Med, 2021, 49(1):70-78. doi:10.1097/CCM. 0000000000004723.
[17]	BAGSHAW S M, STELFOX H T, IWASHYNA T J, et al. Timing of onset of persistent critical illness:a multi-centre retrospective cohort study[J]. Intensive Care Med, 2018, 44(1):2134-2144. doi:10.1007/s00134-018-5440-1.

组别		n	年龄≥75岁		男性		CCI评分≥3分		BMI（kg/m²）							感染部位							CRRT
组别		n	年龄≥75岁		男性		CCI评分≥3分		<24			24~27.9		≥28.0		肺部		泌尿系		腹腔		其他	CRRT
非慢重症组		166	90（54.2）		91（54.8）		40（24.1）		63（38.0）			79（45.6）		24（14.5）		64（38.6）		57（34.3）		37（22.3）		8（4.8）	58（35.0）
慢重症组		86	58（67.4）		52（60.5）		46（53.5）		36（41.9）			35（40.7）		15（17.4）		30（34.9）		25（29.1）		26（30.2）		5（5.8）	42（53.5）
χ²			4.088^＊		0.736		21.770^＊＊		1.141							2.226							4.571^＊
组别	MV			Lac≥4 mmol/L		PCT（μg/L）							SOFA评分（分）					IAP（mmHg）
组别	MV			Lac≥4 mmol/L		<2		2~10		>10			2~5		6~10		>10	≤15	16~20		21~25			>25
非慢重症组	40（24.1）			79（47.6）		39（23.5）		100（60.2）			27（16.3）		96（57.8）		60（36.1）		10（6.0）	47（28.3）	51（30.7）		39（23.5）			29（17.5）
慢重症组	32（37.2）			48（55.8）		13（15.1）		54（62.8）			19（22.1）		24（27.9）		40（46.5）		22（25.6）	11（12.8）	13（15.1）		32（37.2）			30（34.9）
χ²	4.773^＊			1.533		3.041							29.251^＊＊					22.484^＊＊

组别		n	年龄≥75岁		男性		CCI评分≥3分		BMI（kg/m²）							感染部位							CRRT
组别		n	年龄≥75岁		男性		CCI评分≥3分		<24			24~27.9		≥28.0		肺部		泌尿系		腹腔		其他	CRRT
非慢重症组		166	90（54.2）		91（54.8）		40（24.1）		63（38.0）			79（45.6）		24（14.5）		64（38.6）		57（34.3）		37（22.3）		8（4.8）	58（35.0）
慢重症组		86	58（67.4）		52（60.5）		46（53.5）		36（41.9）			35（40.7）		15（17.4）		30（34.9）		25（29.1）		26（30.2）		5（5.8）	42（53.5）
χ²			4.088^＊		0.736		21.770^＊＊		1.141							2.226							4.571^＊
组别	MV			Lac≥4 mmol/L		PCT（μg/L）							SOFA评分（分）					IAP（mmHg）
组别	MV			Lac≥4 mmol/L		<2		2~10		>10			2~5		6~10		>10	≤15	16~20		21~25			>25
非慢重症组	40（24.1）			79（47.6）		39（23.5）		100（60.2）			27（16.3）		96（57.8）		60（36.1）		10（6.0）	47（28.3）	51（30.7）		39（23.5）			29（17.5）
慢重症组	32（37.2）			48（55.8）		13（15.1）		54（62.8）			19（22.1）		24（27.9）		40（46.5）		22（25.6）	11（12.8）	13（15.1）		32（37.2）			30（34.9）
χ²	4.773^＊			1.533		3.041							29.251^＊＊					22.484^＊＊

指标	β	SE	Wald χ²	P	OR（95%CI）
年龄	0.376	0.350	1.153	0.283	1.456（0.733~2.890）
CCI评分	1.062	0.337	9.908	0.002	2.891（1.493~5.600）
SOFA评分			17.039	<0.001
6~10分	0.737	0.357	4.261	0.039	2.089（1.038~4.205）
>10分	2.083	0.509	16.727	<0.001	8.026（2.958~21.776）
IAP			19.685	<0.001
16~20 mmHg	0.332	0.547	0.368	0.544	1.393（0.477~4.074）
21~25 mmHg	1.542	0.505	9.333	0.002	4.673（1.738~12.565）
>25 mmHg	1.817	0.513	12.561	<0.001	6.155（2.253~16.816）
MV	0.734	0.348	4.459	0.035	2.083（1.054~4.116）
CRRT	0.719	0.321	5.007	0.025	2.053（1.093~3.854）
常数项	-2.735	0.569	23.094	<0.001	0.031

指标	β	SE	Wald χ²	P	OR（95%CI）
年龄	0.376	0.350	1.153	0.283	1.456（0.733~2.890）
CCI评分	1.062	0.337	9.908	0.002	2.891（1.493~5.600）
SOFA评分			17.039	<0.001
6~10分	0.737	0.357	4.261	0.039	2.089（1.038~4.205）
>10分	2.083	0.509	16.727	<0.001	8.026（2.958~21.776）
IAP			19.685	<0.001
16~20 mmHg	0.332	0.547	0.368	0.544	1.393（0.477~4.074）
21~25 mmHg	1.542	0.505	9.333	0.002	4.673（1.738~12.565）
>25 mmHg	1.817	0.513	12.561	<0.001	6.155（2.253~16.816）
MV	0.734	0.348	4.459	0.035	2.083（1.054~4.116）
CRRT	0.719	0.321	5.007	0.025	2.053（1.093~3.854）
常数项	-2.735	0.569	23.094	<0.001	0.031