中国呼吸与危重监护杂志

中国呼吸与危重监护杂志

外周血维生素 D 水平在评价危重症患者机械通气撤机结局的临床价值

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目的探讨外周血维生素 D 水平在评价危重症患者机械通气撤机结局的临床价值。方法选择 2014 年 6 月至 2017 年 6 月我院收治的危重症机械通气时间>48 h 患者 130 例为研究对象。收集入院时和自主呼吸测试(SBT)前的血清25-羟基维生素 D3[25(OH)D3]水平,同时记录患者一般临床资料和实验室检查指标。按照撤机结局将患者分为撤机成功组和撤机失败组。采用 Logistic 回归方程分析维生素 D 水平与撤机失败的关系,并利用受试者工作特征(ROC)曲线评估其对撤机失败的预测价值。结果纳入的 130 例患者中,撤机失败 46 例(35.38%);与撤机成功组比较,撤机失败组急性生理学和慢性健康状况评分系统Ⅱ 评分偏高,住重症监护病房时间较长,SBT 前呼吸频率、呼吸浅快指数、C 反应蛋白、N-末端脑钠肽前体、血肌酐均偏高,白蛋白偏低,两组比较差异有统计学意义(均 P<0.05)。撤机失败组入院时、SBT 前 25(OH)D3 水平分级均差于撤机成功组(均 P<0.05);撤机失败组入院时、SBT 前血清 25(OH)D3 水平均低于撤机成功组[入院时:(18.16±4.33)ng/ml 比(21.60±5.25)ng/ml,P<0.05;SBT 前:(13.50±3.52)ng/ml 比(18.61±4.30)ng/ml,P<0.05]。多元 Logistic 回归分析显示入院时、SBT 前 25(OH)D3 缺乏是撤机失败的独立危险因素(OR 值分别为 2.257、2.613,均 P<0.05)。ROC 曲线分析显示入院时、SBT 前 25(OH)D3 水平预测的 ROC 曲线下面积分别为 0.772 和 0.836,敏感性分别为 80.3% 和 85.2%,特异性分别为 69.0% 和 71.0%。结论危重症患者 25(OH)D3 不足或缺乏较为常见,其水平越低则撤机失败风险越高,可能是撤机失败的独立预测因素。

ObjectiveTo investigate the clinical value of peripheral blood vitamin D level in predicting the outcome of weaning from mechanical ventilation in critically ill patients.MethodsA total of 130 critically ill patients who undergoing mechanical ventilation for more than 48 hours in our hospital were recruited from June 2014 to June 2017. Serum 25(OH)D3 was detected on admission and before spontaneous breathing test (SBT) meanwhile general clinical data and laboratory examination indexes were recorded. The cases were divided into a successful weaning group and a failure weaning group according to the outcome of weaning from mechanical ventilation. Logistic regression equation was used to analyze the relationship between vitamin D level and failure weaning, and a receiver operating characteristic (ROC) curve was used to analyze the predictive value for failure weaning.ResultsThere were 46 patients with failure weaning among 130 patients (35.38%). Compared with the successful weaning group, the failure weaning group had significantly higher Acute Physiology and Chronic Health EvaluationⅡ score, longer duration in intensive care unit, higher respiratory rate, higher rapid shallow breathing index, higher C-reactive protein, higher N-terminal prohormone of brain natriuretic peptide, higher serum creatinine, and significantly lower albumin (all P<0.05). 25(OH)D3 level classifications on admission and before SBT in the failure weaning group were worse than those in the successful weaning group (P<0.05). 25(OH)D3 levels of the failure weaning group were lower than those of the successful weaning group [on admission: (18.16±4.33) ng/ml vs. (21.60±5.25) ng/ml, P<0.05; before SBT: (13.50±3.52) ng/mlvs. (18.61±4.30) ng/ml, P<0.05]. Multivariate logistic regression analysis showed that 25(OH)D3 levels on admission and before SBT were independent risk factors for failure weaning (OR values were 2.257 and 2.613, respectively, both P<0.05). ROC curve analysis showed that areas under ROC curve were 0.772 and 0.836, respectively, with sensitivities of 80.3% and 85.2%, specificities of 69.0% and 71.0%, respectively.Conclusions25(OH)D3 deficiency or insufficiency is common in critically ill patients. The lower the level of vitamin D, the higher the risk of failure weaning. So it may be an independent predictor of failure weaning.

关键词: 维生素 D; 25-羟基维生素 D3; 危重症; 机械通气; 撤机失败

Key words: Vitamin D; 25-hydroxy vitamin D3; Critically ill; Mechanical ventilation; Weaning failure

引用本文: 唐荣, 梁建军. 外周血维生素 D 水平在评价危重症患者机械通气撤机结局的临床价值. 中国呼吸与危重监护杂志, 2018, 17(4): 394-399. doi: 10.7507/1671-6205.201711048 复制

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1. Rose L. Strategies for weaning from mechanical ventilation: a state of the art review. Intensive Crit Care Nurs, 2015, 31(4): 189-195.
2. Pu L, Zhu B, Jiang L, et al. Weaning critically ill patients from mechanical ventilation: a prospective cohort study. J Crit Care, 2015, 30(4): 7-13.
3. 王燕, 袁惠敏, 张江蓉, 等. 维生素 D 缺乏对老年重症监护患者预后的影响. 中华老年医学杂志, 2015, 34(2): 155-158.
4. Zhang YP, Wan YD, Sun TW, et al. Association between vitamin D deficiency and mortality in critically ill adult patients: a meta-analysis of cohort studies. Critical Care, 2014, 18(6): 684.
5. Vosoughi N, Kashefi P, Abbasi B, et al. The relationship between Vitamin D, clinical outcomes and mortality rate in ICU patients: a prospective observational study. J Res Med Sci, 2016, 21(5): 75-80.
6. 中华医学会重症医学分会. 机械通气临床应用指南(2006). 中华危重病急救医学, 2007, 19(2): 65-72.
7. Bo Z, Li Z, Li J, et al. Effect of a quality improvement program on weaning from mechanical ventilation: a cluster randomized trial. Intensive Care Med, 2015, 41(10): 1781-1790.
8. Massey K, Dickerson RN, Brown RO. A review of vitamin D deficiency in the critical care population. Pharmacy, 2014, 2(1): 40-49.
9. Tucker A, Ybarra J, Bingham A, et al. American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Standards of Practice for Nutrition Support Pharmacists. Nutr Clin Pract, 2015, 30(1): 139-46.
10. Moraes RB, Friedman G, Wawrzeniak IC, et al. Vitamin D deficiency is independently associated with mortality among critically ill patients. Clinics, 2015, 70(5): 326-332.
11. Chen Z, Luo Z, Zhao X, et al. Association of vitamin D status of septic patients in intensive care units with altered procalcitonin levels and mortality. J Clin Endocrinol Metab, 2015, 100(2): 516-523.
12. Quraishi SA, Mccarthy C, Blum L, et al. Plasma 25-hydroxy vitamin D levels at initiation of care and duration of mechanical ventilation in critically ill surgical patients. JPEN J Parenter Enteral Nutr, 2016, 97(2): 262-269.
13. Amrein K, Schnedl C, Holl A, et al. Effect of high-dose vitamin D3 on hospital length of stay in critically ill patients with vitamin D deficiency: the VITdAL-ICU randomized clinical trial. JAMA, 2014, 312(15): 1520-1530.
14. 杨家来, 徐俊, 张泓. 维生素 D 对脂多糖致急性肺损伤大鼠肺组织血管紧张素转化酶 2 和维生素 D 受体表达水平的影响. 中华急诊医学杂志, 2016, 25(12): 1284-1289.
15. Shi Y, Liu T, Jianhua FU, et al. Vitamin D/VDR signaling attenuates lipopolysaccharide-induced acute lung injury by maintaining the integrity of the pulmonary epithelial barrier. Mol Med Rep, 2016, 13(2): 1186.
16. Thickett DR, Moromizato T, Litonjua AA, et al. Association between prehospital vitamin D status and incident acute respiratory failure in critically ill patients: a retrospective cohort study. BMJ Open Respir Res, 2015, 2(1): e000074.
17. Dancer R C, Parekh D, Lax S, et al. Vitamin D deficiency contributes directly to the acute respiratory distress syndrome (ARDS). Thorax, 2015, 70(7): 617-24.
18. Scheiermann J, Klinman DM. Suppressive oligonucleotides inhibit inflammation in a murine model of mechanical ventilator induced lung injury. J Thorac Dis, 2016, 8(9): 2434-2443.
19. 杨依依, 姚尚龙, 尚游. 呼吸机相关性肺损伤发病机制研究新进展. 中华危重病急救医学, 2016, 28(9): 861-864.
20. Shelhamer MC, Rowan MP, Cancio LC, et al. Elevations in inflammatory cytokines are associated with poor outcomes in mechanically ventilated burn patients. J Trauma Acute Care Surg, 2015, 79(3): 431-436.
21. Jiang M, Song JJ, Guo XL, et al. Airway humidification reduces the inflammatory response during mechanical ventilation. Respir Care, 2015, 60(12): 1720-1728.
22. Larose TL, Brumpton BM, Langhammer A, et al. Serum 25-hydroxyvitamin D level, smoking and lung function in adults: the HUNT Study. Eur Respir J, 2015, 46(2): 355-363.
23. Kim HJ, Jang JG, Hong KS, et al. Relationship between serum vitamin D concentrations and clinical outcome of community-acquired pneumonia. Int J Tuberc Lung Dis, 2015, 19(6): 729-734.
24. 李山峰, 吴璟奕, 邹雅茹,等. 氮末端脑钠肽前体对机械通气撤机的预测价值. 中华急诊医学杂志, 2016, 25(3): 334-337.
25. 王慧, 马明, 陈德生, 等. 左室舒张功能不全对机械通气撤机结果的预测价值. 中华危重病急救医学, 2017, 29(5): 413-418.
26. 秦少博, 王春, 李萍,等. 血清 25-羟维生素 D 与左心室舒张功能. 中华老年医学杂志, 2015, 34(5): 574-577.
27. Hansen D, Rasmussen K, Rasmussen LM, et al. The influence of vitamin D analogs on calcification modulators, N-terminal pro-B-type natriuretic peptide and inflammatory markers in hemodialysis patients: a randomized crossover study. BMC Nephrol, 2014, 15: 130.