中华急诊医学杂志  2016, Vol. 25 Issue (10): 1272-1277
重症患者离子钙水平对预后的影响
夏维, 严洁, 毛文君     
214023 江苏省无锡,南京医科大学附属无锡市人民医院重症医学科(夏维、严洁),胸外科(毛文君)
摘要: 目的 探讨重症监护病房(ICU)重症患者钙代谢异常的发生情况以及离子钙水平对预后的影响。 方法 采用单中心前瞻性观察性研究,选择2013年1月至2015年1月入住无锡市人民医院综合性ICU的重症患者进行筛选,所有入选的患者入ICU后24 h内血标本送检,测离子钙水平记为iCa,按iCa水平进行分组:iCa<1.15 mmol/L纳入低iCa组;iCa>1.25 mmol/L纳入高iCa组;1.15 mmol/L≤iCa≤1.25 mmol/L纳入正常iCa组。统计患者的性别、年龄、手术史、既往病史、入ICU诊断、机械通气时间、ICU住院时间以及转归等信息并计算入ICU24 h内的序贯器官衰竭评分(SOFA)和急性生理学与慢性健康状况评分系统Ⅱ(APACHE Ⅱ)评分。采用Logistic回归分析筛选重症患者死亡的危险因素;采用Kaplan-Meier生存分析,按iCa水平分层,绘制14 d生存曲线,采用log-rank检验比较低iCa组和正常iCa组的累计生存率。 结果 共纳入重症患者368例,其中正常iCa组117例,低iCa组247例,高iCa组4例。正常iCa组以神经系统病变最多见(21.37%),低iCa组以脓毒症最多见(21.46%),高iCa组以肿瘤患者最多见(50%)。低iCa组脓毒症患者(21.46%)多于正常iCa组(10.26%),高iCa组无脓毒症患者,组间差异具有统计学意义(P=0.021)。正常iCa组肿瘤患者(1.71%)明显少于高iCa组(50%)和低iCa组(8.1%),差异具有统计学意义(P=0.002)。低iCa组较正常iCa组有更多患者合并慢性肾功能不全(P=0.042)。两组性别、年龄、血钠、血钾、血氯水平、APACHE Ⅱ评分差异无统计学意义(P>0.05),但低iCa组SOFA评分(P=0.039)和14 d病死率(P=0.035)更高,机械通气时间(P=0.049)和ICU住院天数(P=0.012)也更长。根据多因素Logistic回归分析显示,iCa水平(OR=2.352, 95%CI: 1.039~4.023, P=0.041)和APACHE Ⅱ评分(OR=1.214, 95%CI: 1.067~1.285, P=0.002)为影响ICU重症患者14 d内死亡的独立危险因素。按iCa水平分层绘制Kaplan-Meier生存曲线,低iCa组14 d累计生存率显著低于正常iCa组,差异有统计学意义(P=0.037)。 结论 离子钙水平与ICU重症患者病死率密切相关,临床应重视重症患者低钙血症的发生。
关键词: 重症患者     前瞻性研究     离子钙     低钙血症     SOFA评分     APACHE Ⅱ评分     回归分析     生存分析     预后    
The influence of ionized calcium on the prognosis of critically ill patients
Xia Wei, Yan Jie, Mao Wenjun     
Department of Intensive Care Unit, Affiliated Wuxi People's Hospital, Nanjing Medical University, Wuxi 214023, China(Xia Wei, Yan Jie); Department of Thoracic Surgery, Affiliated Wuxi People' s Hospital, Nanjing Medical University Wuxi 214023, China(Mao WJ)
*Corresponding author: Mao Wenjun, Email:maowenjun1@126.com.
Abstract: Objective To investigate the incidence of ionized hypocalcemia and the effect of ionized calcium (iCa) on the prognosis of critically ill patients in intensive care unit (ICU). Methods Adult patients admitted to ICU from January 2013 to January 2015 were enrolled for prospective observation. Patients were selected to exclude the ineligible ones. All selected patients were monitored for iCa levels within 24 hours after ICU admission, and they were divided into three groups: normo-iCa group (iCa levels < 1.15mmol/L), hypo-iCa group (1.15 mmol/L≤iCa levels≤1.25 mmol/L), hyper-iCa group (iCa > 1.25 mmol/L). Enormous data from every patient including demographics, past history about disease contracted and surgical intervention, laboratory findings, duration of mechanical ventilation, length of ICU stay and outcomes were recorded.The acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score and sequential organ failure assessment (SOFA) score during the first 24 hours after ICU admission were calculated. The risk factors for the death in critically ill patients were postulated by logistic regression analysis. Kaplan-Meier survival estimator was used to draw the 14-day survival curve, and the survival rate was compared between normo-iCa group and hypo-iCa group by log-rank test. Results Atotal of 368 critically ill patients were enrolled and 117 of them were classified into normo-iCa group, 247 into hypo-iCa group, and 4 into hyper-iCa group. As to the nature of various diseases giving different kinds of biochemical impacts on patients, patients in normo-iCa group were mainly consisted of patients with nervous system diseases (21.37%), hypo-iCa group patients were dominant in patients with sepsis (21.46%), and hyper-iCa was often found in patients with tumor (50%). The proportion of patients with sepsis was significantly greater in the hypo-iCa group (21.46%) compared with that of normo-iCa group (10.26%), and there was no sepsis patient found in hyper-iCa group, and there were statistically significant differences in iCa among the three groups (P=0.021). The proportion of patients with tumor was significantly lower in the normo-iCa group (1.71%) compared with that of hypo-iCa group (8.1%) and hyper-iCa group (50%), and there were statistically significant differences among the three groups (P=0.002). There were more patients with chronic renal failure in hypo-iCa group than those in normo-iCa group (P=0.042). Compared with the normo-iCa group, the patients of hypo-iCa group were found to have higher SOFA scores (P=0.039), longer duration of mechanical ventilation (P=0.049), longer ICU stay (P=0.012) and higher mortality (P=0.035), but no statistically significant differences in gender, age, levels of other electrolytes (natrium, potassium, chlorine), and APACHE Ⅱ score between two groups (P > 0.05). As shown in the result of the multivariate logistic regression analysis, iCa level (OR=2.352, 95%CI: 1.039-4.023, P=0.041) and APACHE Ⅱscore (OR=1.214, 95%CI: 1.067~1.285, P=0.002)were independent risk factors for death in critically ill patients. The 14-day accumulative survival rate in hypo-iCa group was significantly lower than that in normo-iCa group (P=0.037). Conclusions The iCa levels are closely related to mortality rate in patients in ICU, and it is worthwhile to pay more attention to the occurrence of ionized hypocalcemia in critically ill patients.
Key words: Critically ill patient     Prospective study     Ionized calcium     Hypocalcemia     SOFA score     APACHE Ⅱ score     Regression analysis     Survival analysis     Prognosis    

钙广泛参与人体各项生理活动,是维持细胞功能和结构完整,参与细胞分泌、代谢过程的重要物质。钙代谢异常是重症患者常见的电解质紊乱之一,临床以低钙血症为多见,研究表明重症患者低钙血症发生率可高达70%以上[1],但临床医生多重视钠、钾等电解质异常,而忽视了血钙水平的异常。血液循环的中钙分离子钙和结合钙两种形式,各约占50%,只有离子钙能直接起生理作用[2]。本研究通过调查本院重症监护病房(ICU)患者入科时离子钙水平,了解重症患者钙代谢异常的发生情况以及离子钙水平对预后的影响。

1 资料与方法 1.1 一般资料

采用单中心前瞻性观察性研究,观察时间为2013年1月至2015年1月,无锡市人民医院ICU为综合性ICU,收治范围包括内、外科患者。入选标准:所有新入ICU住院的重症患者,包括各种器官功能衰竭、重大手术后以及多发伤患者等。排除标准:①预计ICU住院时间≤24 h者;②未成年患者(≤18岁);③不能获得血标本者;④入ICU前已有明确的血钙异常病史或者已接受钙剂、维生素D补充治疗者。⑤甲状旁腺疾病、骨病患者。

本研究符合医学伦理学标准,经医院伦理委员会批准,并获得患者或家属的知情同意。

1.2 研究方法

取所有研究对象入ICU后24 h内血标本送检,测得离子钙水平记为iCa,按iCa水平进行分组:iCa<1.15 mmol/L纳入低iCa组;iCa>1.25 mmol/L纳入高iCa组;1.15 mmol/L≤iCa≤1.25 mmol/L纳入正常iCa组。统计患者的性别、年龄、手术史、既往病史、入ICU诊断、机械通气时间、ICU住院时间以及转归等信息。记录入ICU 24 h内各项实验室指标(肝肾功能、其他血清电解质水平等),计算序贯器官衰竭评分(SOFA)和急性生理学与慢性健康状况评分系统Ⅱ(APACHE Ⅱ)评分。

1.3 统计学方法

使用SPSS 17.0软件进行统计学分析,计量资料以均数±标准差(x±s)表示,两组间比较采用独立样本t检验。计数资料采用χ2检验或fisher确切概率法。采用Logistic回归分析筛选预后危险因素;采用Kaplan-Meier生存分析,按iCa水平分层,绘制14 d生存曲线,累计生存率比较采用log-rank检验。以P<0.05为差异有统计学意义。

2 结果 2.13 组患者一般情况比较

本研究共纳入重症患者368例,其中正常iCa组117例,低iCa组247例,高iCa组4例。iCa水平分别为正常iCa组(1.19±0.03)mmol/L,低iCa组(0.99±0.13)mmol/L,高iCa组(1.32±0.65)mmol/L。在原发疾病组成中,正常iCa组以神经系统病变(脑出血、脑梗死、蛛网膜下腔出血)多见(21.37%),其次为大手术(20.51%)和多发伤(17.09%)。低iCa组也有较多神经系统病变(18.62%),但以脓毒症最多见(21.46%),而正常iCa组脓毒症仅占10.26%,高iCa组无脓毒症患者,组间差异具有统计学意义(P=0.021)。高iCa组4例患者中有2例为肿瘤患者(50%),低iCa组肿瘤占8.1%,均显著高于正常iCa组的1.71%,差异具有统计学意义(P=0.002)。见表 1

表 1 不同iCa水平重症患者原发疾病比较(例) Table 1 Comparison of the primary diseases of three iCa level groups(case)
组别 例数 脓毒症 肺部感染 脑出血 脑梗死 蛛网膜下腔出血 多发伤 大手术后 肾功能不全 心肌梗死 肿瘤 其他
正常iCa组 117 12 14 7 15 3 20 24 8 7 2 5
低iCa组 247 53 28 18 23 5 23 33 24 9 20 11
高iCa组 4 0 0 0 1 0 0 1 0 0 2 0
χ2 7.328 0.122 0.29 2.609 1.067 4.562 3.794 0.798 1.463 13.3 0.364
P 0.021 0.915 0.868 0.259 0.739 0.108 0.126 0.606 0.507 0.002 1
注:低iCa组iCa<1.15 mmol/L,高iCa组iCa>1.25 mmol/L,正常iCa组1.15 mmol/L≤iCa≤1.25 mmol/L
2.2 低iCa组与正常iCa组临床资料比较

两组性别、年龄、血钠、血钾、血氯水平差异无统计学意义(均P>0.05)。低iCa组较正常iCa组有更多患者合并慢性肾功能不全(P=0.042)。两组APACHE Ⅱ评分差异无统计学意义(P>0.05),但低iCa组SOFA评分(P=0.039)和14 d病死率(P=0.035)更高,机械通气时间(P=0.049)和ICU住院天数(P=0.012)也更长。见表 2

表 2 低iCa组与正常iCa组重症患者临床资料比较 Table 2 Comparison of the parameters between hypo-iCa group and normo-iCa group
组别 例数 性别(男/女) 年龄(岁,x±s) 慢性基础疾病(例) 电解质(mmol/L x±s) APACHE Ⅱ评分(分x±s) SOFA评分(分,x±s) 机械通气时间(d,x±s) ICU住院天数(d,x±s) 14 d病死率(%)
COPD 冠心病 糖尿病 脑卒中 慢性肾病 高血压 外周血管病 其他 血钠 血钾 血氯
正常iCa组 117 64/53 56.43±18.75 30 14 28 35 12 54 2 4 138±7.93 3.94±0.78 105±11.61 20.18±13.27 6.78±3.82 15.62±14.83 9.36±14.29 18.8
低iCa组 247 136/111 63.16±21.83 62 36 43 73 46 122 5 12 141±8.24 4.21±0.92 97±12.84 22.38±12.86 8.93±2.73 17.58±16.14 12.83±16.82 29.15
t2 0.004 3.728 0.012 0.456 2.151 0.005 4.149 0.334 0.042 0.391 5.31 3.915 1.057 2.651 4.854 5.973 9.362 4.437
P 0.949 0.164 0.912 0.499 0.142 0.944 0.042 0.564 0.838 0.532 0.082 0.148 0.372 0.273 0.039 0.049 0.012 0.035
注:低iCa组iCa<1.15 mmol/L,正常iCa组1.15 mmol/L≤iCa≤1.25 mmol/L;COPD为慢性阻塞性肺疾病,APACHE Ⅱ为急性生理学与慢性健康状况评分系统Ⅱ,SOFA为序贯器官衰竭评分。
2.3 Logistic回归分析

以所有研究对象的iCa水平、APACHE Ⅱ评分、SOFA评分、年龄、性别、血钠、血钾等因素为自变量,以14 d是否死亡为因变量,根据多因素Logistic回归分析可知,iCa水平(OR=2.352, 95%CI=1.039~4.023, P=0.041)和APACHE Ⅱ评分(OR=1.214, 95%CI=1.067~1.285, P=0.002)为影响ICU重症患者14 d内死亡的独立危险因素。见表 3

表 3 多因素Log回归分析重症患者14 d内死亡的危险因素 Table 3 Multivariable Logistic regression analysis for the risk factors of the 14d death in critically ill patients
危险因素 OR 95% CI P
iCa水平 2.352 1.039~4.023 0.041
APACHE Ⅱ评分 1.214 1.067~1.285 0.002
SOFA评分 1.048 0.874~1.198 0.406
年龄 0.988 0.932~1.164 0.934
性别 1.021 0.976~1.128 0.893
血钾 1.089 0.983~1.084 0.302
血钠 1.153 1.023~1.210 0.426
注:APACHE Ⅱ为急性生理学与慢性健康状况评分系统Ⅱ,SOFA为序贯器官衰竭评分,OR值为优势比,95% CI为95%可信区间
2.4 低iCa组与正常iCa组生存率比较

按iCa水平分层绘制Kaplan-Meier生存曲线,低iCa组14 d累计生存率显著低于正常iCa组,差异具有统计学意义(P=0.037),见图 1

图 1 Kaplan-Meier survival analysis for the normo-iCa group and hypo-iCa group
3 讨论

钙是机体各项生理活动不可缺少的重要物质,生理功能涉及神经传导、肌肉伸缩舒张、激素合成与分泌、凝血过程等诸多方面。离子钙是血钙的生理活性形式,上述重要的生理过程都与离子钙的浓度有关。临床上重症患者钙代谢异常非常普遍且以低钙血症多见[3],本研究中重症患者钙代谢异常率高达68.21%,其中低钙血症(67.12%)远高于高钙血症(1.09%)。

引起重症患者钙代谢异常的原因很多:①激活凝血、纤溶系统,钙离子作为重要的凝血因子被消耗;②组织器官缺血缺氧,细胞膜损伤使细胞膜对钙离子通透性增加;③降钙素原或乳酸促使钙螯合增加;④交感兴奋和炎症反应使PTH分泌障碍或PTH抵抗;⑤钙摄入不足或吸收障碍。⑥低蛋白血症和酸碱异常。本研究中,与正常iCa组相比,低iCa组脓毒症患者更为多见。近年来的研究也表明,离子钙水平与感染的严重程度呈负相关[4]。目前有关脓毒症患者发生低钙血症的机制尚不明确,其原因有多种,可能与脓毒症器官功能障碍、大量炎症因子释放和交感神经兴奋等有关[5-7]。比较正常iCa组与低iCa组患者慢性基础疾病情况发现,与正常iCa组相比,低iCa组慢性肾病患者更多,这可能与慢性肾病患者多合并低蛋白血症、酸碱平衡失调或肾衰后继发性甲旁亢等因素相关。ICU中高钙血症相对少见,大规模研究显示ICU高钙血症患者比例仅0.75%[8]。大部分高钙血症的患者有原发性甲状旁腺功能亢进或恶性肿瘤病史[9]。本研究4例高iCa组患者有2例为肿瘤患者,1例为肺癌,1例为前列腺癌,均伴有广泛骨转移。恶性肿瘤除了伴发高钙血症也容易伴发低钙血症,如肿瘤成骨细胞转移,骨的形成加速导致低钙血症,淋巴瘤、白血病化疗时发生肿瘤溶解综合征,大量组织破坏,磷酸盐释放入血,血钙可明显下降[10]。本研究中低iCa组肿瘤患者亦显著多于正常iCa组(P=0.002)。

低钙血症最突出的临床表现为神经-肌肉兴奋性增高,轻症时出现感觉异常、四肢发麻、刺痛;当血钙进一步降低时,可发生手足抽搐;严重时全身骨骼及平滑肌痉挛,当呼吸道平滑肌受累时就会导致喉及支气管痉挛,喘息发作。研究发现Digeorge综合征的患者多伴有顽固性的低钙血症,术后常需较长时间机械通气支持[11]。低钙血症是发生低镁血症的原因,已有多项研究证明低镁血症可引起肌无力,进而导致呼吸衰竭,是引起呼吸机支持患者脱机困难的原因之一[12-13]。故低钙血症可能通过神经-肌肉因素或电解质紊乱影响机械通气患者的预后,本研究发现低iCa组较正常iCa组患者机械通气时间更长(P=0.049),同时ICU住院天数也明显延长(P=0.012)。

APACHE Ⅱ评分是目前国内外最常用的危重症评估系统之一,其对判断危重症患者病情严重程度及预后的评估价值已被国内外许多研究证实[14-15]。SOFA评分在判断重症患者预后的作用上与APACHE Ⅱ评分相仿,但更简单易行,不仅对多器官功能障碍综合征患者有良好的预后评价作用,而且还有助于脓毒症的早期诊断[16-18]。虽然在本研究中,根据多因素Logistic回归分析,APACHE Ⅱ评分为影响重症患者14 d内死亡的独立危险因素,但低iCa组与正常iCa组APACHE Ⅱ评分的差异无统计学意义,而低iCa组较正常iCa组SOFA评分更高(P=0.039)。分析原因可能与血钙水平异常为器官功能障碍直接体现有关。

早在1982年,Chernow等[19]的回顾性病例研究即发现低钙血症和ICU住院时间延长有关,并导致病死率增加。之后Zaloga和Chernow [20]的前瞻性研究发现低钙血症会增加成人脓毒血症患者的病死率。近年来一项多中心回顾性大样本研究显示中重度低钙血症(<0.88 mmol/L)与病死率增加有关[21]。关于血钙水平和病死率之间的的关系目前仍处于研究中,但是值得确定的是无论成人还是儿童,血钙降低通常与严重的疾病相关。故血钙是评价疾病严重程度的一个指标,而不是增加病死率的直接原因。本研究发现,低iCa组较正常iCa组患者14 d病死率明显增加(P=0.035)。根据多因素Logistic回归分析,iCa水平为影响重症患者14 d内死亡的独立危险因素(OR=2.352, 95%CI: 1.039~4.023, P=0.041)。按iCa水平分层绘制Kaplan-Meier生存曲线,低iCa组14 d累计生存率显著低于正常iCa组(P=0.037)。上述结果均预示低钙血症患者14 d预后不良。

2014年一项包括15 409例ICU患者的大型临床研究数据显示低钙血症和高钙血症都会影响病死率,而轻度的高钙血症(1.25~1.35 mmol/L)可减少患者的死亡风险[8]。低钙血症往往预示着患者预后不良,然而对于补充钙剂是否能改善患者生存率目前研究结果并不乐观。近期的文献综述并未发现任何静脉补充钙剂有助于改善患者预后的明确证据,且Collage等[22]以脓毒症小鼠为模型研究发现补充钙剂不但不能改善预后,反而会加重脏器功能损害。

综上所述,低钙血症是ICU最常见的电解质紊乱之一,发生率较高。低钙血症可延长患者机械通气时间和ICU住院时间,增加病死率,是影响重症患者死亡的独立危险因素,但在目前临床上却常常被忽视。因此临床医生应重视对重症患者离子钙水平的监测。本研究作为单中心研究,样本量有限,且未对低钙血症导致病死率增加的内在机制以及是否需钙剂治疗的多方面进行深入探讨,故存在一定局限性,期待未来有更大规模的临床研究。

参考文献
[1] H stbacka J, Pettil V. Prevalence and predictive value of ionized hypocalcemia among critically ill patients[J]. Act Anaes Scand , 2003, 47 (10) : 1264-1269 DOI:10.1046/j.1399-6576.2003.00236.x
[2] Lafrance JP, Leblanc M. Metabolic, electrolytes, and nutritional concerns in critical illness[J]. Crit Care Clin , 2005, 21 (2) : 305-327 DOI:10.1016/j.ccc.2004.12.006
[3] Singhi SC, Singh J, Prasad R. Hypocalcaemia in a paediatric intensive care unit[J]. J Trop Pediatr , 2003, 49 (5) : 298-302 DOI:10.1093/tropej/49.5.298
[4] Holowaychuk MK, Birkenheuer AJ, Li J, et al. Hypocalcemia and hypovitaminosis D in dogs with induced endotoxemia[J]. J Vet Intern Med , 2012, 26 (2) : 244-251 DOI:10.1111/j.1939-1676.2012.00886.x
[5] Zaloga GP. Ionized hypocalcemia during sepsis[J]. Crit Care Med , 2000, 28 (1) : 266-268 DOI:10.1097/00003246-200001000-00054
[6] 温前宽, 李彦, 杨建萍, 等. 严重脓毒症患者炎症因子的动态变化及预后意义[J]. 中华急诊医学杂志 , 2015, 24 (7) : 779-783
Wen QK, Li Y, Yang JP, et al. Dynamic changes and prognostic significance of inflammatory factors in patients with severe sepsis[J]. Chin J Emerg Med , 2015, 24 (7) : 779-783 DOI:10.3760/cmaj.issn.1671-0282.2015.07.020
[7] Chen JP, Fang XM, Jin XJ, et al. Expert consensus on the perioperative management of patients with sepsis[J]. World J Emerg Med , 2015, 6 (4) : 245-260 DOI:10.5847/wjem.j.1920-8642.2015.04.001
[8] Zhang Z, Xu X, Ni H, et al. Predictive value of ionized calcium in critically ill patients: an analysis of a large clinical database MIMIC Ⅱ[J]. PLoS One , 2014, 9 (4) : e95204 DOI:10.1371/journal.pone.0095204
[9] Jacobs TP, Bilezikian JP. Clinical review: Rare causes of hypercalcemia[J]. J Clin Endocrinol Metab , 2005, 90 (11) : 6316-6322 DOI:10.1210/jc.2005-0675
[10] Saleh RR, Rodrigues J, Lee TC. A tumour lysis syndrome in a chemotherapy na ve patient with metastatic pancreatic adenocarcinoma[J]. BMJ Case Rep , 2015, 2015 (pⅡ) : bcr2014207748 DOI:10.1136/bcr-2014-207748
[11] Yeoh TY, Scavonetto F, Hamlin RJ, et al. Perioperative management of patients with DiGeorge syndrome undergoing cardiac surgery[J]. J Cardiothorac Vasc Anesth , 2014, 28 (4) : 983-989 DOI:10.1053/j.jvca.2013.10.025.Epub2014Jan23
[12] Fiaccadori E, Del Canale S, Coffrini E, et al. Muscle and serum magnesium in pulmonary intensive care unit patients[J]. Crit Care Med , 1988, 16 (8) : 751-760 DOI:10.1097/00003246-198808000-00004
[13] Safavi M, Honarmand A. Admission hypomagnesemia--impact on mortality or morbidity in critically ill patients[J]. Mid East J Anaes , 2007, 19 (3) : 645-660
[14] 何绍亚, 向阳生, 王岭, 等. 重症急性胰腺炎早期5因素体系与分级评分对患者死亡的评估价值研究[J]. 中国急救复苏与灾害医学杂志 , 2016, 11 (1) : 23-27
He SY, Xiang YS, Wang L, et al. The assessment value of early 5 factors system with APACHE Ⅱ, Ranson and CT grading in death of patients with severe acute pancreatitis[J]. Chin J Emerg Resus Disaster Med , 2016, 11 (1) : 23-27 DOI:10.3969/j.issn.1673-6966.2016.01.008
[15] 董自平, 刘创建, 路桂杰. SCS评分在急诊老年危重患者中的应用价值[J]. 中国急救复苏与灾害医学杂志 , 2015, 10 (8) : 719-721
Dong ZP, Liu CJ, Lu GJ. The applicable value of SCS for elderly critically ill patients in the emergency department[J]. Chin J Emerg Resus Disaster Med , 2015, 10 (8) : 719-721 DOI:10.3969/j.issn.1673-6966.2015.08.006
[16] Knox DB, Lanspa MJ, Pratt CM, et al. Glasgow Coma Scale score dominates the association between admission Sequential Organ Failure Assessment score and 30-day mortality in a mixed intensive care unit population[J]. J Crit Care , 2014, 29 (5) : 780-785 DOI:10.1016/j.jcrc.2014.05.009
[17] Chen K, Zhou QX, Shan HW, et al. Prognostic value of CD4(+)CD25(+) Tregs as a valuable biomarker for patients with sepsis in ICU[J]. World J Emerg Med , 2015, 6 (1) : 40-43 DOI:10.5847/wjem.j.1920-8642.2015.01.007
[18] 杨旭, 刘志. 联合应用早期体温峰值及48 h-△SOFA评分对急诊脓毒症患者预后评估的临床价值[J]. 中华急诊医学杂志 , 2016, 25 (1) : 68-72
Yang X, Liu Z. The clinical value of combining early peak temperature with 48 h-△sequential organ failure assessment score in predicting prognosis for patients with sepsis in emergency department[J]. Chin J Emerg Med , 2016, 25 (1) : 68-72 DOI:10.3760/cma.j.issn.1671-0282.2016.01.016
[19] Chernow B, Zaloga G, McFadden E, et al. Hypocalcemia in critically ill patients[J]. Crit Care Med , 1982, 10 (12) : 848-851 DOI:10.1097/00003246-198212000-00008
[20] Zaloga GP, Chernow B. The multifactorial basis for hypocalcemia during sepsis. Studies of the parathyroid hormone-vitamin D axis[J]. Ann Intern Med , 1987, 107 (1) : 36-41 DOI:10.7326/0003-4819-107-1-36
[21] Egi M, Kim I, Nichol A, et al. Ionized calcium concentration and outcome in critical illness[J]. Crit Care Med , 2011, 39 (2) : 314-321 DOI:10.1097/CCM.0b013e3181ffe23e
[22] Collage RD, Howell GM, Zhang X, et al. Calcium supplementation during sepsis exacerbates organ failure and mortality via calcium/calmodulin-dependent protein kinase kinase signaling[J]. Crit Care Med , 2013, 41 (11) : e352-360 DOI:10.1097/CCM.0b013e31828cf436