The Influence Of Intra-abdominal Pressure On The Severity And Prognosis Of Sepsis Patients

Objective（s）:To study the changes of intra-abdominal pressure（IAP）in sepsis patients,and to explore the influence of IAP on the severity and prognosis of sepsis patients,so as to provide a theoretical basis for judging the severity of sepsis,evaluating prognosis,early intervention and standardizable monitoring of intra-abdominal pressure.Methods:According to the inclusion and exclusion criteria,70 patients with sepsis admitted to the Emergency Intensive Care Unit（EICU）of the Second Affiliated Hospital of Kunming Medical University from February 2022 to January 2023 were included in this study.Abdominal pressure of sepsis patients was monitored by bladder manometry,and IAH was diagnosed as intra-abdominal hypertension（IAH）with IAP≥12mm Hg.IAP≥12mm Hg was diagnosed as intra-abdominal hypertension（IAH）.And when IAP remained above 20mm Hg,with or without abdominal perfusion pressure<60mm Hg,accompanied by a new definition of organ dysfunction called abdominal compartment syndrome（ACS）.Data collected included general information for all patients,vital signs on admission,interleukin-6（IL-6）,site of primary infection,length of stay in EICU,total length of stay,and 28-day prognosis（survival or death）,IAP,procalcitonin（PCT）,blood routine,arterial blood gas analysis,liver function,kidney function,blood electrolytes,coagulation function,24-hour fluid balance,and relevant treatment status[including whether mechanical ventilation was used,renal replacement therapy,and vasoactive drugs,and record the positive end-expiratory pressure（PEEP）when mechanical ventilation is used.]of all subjects were recorded on the first,second and third days of admission.sequential organ failure assessment(sequential organ failure assessment,SOFA score and acute physiology and chronic health evaluation II（APACHE II）score were used to calculate the number and condition of organ dysfunction.According to the diagnostic criteria of IAH,there were 39 cases in non-IAH group and 31 cases in IAH group.According to the diagnostic criteria of sepsis and septic shock,there were 41 cases in septic shock group and 29 cases in septic shock group.Then they were divided into survival group（41 cases）and death group（29 cases）according to the prognosis at 28days.Statistical analysis:SPSS 26.0 statistical software was used for analysis and processing.The variables among each group were analyzed and compared.Multivariate analysis was performed by binary Logistic regression to screen out the independent risk factors of IAH with sepsis.Spearman correlation analysis was performed between IAP and sepsis severity.Draw receiver operating characteristic（ROC）curve,Logistic regression method was used to analyze the predictive value of IAP,PCT,Lactic acid（Lac）,IL-6,SOFA score and APACHE II score on the prognosis of septic shock and sepsis,and P<0.05 was considered statistically significant.Results:（1）A total of 70 patients with sepsis were included in this study.31 cases of IAH were diagnosed according to the diagnostic criteria,with an incidence of44.3%（31/70）and 2.9%（2/70）of ACS.The inpatient mortality rate of IAH was higher than that of non-IAH（38.7%vs23.1%）,but the difference was not statistically significant（P>0.05）.（2）The length of EICU stay,total length of stay,number of involved organ dysfunction,positive end-expiratory pressure（PEEP）value,proportion of PEEP≥7cm H₂O,APACHE II score and SOFA score in IAH group were significantly higher than those in non-IAH group,and the differences were statistically significant（all P<0.05）.The incidence of acute kidney injury（AKI）,disseminated intravascular coagulation（DIC）,gastrointestinal injury（AGI）and abdominal fluid in IAH group was significantly higher than that in non-IAH group,with statistical significance（all P<0.05）.Pulmonary infection was higher in the non-IAH group（53.8%）,and abdominal/intestinal infection was higher in the IAH group（58.1%）.There were statistically significant differences in the primary infection sites in the lungs and abdominal/intestinal tract between the two groups（P<0.05）.Multivariate Logistic regression analysis showed that PEEP≥7cm H2O and AGI had statistically different effects on IAH in sepsis（all P<0.05）,and they were independent risk factors for sepsis complicated with IAH.The risk of IAH in sepsis patients with PEEP≥7cm H2O was 8.732 times higher than that with PEEP<7cm H2O（OR=8.732,95%CI was 1.065-71.596）.Sepsis patients with AGI had a 12.226 times greater risk of IAH than those without AGI（OR=12.226,95%CI was 2.341-63.850）.（3）Comparison of related indexes in sepsis patients:The IAP,24h fluid balance,PCT,Lac,IL-6,SOFA score and APACHE II score of sepsis shock group were significantly higher than those of sepsis group,and the differences were statistically significant（all P<0.05）.（4）Analysis of the correlation between IAP and sepsis severity showed:IAP level was positively correlated with SOFA score and APACHE II score（disease severity）（r_s=0.562 and 0.395,all P<0.05）,suggesting that the higher IAP was,the more severe sepsis was.（5）The predictive value of IAP for septic shock:ROC curve analysis showed that IAP level,PCT level,Lac level,IL-6 level,SOFA score and APACHE II score were equivalent in predicting septic shock（AUC=0.705,0.709,0.767,0.770,0.709,0.701,respectively）.When the optimal cut-off value of IAP was 9.05mm Hg,the sensitivity and specificity for predicting septic shock were 78%and 68%.Logistic regression method was used to establish a new predictive index by combining IAP with PCT,Lac,SOFA score and APACHE II score respectively.The predictive value of IAP in predicting septic shock was higher than before,especially after the combination of IAP and Lac（AUC=0.807）.（6）28-day prognosis of sepsis patients showed that septic shock accounted for75.9%（22/29）in the death group,which was significantly higher than that in the survival group[46.3%（19/41）],P<0.05;The number of organ dysfunction in death group was significantly higher than that in survival group（survival group/death group:[2（1.5,3）]/[4（3,4）],P<0.05）.Compared with the survival group,IAP of the death group was higher and showed an increasing trend.IAP of the death group was significantly higher than that of the survival group on the first and third days,and the difference was statistically significant（P<0.05）.Compared with the survival group,Lac,SOFA scores and APACHE II scores in the death group continued to maintain a higher level at the first,second and third days,with no significant downward trend,and were significantly higher than those in the survival group,with statistical significance（all P<0.05）.（7）The AUCs predicting 28-day death of sepsis patients at 1,2 and 3 days after admission were:IAP 0.639,0.644,0.682,Lac 0.683,0.694,0.696,SOFA score 0.685,0.691,0.750,APACHE II score 0.664,0.640,0.667,and the prognostic value of the above indexes was higher on day 3.Combining IAP,Lac,SOFA scores and APACHE II scores on day 3 significantly improved the predictive value of outcomes（AUC=0.761）.Conclusion（s）:（1）IAH has a high incidence in patients with sepsis;Sepsis patients of IAH combined with IAH had high in-hospital mortality,severe organ function impairment,long stay in hospital and severe illness.（2）AKI,DIC,peritoneal effusion,PEEP,SOFA score,APACHE II score and peritoneal/intestinal infection were risk factors for IAH;AGI and PEEP≥7cm H₂O were independent risk factors for IAH in sepsis patients.（3）IAP level was positively correlated with the severity of sepsis.The higher the IAP level was,the more severe the sepsis was.Patients with continuously elevated IAP levels are critically ill with poor prognosis,and dynamic monitoring of IAP changes can be used as an indicator to assess the evolution of the disease.（4）IAP level was predictive of sepsis shock and sepsis death at 28 days.