维生素D对脓毒性休克导致急性呼吸窘迫综合征患者的干预价值研究

目的探索维生素D对脓毒性休克致急性呼吸窘迫综合征（ARDS）的干预效果。 方法选取2017年6月至2019年6月入住山西医科大学第一医院重症监护室发生脓毒性休克导致ARDS的80例患者，根据25-羟维生素D水平分级分为维生素D正常组（17例，25-羟维生素D ≥ 50 nmol /L）和维生素D降低组（63例，25-羟维生素D < 50 nmol /L）。然后再根据25-羟维生素D水平的降低程度进一步将维生素D降低组分为维生素D缺乏组（35例，30 nmol /L ≤25-羟维生素D ≤ 49.9 nmol /L）和维生素D严重缺乏组（28例，25-羟维生素D <30 nmol/L）。采用随机数字表法将维生素D缺乏组患者分为A组（对照组，17例）和B组（干预组，18例），将维生素D严重缺乏组患者分为C组（对照组，14例）和D组（干预组，14例）。A、C组患者给予经胃管、肠内营养管补充淀粉胶囊0.5 g/d；B、D组患者给予经鼻胃管、鼻肠管补充阿法骨化醇软胶囊0.5 g/d，疗程均为7 d。记录所有患者的年龄、性别、25-羟维生素D、氧合指数、急性病生理学和长期健康评价（APACHE）Ⅱ评分、血管外肺水指数（EVLWI）、肺血管通透性指数（PVPI）及28 d死亡情况，采用Cox回归分析影响脓毒性休克致ARDS患者28 d病死率的危险因素。 结果维生素D正常组和维生素D降低组患者25-羟维生素D （57 ± 4）nmol /L vs.（33 ± 8）nmol /L]、氧合指数（135 ± 25）mmHg vs.（114 ± 18）mmHg]、APACHEⅡ评分（14.7 ± 1.6）分vs.（16.0 ± 2.0）分]、EVLWI （11.4 ± 2.1）mL/kg vs.（14.5 ± 2.7）mL/kg]、PVPI （3.61 ± 0.32）vs.（5.05 ± 0.68）]及28 d死亡情况（1/17 vs. 20 /63）比较，差异均有统计学意义（t = 11.448、3.872、8.864、5.097、8.409，χ² = 4.626；P均< 0.05）。Cox回归分析结果显示，25-羟维生素D 相对危险度= 4.183，95%置信区间（1.787，10.594），P = 0.012]是脓毒性休克致ARDS患者预后的保护因素。且干预后，C、D组患者25-羟维生素D （25 ± 4）nmol /L vs.（37 ± 4）nmol /L]、氧合指数（152 ± 18）mmHg vs.（171 ± 13）mmHg]、APACHEⅡ评分（12.8 ± 1.4）分vs.（11.0 ± 1.7）分]、EVLWI （9.5 ± 0.9）mL /kg vs.（7.9 ± 1.4）mL /kg]及PVPI （3.63 ± 0.28）vs.（2.95 ± 0.48）]比较，差异均有统计学意义（t = 7.493、3.246、3.016、3.420、4.373，P均< 0.05），而28 d死亡情况（6 /14 vs. 4 /14）比较，差异无统计学意义（χ² = 0.622，P = 0.430）。 结论维生素D降低在脓毒性休克致ARDS患者中普遍存在，且维生素D是脓毒性休克ARDS患者28 d病死率的保护因素，而补充维生素D可改善维生素D严重缺乏者ARDS的严重程度。

Intervention of vitamin D on acute respiratory distress syndrome caused by septic shock

ObjectiveTo explore the intervention effect of vitamin D on acute respiratory distress syndrome (ARDS) patients caused by septic shock. MethodsFrom June 2017 to June 2019, 80 ARDS patients with septic shock in the Intensive Care Unit of the First Hospital of Shanxi Medical University were selected. Based on the 25-hydroxyvitamin D level, they were classified into a normal vitamin D group (17 patients, 25-hydroxyvitamin D ≥ 50 nmol/L) and a vitamin D reduction group (63 patients, 25-hydroxyvitamin D < 50 nmol/L). Then according to the decreased level of 25-hydroxyvitamin D, patients in the vitamin D reduction group were further divided into a vitamin D deficiency group (35 patients, 30 nmol/L ≤ 25-hydroxyvitamin D ≤ 49.9 nmol/L) and a severe vitamin D deficiency group (28 patients, 25-hydroxyvitamin D < 30 nmol/L). Using a random number table method, patients in the vitamin D deficiency group were divided into an A group (control group, 17 patients) and a B group (intervention group, 18 patients), and patients in the severe vitamin D deficiency group were divided into a C group (control group, 14 patients) and a D group (intervention group, 14 patients). Patients in the A and C groups were given 0.5 g/d starch capsule through the stomach tube and enteral nutrition tube, while patients in the B and D groups were given 0.5 g/d alfacalcidol soft capsule through the nasogastric tube and nasointestinal tube, all for 7 days. The age, sex, 25-hydroxyvitamin D, oxygenation index, acute physiology and chronic health evaluation (APACHE) Ⅱ score, extra vascular lung water index (EVLWI), pulmonary vascular permeability index (PVPI), and 28-d mortality of all patients were recorded, and risk factors influencing 28-d mortality of ARDS patients with septic shock were analyzed by Cox regression analysis. ResultsThe 25-hydroxyvitamin D (57 ± 4) nmol/L vs. (33 ± 8) nmol/L], oxygenation index (135 ± 25) mmHg vs. (114 ± 18) mmHg], APACHE Ⅱ score (14.7 ± 1.6) scores vs. (16.0 ± 2.0) scores], EVLWI (11.4 ± 2.1) mL/kg vs. (14.5 ± 2.7) mL/kg], PVPI (3.61 ± 0.32) vs. (5.05 ± 0.68)] and 28-d mortality (1/17 vs. 20/63) were statistically significantly different betwwen the normal vitamin D group and vitamin D reduction group (t = 11.448, 3.872, 8.864, 5.097, 8.409; χ² = 4.626; all P < 0.05). Cox regression analysis showed that the 25-hydroxyvitamin D relative risk = 4.183, 95% confidence interval (1.787, 10.594), P = 0.012] was a protective factor for the prognosis of ARDS patients with septic shock. After the intervention, the 25-hydroxyvitamin D (25 ± 4) nmol/L vs. (37 ± 4) nmol/L], oxygenation index (152 ± 18) mmHg vs. (171 ± 13) mmHg], APACHE Ⅱ score (12.8 ± 1.4) scores vs. (11.0 ± 1.7) scores], EVLWI (9.5 ± 0.9) mL/kg vs. (7.9 ± 1.4) mL/kg] and PVPI (3.63 ± 0.28) vs. (2.95 ± 0.48)] were statistically significantly different between the C and D groups (t = 7.493, 3.246, 3.016, 3.420, 4.373; all P < 0.05), while the 28-d mortality was not statistically significantly different (6/14 vs. 4/14, χ² = 0.622, P = 0.430). ConclusionsThe decrease of vitamin D is common in ARDS patients caused by septic shock, and vitamin D is a protective factor for their 28-d mortality. The supplementation of vitamin D may improve the severity of ARDS in patients with severe vitamin D deficiency.