[Development and validation of a nomogram prediction model for in-hospital mortality risk in patients with sepsis complicated with acute pulmonary embolism].

Abstract

Objective: To explore the risk factors affecting the prognosis of patients with sepsis complicated with acute pulmonary embolism, and to construct and validate a nomogram predictive model for in-hospital mortality risk.

Methods: Based on the American Medical Information Mart for Intensive Care (MIMIC-III, MIMIC-IV) databases, the data were collected on patients with sepsis complicated with acute pulmonary embolism from 2001 to 2019, including baseline characteristics, and vital signs, disease scores, laboratory tests within 24 hours of admission to the intensive care unit (ICU), and interventions. In-hospital mortality was the outcome event. The total samples were divided into training and testing sets in a 7:3 ratio by random sampling. Univariate Cox regression analysis was used to verify the impact of all variables on the risk of in-hospital mortality, thereby screen potential influencing factors. Subsequently, a stepwise bi-directional regression method was applied to select factors one by one, leading to the construction of a nomogram prediction model. Collinearity testing was used to demonstrate the absence of strong multicollinearity among the influencing factors in the nomogram prediction model. The discrimination of the nomogram model, sequential organ failure assessment (SOFA), and simplified pulmonary embolism severity index (sPESI) was evaluated using C-index in the test set. Receiver operator characteristic curve (ROC curve) was drawn to evaluate the predictive value of various models for in-hospital mortality in patients with sepsis complicated with acute pulmonary embolism.

Results: A total of 562 patients with sepsis complicated with acute pulmonary embolism were included, including 393 in the training set and 169 in the testing set. Univariate Cox regression analysis showed that 30 factors associated with in-hospital mortality in patients with sepsis complicated with acute pulmonary embolism. Through stepwise bi-directional regression, 12 variables were ultimately selected, including gender, presence of malignant tumors, body temperature, red cell distribution width (RDW), blood urea nitrogen (BUN), serum potassium, prothrombin time (PT), 24-hour urine output, mechanical ventilation, vasoactive drugs, warfarin use, and sepsis-induced coagulopathy (SIC). Collinearity testing indicated no strong multicollinearity among the influencing factors [all variance inflation factor (VIF) > 10]. A nomogram model was constructed using the 12 variables mentioned above. The nomogram model predicted the C-index and its 95% confidence interval (95%CI) of in-hospital mortality in patients with sepsis complicated with acute pulmonary embolism better than SOFA score and sPESI [0.771 (0.725-0.816) vs. 0.579 (0.519-0.639), 0.608 (0.554-0.663)]. The ROC curve showed that the area under the curve (AUC) and its 95%CI of the nomogram model were higher than those of the SOFA score and sPESI [0.811 (0.766-0.857) vs. 0.630 (0.568-0.691), 0.623 (0.566-0.680)]. These findings were consistently replicated in the internal validation of the testing set. In both the training and testing sets, Delong's test showed that the AUC of the nomogram model was significantly higher than the SOFA score and sPESI (both P < 0.05).

Conclusion: The nomogram model demonstrated good predictive effectiveness for the risk of in-hospital mortality in patients with sepsis complicated with acute pulmonary embolism, enabling clinicians to predict mortality risk in advance and take timely interventions to reduce mortality.