降钙素原和降钙素原清除率在脓毒症诊断及预后判断中的应用价值研究

发布时间：2019-05-24 00:03

【摘要】：目的:降钙素原(procalcitonin,PCT)作为一种新型的独具优势的感染标记物在感染疾病的早期诊断、治疗效果监测、转归预警及抗生素治疗方案的决策等方面具有较高的应用价值。本研究通过启用PCT清除率(procalcitoninclearance,PCTc)的概念,通过观察ICU脓毒症患者血清降钙素原在全身感染性疾病中的动态变化趋势,分析降钙素原及其清除率在全身感染性疾病中的应用价值。因为降钙素原作为一个炎症指标,在全身炎症反应过程中作用机理不明,本研究通过观察动物实验中降钙素原和其它炎症因子的变化趋势,探讨其可能的作用机制。方法:1)研究纳入了2012年7月至2014年7月入住本地综合ICU内的符合脓毒症诊断的患者。纳入患者在进入ICU的24小时内检测PCT浓度,并进行APACHEⅡ评分、SOFA评分。其后分别于第1、3、5、7、9天晨8点抽血检测患者的PCT血清浓度,并计算各日的PCT清除率。根据患者28天生存情况,将患者分为生存组和死亡组,对比两组间各指标的差异,并评价各指标对患者预后的影响。2)采用前瞻性单中心观察性研究方法,纳入2012年2月至2014年6月入住本院ICU的VAP患者。所有患者在诊断为VAP后立即给予经验性抗感染治疗,10d后进行疗效评价,并根据临床疗效将患者分为好转组和恶化组。以诊断VAP的时间为研究起点,分别于确诊1、3、5、7、9d清晨取血检测血清PCT水平,并计算PCTc。分别对比各指标在好转组及恶化组中不同,确定降钙素原在判断VAP患者预后中的价值。通过对降钙素原在实体器官移植应用相关文章的荟萃分析,评价其在实体器官移植中的价值。3)通过观察不同时期脓毒症大鼠血清降钙素原及各种炎症因子的变化趋势,通过干预其中一种炎症因子,了解降钙素原是否和其存在相关性。结果:1)生存组与死亡组相比,第一天及第三天的PCT值两组间比较无差异,第五天以后的PCT值死亡组明显高于存活组。两组间清除率比较可见,死亡组各天的PCT清除率均低于存活组,(P0.01)。第一天降钙素原绝对值对预后的判断价值明显不如常规使用的评分系统如APACHE-II及SOFA评分,但降钙素原清除率对预后的判断明显好于常规使用评分系统。2)共纳入VAP患者128例,其中好转组88例,恶化组40例。分析数据的变化趋势可见,PCT在好转组随治疗时间的延长明显下降,在恶化组中保持较高水平,好转组确诊5、7、9d时PCT水平均明显低于恶化组(P0.05或P0.01)。PCTc在好转组中维持高水平,并随病情好转而升高;在恶化组中则较低,并随病情发展逐渐下降,好转组确诊5、7、9d时PCTc均明显高于恶化组(P0.05或P0.01)。PCT、PCTc、APACHEⅡ评分对VAP患者预后评估的ROC曲线分析:确诊后9d,PCT、PCTc及24h内APACHEⅡ评分对VAP患者预后预测价值最高,敏感度和特异度也最高。通过荟萃分析,可见降钙素原在实体器官移植患者中对感染的判断具有一定价值。3)随着脓毒症时间的延长降钙素原,IL-6,IL-10都呈明显增高趋势,而i NOS的变化趋势在不同时间不同脏器的变化和其不同,干预i NOS并未对降钙素原有影响。结论:PCT在重症感染中具有良好的诊断价值;PCT绝对值并不能作为脓毒症患者预后判断的一个良好指标,其效价甚至比常用评价预后评分标准如APACHEII或SOFA低;PCT清除率对重症感染疾病患者的预后判断效价明显高于PCT绝对值,比常用评价预后评分标准如APACHEII或SOFA的效价高可以作为判断预后的一个良好指标。2)降钙素原及其清除率可以良好的预测呼吸机相关性肺炎患者的预后。降钙素原清除率的预测效果要好于降钙素原绝对值。降钙素原在诊断实体器官移植受体细菌感染方面具有一定价值。3)i NOS在脓毒症早期表达显著升高,可能与脓毒症早期死亡有关。干预i NOS未能降低脓毒症时期炎症因子和PCT的水平,而IL-6,TNF-α,PCT是评价脓毒症预后的重要指标,这也可能是抑制i NOS难以改变脓毒症预后的重要原因。
[Abstract]:Objective: Procalcitonin (PCT), as a novel and unique infection marker, has high application value in the early diagnosis, treatment effect monitoring, outcome early warning and antibiotic treatment of the infection disease. In this study, the application value of procalcitonin and its clearance in whole-body infectious diseases was analyzed by using the concept of procalcitrinone (PCTc) and observing the dynamic change trend of the serum procalcitonin in the whole-body infectious diseases by observing the serum procalcitonin in the patients with sepsis. Because the procalcitonin is an inflammatory index, the mechanism of the action of procalcitonin and other inflammatory factors in animal experiments is unknown, and its possible mechanism of action is discussed by observing the change trend of procalcitonin and other inflammatory factors in animal experiments. Method:1) The study included patients with sepsis diagnosed in the local integrated ICU from July 2012 to July 2014. The PCT concentration was detected within 24 hours of the patient entering the ICU and the APACHE II score and the SOFA score were performed. The PCT serum concentration of the patient was then measured at 8 o 'clock on Days 1,3,5,7 and 9, respectively, and the PCT clearance on each day was calculated. According to the patient's 28-day survival, the patient was divided into the survival group and the death group, the difference between the two groups was compared, and the effect of each index on the patient's prognosis was evaluated. All patients were given an empirical anti-infection treatment immediately after diagnosis of VAP, and the efficacy was evaluated after 10 days, and the patients were divided into the improvement group and the worsening group according to the clinical curative effect. In order to diagnose the time of the VAP as the starting point of the study, the serum PCT level was detected in the morning of the first, third, fifth, 7th and 9th day of the diagnosis, and the PCTc was calculated. The value of procalcitonin in the determination of the prognosis of patients with VAP was determined. A meta-analysis of procalcitonin in solid organ transplantation was carried out to evaluate its value in solid organ transplantation. It is known whether the procalcitonin is related to its presence. Results:1) There was no difference between the two groups of PCT values on the first day and the third day of the survival group, and the number of PCT values after the fifth day was significantly higher than that of the surviving group. The clearance between the two groups was found to be lower than that of the surviving group (P0.01). The first day the value of procalcitonin absolute value on the prognosis was less than that of the conventional scoring system, such as the APACHE-II and the SOFA scores, but the determination of the procalcitonin clearance on the prognosis was better than that of the normal use scoring system. The trend of the analysis data showed that PCT in the improved group decreased significantly with the treatment time, and remained high in the worsening group, and the PCT level in the improved group was significantly lower than that in the worsening group (P0.05 or P0.01). PCTc was maintained at a high level in the improved group and increased with the improvement of the condition; in the deteriorated group, the PCTc was lower and gradually decreased with the development of the disease, and the PCTc in the improved group was significantly higher than that in the worsening group (P0.05 or P0.01). The results of ROC curve of PCT, PCTc and APACHE 鈪，

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