动态监测血清降钙素原在继发性腹膜炎中的临床应用研究

发布时间：2018-07-22 12:09

【摘要】：[目的]由于目前降钙素原在临床特异性疾病中的应用越加重要,故本研究的目的主要是:第一、验证PCT的连续性监测在外科中,对缩短继发性腹膜炎患者的抗生素应用时间及住院时间等方面具有较高的临床与经济价值;第二、探究不同腹腔积液类型的继发性腹膜炎患者在PCT监测水平及临床抗感染治疗方面是否存在差异,如存在,该种差异是否可为积液的诊断及鉴别诊断提供有效信息;第三、因继发性腹膜炎病情复杂,传统用来判定细菌感染情况的PCT(Procalcitonin,降钙素原)交界值,即CUT OFF(被检分析物的量值,用于确定结果高于还是低于临床或分析决断点)可能发生变化,重新统计此类患者的CUT OFF值有利于对其感染情况进行更准确的把握;第四、结合其他常见感染性炎症标志物探讨提高细菌感染诊断效能的方式。[方法]该研究以昆明医科大学第六附属医院为研究单位,选择普外一科和普外二科2013年1月至2016年7月,单纯胃液性、肠内容物性及血液性腹腔积液型继发性腹膜炎手术患者。第一、将非感染组中PCT监测组与非监测组的住院时间、抗生素费用、住院费用进行统计分析;第二、将不同腹腔积液类型腹膜炎患者入院急查、手术当天、术后第一天及第二天PCT的监测结果平均值进行统计分析并制成趋势图,观察三种不同继发性腹膜炎类型对PCT水平的影响差异;再将该组研究对象的住院时间、抗生素费用和拔管时间分别进行统计分析,了解上述因素之间的相关性;第三、为指出该项指标在辅助判断细菌感染方面具有较高的灵敏度,绘制自手术之日起连续六天监测PCT水平变化趋势图,观察两组PCT平均值在排除致病因素后的变化情况,分析二者在时间节点上的差异;第四、为统计PCT在诊断不同类型继发性腹膜炎时的CUT OFF值及效能,利用研究对象入院当天急查的PCT值绘制受试者单独检测PCT时的工作特征曲线(receiver operating characteristic curve,简称 ROC 曲线);利用入院当天急查PCT、白介素-6(Interleukin 6,IL-6)、C-反应蛋白(C-reactive protein,CRP)和白细胞(leukocyte,WBC)值,探究上述四项指标在联合应用时是否可进一步提升对细菌感染的诊断效能。[结果]第一、对PCT连续监测的必要性与PCT在不同类型腹膜炎中的变化情况进行分析的统计结果可见,PCT连续性监测情况良好组的住院时间、抗生素疗程、抗生素费用和住院费用均明显低于对照组;第二、在非感染性炎症监测方面,血液性腹膜炎患者入院急查PCT水平较低(0.5ng/mL),且变化幅度最小,肠内容物性及胃液性腹膜炎患者PCT水平变化趋势较为相似,远高于血液性腹膜炎患者,而胃液性腹膜炎患者的PCT水平又高于肠内容物性腹膜炎患者,于手术当天达到峰值,术后胃液性及肠内容物性腹膜炎患者的PCT变化呈同步快速回落趋势。再根据血液性、肠内容物性和胃内容物性腹膜炎患者住院时间、抗生素费用和拔管时间的比较可见,血液性腹膜炎患者住院时间和抗生素费用明显低于肠内容物性和胃液性患者;第三、从PCT对细菌感染的诊断效能评估角度分析,自手术当天到第二天,感染组与非感染组的PCT平均值之间的差距达到最大;第四、将PCT诊断继发性腹膜炎细菌感染的CUT OFF值重新确定为1ng/mL;将PCT、IL-6、CRP及WBC四项感染性标记物分别作为辅助判断感染的监测项目时,诊断感染时的灵敏度大小为:PCTIL-6CRPWWBC,在诊断继发性腹膜炎的细菌感染时准确度最高的为PCT,再将四个指标进行多项联合诊断分析,得出ROC曲线下面积为0.981,进一步提高了对细菌感染的诊断效能。[结论]1、PCT的动态监测可适当控制患者的抗生素使用。2、PCT的动态监测水平可为继发性腹膜炎不同类型积液的诊断及鉴别诊断提供一定的参考依据。3、本次研究结果得出,在继发性腹膜炎患者中PCT指导抗生素应用的CUT OFF值为 1ng/mL。4、在继发性腹膜炎中,PCT对细菌感染的诊断效能高于其他传统感染性炎症标志物;如联合IL-6、CRP及WBC等传统炎症标志物,诊断效能将进一步提升。
[Abstract]:[Objective] because the application of calcitonin in the clinical specific diseases is more and more important, the purpose of this study is mainly: first, to verify the continuous monitoring of PCT in surgery, to shorten the time of the application of antibiotics and the time of hospitalization for the patients with secondary peritonitis, and second, to explore the different abdomen. Whether there are differences in PCT monitoring level and clinical anti infection treatment in patients with secondary peritonitis of the type of cavity effusion, for example, whether this difference can provide effective information for the diagnosis and differential diagnosis of effusion; third, PCT (Procalcitonin, calcitonin), which is traditionally used to determine the condition of bacterial infection because of the complication of secondary peritonitis The boundary value, that is, CUT OFF (the value of the detected analyte, is used to determine whether the result is higher or below the clinical or analysis decision point) may change. The re statistics of the CUT OFF value of such patients is beneficial to the more accurate grasp of the infection situation; fourth, to improve the diagnosis of bacterial infection in combination with other common infectious inflammatory markers. Method of effectiveness. [Methods] the study took the Sixth Affiliated Hospital of Kunming Medical University as the research unit, and selected the patients with simple gastric juice, intestinal content and hematologic secondary peritonitis from January 2013 to July 2016 of the first and two families of the Kunming Medical University. First, the non infection group and the non monitoring group were hospitalized. Time, cost of antibiotics and hospitalization expenses were statistically analyzed. Second, the patients with peritonitis with different peritoneal effusion were admitted to hospital, the day of operation, the average value of PCT monitoring results on the first day and the first two days after operation were statistically analyzed and the trend map was made to observe the difference of the effect of three types of successive peritonitis to the level of PCT. The time of hospitalization, the cost of antibiotics and the time of extubation were statistically analyzed to understand the correlation between the above factors. Third, it was pointed out that the index had a high sensitivity in auxiliary judgment of bacterial infection, and the trend map of monitoring PCT level for six consecutive days from the day of operation was drawn, and the average of the two groups of PCT was observed. The difference in the time node was analyzed after the elimination of the pathogenic factors, and the difference between the two in time nodes was analyzed. Fourth, the value and efficacy of PCT in the diagnosis of different types of secondary peritonitis of different types were calculated, and the PCT value of PCT was plotted by the PCT values of the subjects who were examined on the day of admission (receiver operating characteristi). C curve, referred to as the ROC curve); to explore whether the above four indicators can further improve the diagnostic efficiency of the bacterial infection when combined application of PCT, -6 (Interleukin 6, IL-6), C- reactive protein (C-reactive protein, CRP) and leukocyte (leukocyte)) on the day of admission. [results] first, the necessity of continuous monitoring The analysis of the changes in different types of peritonitis with PCT showed that the time of hospitalization of the group with good PCT continuity monitoring, antibiotic treatment course, antibiotic cost and hospitalization cost were significantly lower than those of the control group; second, the level of PCT in the patients with hematologic peritonitis in the non infectious inflammation monitoring was lower (0.5N G/mL), with the smallest change range, the change trend of PCT level in intestinal contents and gastric juice peritonitis was similar, far higher than that of patients with hematological peritonitis, and the PCT level of patients with gastric juice peritonitis was higher than that of intestinal material peritonitis. The peak value of the operation day, the postoperative gastric juice and the PCT of the patients with intestinal contents peritonitis were higher than those of the patients with gastric juice peritonitis. The change showed a synchronous and rapid decline trend. According to the blood sex, intestinal content physical properties and gastric content physical peritonitis patients' hospitalization time, antibiotic cost and extubation time, the hospitalization time and antibiotic cost of patients with hematologic peritonitis were significantly lower than those of intestinal content and gastric juice; third, the diagnosis of bacterial infection from PCT The difference between the PCT average of the infection group and the non infected group reached the maximum from the day of the operation to second days. Fourth, the CUT OFF value of the PCT diagnosis of secondary peritonitis infection was redefined as 1ng/mL, and four infectious markers of PCT, IL-6, CRP and WBC were used as the auxiliary monitoring items for the detection of infection, The sensitivity of the diagnosis of infection was: PCTIL-6CRPWWBC, the highest degree of accuracy was PCT in the diagnosis of secondary peritonitis, and four indexes were combined with multiple diagnostic analyses. The area under the ROC curve was 0.981, which further improved the diagnostic efficacy of bacterial infection. [conclusion]1, dynamic monitoring of PCT can properly control the patient. The use of.2, the dynamic monitoring level of PCT can provide a reference for the diagnosis and differential diagnosis of different types of secondary peritonitis. The results of this study showed that the CUT OFF value of the application of PCT in secondary peritonitis was 1ng/mL.4, and in secondary peritonitis, the diagnosis of PCT for bacterial infection was found in secondary peritonitis. The diagnostic efficacy is higher than other traditional inflammatory markers. If combined with IL-6, CRP, WBC and other traditional inflammatory markers, the diagnostic efficiency will be further improved.
【学位授予单位】：昆明医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R572.2

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