【摘要】：目的:降鈣素原(procalcitonin,PCT)作為一種新型的獨具優(yōu)勢的感染標(biāo)記物在感染疾病的早期診斷、治療效果監(jiān)測、轉(zhuǎn)歸預(yù)警及抗生素治療方案的決策等方面具有較高的應(yīng)用價值。本研究通過啟用PCT清除率(procalcitoninclearance,PCTc)的概念,通過觀察ICU膿毒癥患者血清降鈣素原在全身感染性疾病中的動態(tài)變化趨勢,分析降鈣素原及其清除率在全身感染性疾病中的應(yīng)用價值。因為降鈣素原作為一個炎癥指標(biāo),在全身炎癥反應(yīng)過程中作用機理不明,本研究通過觀察動物實驗中降鈣素原和其它炎癥因子的變化趨勢,探討其可能的作用機制。方法:1)研究納入了2012年7月至2014年7月入住本地綜合ICU內(nèi)的符合膿毒癥診斷的患者。納入患者在進(jìn)入ICU的24小時內(nèi)檢測PCT濃度,并進(jìn)行APACHEⅡ評分、SOFA評分。其后分別于第1、3、5、7、9天晨8點抽血檢測患者的PCT血清濃度,并計算各日的PCT清除率。根據(jù)患者28天生存情況,將患者分為生存組和死亡組,對比兩組間各指標(biāo)的差異,并評價各指標(biāo)對患者預(yù)后的影響。2)采用前瞻性單中心觀察性研究方法,納入2012年2月至2014年6月入住本院ICU的VAP患者。所有患者在診斷為VAP后立即給予經(jīng)驗性抗感染治療,10d后進(jìn)行療效評價,并根據(jù)臨床療效將患者分為好轉(zhuǎn)組和惡化組。以診斷VAP的時間為研究起點,分別于確診1、3、5、7、9d清晨取血檢測血清PCT水平,并計算PCTc。分別對比各指標(biāo)在好轉(zhuǎn)組及惡化組中不同,確定降鈣素原在判斷VAP患者預(yù)后中的價值。通過對降鈣素原在實體器官移植應(yīng)用相關(guān)文章的薈萃分析,評價其在實體器官移植中的價值。3)通過觀察不同時期膿毒癥大鼠血清降鈣素原及各種炎癥因子的變化趨勢,通過干預(yù)其中一種炎癥因子,了解降鈣素原是否和其存在相關(guān)性。結(jié)果:1)生存組與死亡組相比,第一天及第三天的PCT值兩組間比較無差異,第五天以后的PCT值死亡組明顯高于存活組。兩組間清除率比較可見,死亡組各天的PCT清除率均低于存活組,(P0.01)。第一天降鈣素原絕對值對預(yù)后的判斷價值明顯不如常規(guī)使用的評分系統(tǒng)如APACHE-II及SOFA評分,但降鈣素原清除率對預(yù)后的判斷明顯好于常規(guī)使用評分系統(tǒng)。2)共納入VAP患者128例,其中好轉(zhuǎn)組88例,惡化組40例。分析數(shù)據(jù)的變化趨勢可見,PCT在好轉(zhuǎn)組隨治療時間的延長明顯下降,在惡化組中保持較高水平,好轉(zhuǎn)組確診5、7、9d時PCT水平均明顯低于惡化組(P0.05或P0.01)。PCTc在好轉(zhuǎn)組中維持高水平,并隨病情好轉(zhuǎn)而升高;在惡化組中則較低,并隨病情發(fā)展逐漸下降,好轉(zhuǎn)組確診5、7、9d時PCTc均明顯高于惡化組(P0.05或P0.01)。PCT、PCTc、APACHEⅡ評分對VAP患者預(yù)后評估的ROC曲線分析:確診后9d,PCT、PCTc及24h內(nèi)APACHEⅡ評分對VAP患者預(yù)后預(yù)測價值最高,敏感度和特異度也最高。通過薈萃分析,可見降鈣素原在實體器官移植患者中對感染的判斷具有一定價值。3)隨著膿毒癥時間的延長降鈣素原,IL-6,IL-10都呈明顯增高趨勢,而i NOS的變化趨勢在不同時間不同臟器的變化和其不同,干預(yù)i NOS并未對降鈣素原有影響。結(jié)論:PCT在重癥感染中具有良好的診斷價值;PCT絕對值并不能作為膿毒癥患者預(yù)后判斷的一個良好指標(biāo),其效價甚至比常用評價預(yù)后評分標(biāo)準(zhǔn)如APACHEII或SOFA低;PCT清除率對重癥感染疾病患者的預(yù)后判斷效價明顯高于PCT絕對值,比常用評價預(yù)后評分標(biāo)準(zhǔn)如APACHEII或SOFA的效價高可以作為判斷預(yù)后的一個良好指標(biāo)。2)降鈣素原及其清除率可以良好的預(yù)測呼吸機相關(guān)性肺炎患者的預(yù)后。降鈣素原清除率的預(yù)測效果要好于降鈣素原絕對值。降鈣素原在診斷實體器官移植受體細(xì)菌感染方面具有一定價值。3)i NOS在膿毒癥早期表達(dá)顯著升高,可能與膿毒癥早期死亡有關(guān)。干預(yù)i NOS未能降低膿毒癥時期炎癥因子和PCT的水平,而IL-6,TNF-α,PCT是評價膿毒癥預(yù)后的重要指標(biāo),這也可能是抑制i NOS難以改變膿毒癥預(yù)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，

本文編號：2484364