肺炎继发脓毒症患者血清降钙素原和C反应蛋白变化及预后因素分析Changes of serum procalcitonin and C-reactive protein and prognostic risk factors in patients with pneumonia-associated sepsis
贾建超,张文平,杨金坡,张安然,马利军
JIA Jian-chao,ZHANG Wen-ping,YANG Jin-po,ZHANG An-ran,MA Li-jun
摘要(Abstract)：
目的探讨肺炎继发脓毒症患者血清降钙素原(procalcitonin,PCT)、C反应蛋白(C-reactive protein,CRP)的变化及预后危险因素。方法 122例肺炎患者,其中单纯肺炎52例为肺炎组,肺炎继发脓毒症57例为继发脓毒症组,肺炎继发脓毒性休克13例为脓毒性休克组;比较3组PCT、CRP、急性生理与慢性健康状况(Acute Physiology and Chronic Health EvaluationⅡ,APACHEⅡ)评分、序贯器官衰竭估计(Sequential Organ Failure Assessment,SOFA)评分;绘制ROC曲线,分析PCT、CRP、APACHEⅡ评分对肺炎继发脓毒症和脓毒性休克的诊断价值;继发脓毒症患者70例根据预后分为存活组32例和死亡组38例,比较2组临床资料及PCT、CRP、APACHEⅡ评分和SOFA评分,采用多因素logistic回归分析肺炎继发脓毒症死亡的危险因素。结果肺炎组白细胞计数、PCT、CRP、APACHEⅡ评分[7.59(5.44,10.28)×10~9/L、0.12(0.05,0.33)μg/L、26.85(7.95,74.40)mg/L、2.0(1.0,4.0)分]低于继发脓毒症组[12.20(7.25,17.55)×10~9/L、0.80(0.21,1.96)μg/L、97.80(55.95,127.40)mg/L、11.0(7.5,17.0)分]、脓毒性休克组[15.90(7.00,22.34)×10~9/L、3.49(0.29,50.00)μg/L、122.90(48.90,200.00)mg/L、21.0(15.5,26.0)分](P<0.05),继发脓毒症组PCT、APACHEⅡ评分及SOFA评分[5.0(3.0,7.0)分]低于脓毒性休克组[9.0(7.5,11.5)分](P<0.05),白细胞计数、CRP水平与脓毒性休克组比较差异无统计学意义(P>0.05);PCT、CRP、APACHEⅡ评分及三者联合检测诊断肺炎继发脓毒症的AUC分别为0.791、0.770、0.924、0.943,诊断脓毒性休克AUC分别为0.736、0.718、0.898、0.899;肺炎继发脓毒症死亡组年龄[(69.9±15.2)岁]、SOFA评分[(7.7±3.5)分]、氧合指数SOFA评分[3.0(2.0,4.0)分]、意识障碍发生率(71.1%)、APACHEⅡ评分[(16.7±7.1)分]高于生存组[(58.6±21.3)岁、(4.7±1.9)分、3.0(2.0,3.0)分、37.5%、(9.6±5.0)分](P<0.05);氧合指数SOFA评分增高及APACHEⅡ评分增高是肺炎继发脓毒症死亡的独立危险因素(OR=2.979,95%CI:1.307~6.791,P=0.009;OR=1.179,95%CI:0.997~1.394,P=0.050)。结论 PCT、CRP及APACHEⅡ评分对肺炎继发脓毒症诊断有一定价值,APACHEⅡ评分对肺炎继发脓毒症及脓毒性休克的诊断准确性高于PCT、CRP,且三者联合可提高肺炎继发脓毒症的诊断效能;氧合指数SOFA评分和APACHEⅡ评分升高是肺炎继发脓毒症患者死亡的危险因素。
Objective To investigate the changes of serum procalcitonin(PCT)and C-reactive protein(CRP)in patients with pneumonia-associated sepsis and the prognostic risk factors.Methods Totally 122 patients were divided into pneumonia group(n=52),pneumonia-associated sepsis group(n=57)and pneumonia-associated septic shock group(n=13).The changes of PCT,CRP,Acute Physiology and Chronic Health EvaluationⅡ(APACHEⅡ)score and Sequential Organ Failure Assessment(SOFA)score were compared among three groups.ROC curve was drawn to assess the diagnostic values of PCT,CRP and APACHEⅡto pneumonia-associated sepsis and septic shock.According to the prognosis,the patients with pneumonia-associated sepsis were divided into survival group(n=32)and death group(n=38).The clinical data,PCT,CRP,APACHEⅡscore and SOFA score were compared between two groups.Binary logistic regression analysis was adopted to evaluate the risk factors for the death of pneumonia-associated sepsis.Results The levels of white blood count,PCT,CRP and APACHEⅡscore were significantly lower in pneumonia group(7.59(5.44,10.28)×10~9/L,0.12(0.05,0.33)ng/mL,26.85(7.95,74.40)mg/L,2.0(1.0,4.0))than those in pneumonia-associated sepsis group(12.20(7.25,17.55)×10~9/L,0.80(0.21,1.96)ng/mL,97.80(55.95,127.40)mg/L,11.0(7.5,17.0))and pneumonia-associated septic shock group(15.90(7.00,22.34)×10~9/L,3.49(0.29,50.00)ng/mL,122.90(48.90,200.00)mg/L,21.0(15.5,26.0))(P<0.05).The PCT level,APACHEⅡscore and SOFA score(5.0(3.0,7.0))in pneumonia-associated sepsis group were significantly lower than those in pneumonia-associated septic shock group(9.0(7.5,11.5))(P<0.05),and there were no significant differences in the levels of white blood count and CRP between these two groups(P>0.05).The AUCvalues of PCT,CRP,APACHEⅡscore and the joint detection of them three for diagnosing pneumonia-associated sepsis were 0.791,0.770,0.924and0.943,respectively,and for diagnosing pneumonia-associated septic shock were 0.736,0.718,0.898and 0.899,respectively.The age((69.9±15.2)years)was significantly older,while the SOFA score(7.7±3.5),oxygenation index SOFA score(3.0(2.0,4.0)),incidence of disturbance of consciousness(71.1%)and APACHEⅡscore(16.7±7.1)in death group were significantly higher than those in survival group((58.6±21.3)years,4.7±1.9,3.0(2.0,3.0),37.5%,9.6±5.0)(P<0.05).And the oxygenation index SOFA score and APACHEⅡscore were the independent prognostic risk factors for the death of pneumonia-associated sepsis(OR=2.979,95%CI:1.307-6.791,P=0.009;OR=1.179,95%CI:0.997-1.394,P=0.050).Conclusion PCT,CRP and APACHEⅡscore have certain values to the diagnosis of pneumonia-associated sepsis.The accuracy of APACHEⅡscore is higher than that of PCT and CRP for the diagnosis of pneumonia-associated sepsis and septic shock,and the joint detection of them three can improve the diagnostic efficacy of pneumonia-associated sepsis.The high oxygenation index SOFA score and APACHEⅡscore are the risk factors for pneumonia-associated sepsis.
关键词(KeyWords)：
肺炎;脓毒症;降钙素原;C反应蛋白;急性生理与慢性健康状况评分;序贯器官衰竭估计评分;预后
Pneumonia;sepsis;procalcitonin;C-reactive protein;Acute Physiology and Chronic Health EvaluationⅡ;Sequential Organ Failure Assessment;prognosis
基金项目(Foundation): 河南省基础与前沿技术研究计划项目(152300410148)
作者(Author):
贾建超,张文平,杨金坡,张安然,马利军
JIA Jian-chao,ZHANG Wen-ping,YANG Jin-po,ZHANG An-ran,MA Li-jun
参考文献(References)：
- [1]PRINA E,RANZANI O T,TORRES A.Community-acquired pneumonia[J].Lancet,2015,386(9998):1097-1108.
- [2]SINGER M,DEUTSCHMAN C S,SEYMOUR C W,et al.The Third International Consensus Definitions for Sepsis and Septic Shock(Sepsis-3)[J].JAMA,2016,315(8):801-810.
- [3]MANDELL L A,WUNDERINK R G,ANZUETO A,et al.Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Communityacquired Pneumonia in Adults[J].Clin Infect Dis,2007,44Suppl2:S27-72.
- [4]KALIL A C,METERSKY M L,KLOMPAS M,et al.Executive Summary:Management of Adults with Hospitalacquired and Ventilator-associated Pneumonia:2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society[J].Clin Infect Dis,2016,63(5):575-582.
- [5]SUBERVIOLA B,CASTELLANOS-ORTEGA A,GonzálezCastro A,et al.Prognostic value of procalcitonin,C-reactive protein and leukocytes in septic shock[J].Med Intensiva,2012,36(3):177-184.
- [6]SHEHABI Y,STERBA M,GARRETT P M,et al.Procalcitonin algorithm in critically ill adults with undifferentiated infection or suspected sepsis:a randomized controlled trial[J].Am J Respir Crit Care Med,2014,190(10):1102-1110.
- [7]赵倩,谢月群,张涛,等.降钙素原对脓毒症患者病情及预后的临床价值[J].中华急诊医学杂志,2016,25(7):937-943.
- [8]LUZZANI A,POLATI E,DORIZZI R,et al.Comparison of procalcitonin and C-reactive protein as markers of sepsis[J].Crit Care Med,2003,31(6):1737-1741.
- [9]孙萍,王东强,谢丽莉.超敏C-反应蛋白与白细胞计数联合检测在感染性疾病中的诊断价值[J].中国中西医结合急救杂志,2013,20(3):189.
- [10]HAUSFATER P.Biomarkers and infection in the emergency unit[J].Med Mal Infect,2014,44(4):139-145.
- [11]ERENLER A K,YAPAR D,TERZI.Comparison of procalcitonin and C-reactive protein in differential diagnosis of sepsis and severe sepsis in emergency department[J].Dicle Med J,2017,44(2):175-182.
- [12]陈淼,林晓军,张红璇,等.降钙素原和C反应蛋白在肺炎合并脓毒血症中的意义[J].中华急诊医学杂志,2017,26(7):807-810.
- [13]刘慧琳,刘桂花.脓毒症患者降钙素原与APACHEⅡ评分的相关性探讨[J].中华急诊医学杂志,2012,21(4):371-374.
- [14]KARTAL E D,KARKAC E,GULBAS Z,et al.Several cytokines and protein C levels with the APACHEⅡscoring system for evaluation of patients with sepsis[J].Balkan Med J,2012,29(2):174-178.
- [15]王胜云,陈德昌.降钙素原和C-反应蛋白与脓毒症患者病情严重程度评分的相关性研究及其对预后的评估价值[J].中华危重病急救医学,2015,27(2):97-101