脓毒症和脓毒性休克的实验室诊断进展

脓毒症(sepsis)是多器官功能障碍(MODS)的前兆,是当前危重病医学面临的棘手问题,由其导致的脓毒症性休克仍然是ICU中的主要死亡原因.尽管目前我国尚无确切的统计学数据,有资料显示:美国每年约有75万人发生脓毒症休克,病死率达50%以上[1].因此早期识别、诊断脓毒性休克,并及时进行充分、恰当的治疗是减少死亡、降低病死率的关键.     

前降钙素和C反应蛋白在脓毒症诊疗中的价值

脓毒症（sepsis）是一种由感染因素诱发、多种炎症反应物质介导的全身综合征，是重症患者和疾病晚期患者的常见死亡原因，其早期诊断较为困难，现今仍沿用2001年的国际脓毒症诊断标准。     

前降钙素在脓毒症诊断中的作用

脓毒症（sepsis）是指由细菌或其他病原体感染引起的全身炎症反应综合征.据报道,可引起脓毒症的病原体包括细菌、病毒、真菌、寄生虫等.在临床上,脓毒症是由于机体过度炎症反应或者炎症失控的结果,而非由于感染的病原体或毒素直接作用所致,但在很多情况下,在病原体得到清除后,脓毒症仍可能继续发展,甚至导致脓毒性休克.目前对于脓毒症的诊断仍缺乏金标准,本实验探讨了前降钙素在脓毒症诊断中的作用[1].     

客观评价脓毒症生物标志物的临床意义

脓毒症(sepsis)及其诱发的多器官功能障碍综合征(MODS)仍然是目前重症监护病房(ICU)的主要死因,且其发生率呈上升趋势.由于临床上仍缺乏早期敏感性诊断手段,目前病死率依然很高.随着分子生物学和现代生物技术的不断发展,人们发现多种生物标志物( biomarker)在脓毒症的早期诊断、病情及预后判断、疗效评估中发挥重要作用.因此,深入了解脓毒症病理生理机制中不同生物标志物的意义及价值,对于脓毒症及其并发症的早期识别及干预,降低患者的病死率及提高生活质量具有积极意义.     

降钙素原及其在脓毒症诊断中的应用

脓毒症 (sepsis)是由感染因素引起的全身性炎症反应综合症 (SIRS)。脓毒症及其随后发生的多器官功能不全综合征 (MODS)是危重症患者的重要死亡原因。因此 ,早期诊断脓毒症、判断其严重度以及预后评估 ,对降低脓毒症、MODS的发生率和病死率 ,提高患者的生存率具有重要意义。近年的研究表明 ,降钙素原 (procalcitonin ,PCT)是脓毒症诊断和鉴别诊断的重要指标[1 ] 。现简介如下。1 .PCT概述 :PCT是一种糖蛋白 ,为降钙素 (calcitonin ,CT)的前肽 ,无激素活性 ,由 1 1 6个氨基酸组成 ,相对分子量为 1 3kD。正常情况下 ,PCTmRNA在甲状…     

血清前清蛋白水平与脓毒症的早期诊断

目的探讨血清前清蛋白（PA）在鉴别诊断全身性炎性反应综合征（SIRS）与脓毒症（sepsis）中的价值，研究血清PA能否对脓毒症的早期诊断提供帮助。方法共有48例SIRS患者及36例sepsis患者入选。在患者入选后的第2天进行PA测定，并进行急性生理和慢性健康状况评分。结果sepsis组PA水平明显低于SIRS组，差异有统计学意义（P〈0．01），若以PA〈170mg／L作为诊断sepsis的阳性标准，PA的敏感性和特异性分别为80．55％和87．50％。结论血清PA有助于早期诊断sepsis。     

应重视脓毒症的抗凝治疗

脓毒症(sepsis)患者是重症监护病房(ICU)最常见的疾病人群,近1/3的脓毒症患者存在器官功能损伤或衰竭,病死率可达50%～70%.早期炎症介质的过度释放一直被认为是脓毒症发生发展的至关重要环节.因此,20多年来治疗严重脓毒症的重点主要是针对体内失控的炎症反应,包括各种炎症介质的单克隆抗体、各种致炎细胞因子的特异性抑制剂及糖皮质激素等.但是多项大规模、多中心的临床试验结果均未证实这种抗炎治疗能够改善脓毒症患者的预后.     

新型感染标志物在脓毒症早期诊断中的应用及研究进展

脓毒症 (sepsis)是感染引起宿主反应失调，导致危及生命的器官功能障碍症候群，病情危急，死亡率高。血培养是诊断的金标准，但培养及鉴定时间较长，而临床治疗需要在脓毒症早期杀灭病原菌以控制患者病情，提高治愈率，减少用药时间，降低死亡率。因此，迫切需要能够快速、准确诊断早期脓毒症的实验室指标以指导临床抗生素治疗。血清炎性介质和氧化应激介质是近年来发展起来的对判断早期感染有益的实验室指标，能够帮助临床医生快速判断感染的存在以及推断可能感染病原体的类型。快速诊断早期脓毒症对早期给药和制定抗菌治疗方案很重要。最终，这可能会提高患者生存率和治疗质量，并且减少抗生素耐药性的产生。     

外周血单核细胞HLA-DR表达与脓毒症的关系

脓毒症(sepsis)是指由感染引发的全身炎症反应综合征。可能并不像以往的“过度炎症反应”,更多的是由于“过度抑制”参与其中;有学者[1]认为在初期炎症反应之后会导致单核细胞失活所致的免疫功能不全,称之为免疫麻痹。1资料与方法1.1一般资料2006年1至6月健康体检人群为对照组20例。ICU病房患者(包括创伤烧伤、大手术和胰腺炎等)67例,男39例,女28例。将其分为A组(非脓毒症)、B组(符合脓毒症但未达到严重脓毒症诊断标准)、C组(符合严重脓毒症诊断标准)。诊断标准:脓毒症、严重脓毒症、MODS的诊断标准参考美国胸科医师协会(ACCP)和美国…     

术后全身炎性反应高危性的评估

脓毒症 ( sepsis)及其后续症包括了严重脓毒症 ( severe sepsis)、脓毒性休克( septic shock)以及多器官功能障碍综合征 ( multiple organ dysfunction syn-drome,MODS)是外科术后危重患者死亡的主要原因 ,而机体促炎反应和抗炎反应间的不平衡是脓毒症及其后续症发生、发展的病理基础。早在 2 0世纪 70年代 ,Fry等就提出了感染学说 ,认为病原微生物的入侵直接导致了组织损伤和器官功能障碍。80年代 Goris等认识到炎症反应的重要性 ,强调持续过度炎症反应在器官功能障碍中的重要作用。 90年代以 Bone等为代表的科学家提出了全身性炎症反应…     

血清淀粉样蛋白A对成人脓毒症诊断价值的Meta分析

目的系统评价血清淀粉样蛋白A(serum amyloid A,SAA)对成人脓毒症诊断的准确性。方法通过计算机检索知网、维普、万方、Sinomed、PubMed、Embase、Cochrane图书馆等公开发表的有关文献,通过QUADAS量表对纳入文献进行质量评估。采用Metadisc1.4和Stata12.0进行异质性分析,根据异质性结果选择效应模型进行定量合成;为减小异质性和阈值的影响,综合灵敏度和特异度的信息,以受试者工作特征曲线(SROC)、曲线下面积(AUC)及Q*指数进行综合评价。结果最终有13篇文献纳入Meta分析,结果显示,SAA对成人脓毒症诊断敏感度为0.72(95%CI 0.70~0.75)和特异度为0.69(95%CI 0.66~0.71),SROC的AUC为0.78,Q*指数为0.72。结论SAA对成人脓毒症诊断的敏感度和特异度较高,可为诊断成人脓毒症提供依据。     

脓毒症诱导急性肾损伤的研究进展

脓毒症是一种发病急、病情进展迅速、病死率高的危重疾病,急性肾损伤(AKI)被认为是预测脓毒症患者死亡的独立危险因素,但脓毒症诱导AKI的机制并不十分清楚.另外,RIFLE 标准中的血清肌酐增加和尿量减少已经使我们能够在相对早的阶段诊断AKI,中性粒细胞明胶酶相关载脂蛋白(NGAL)作为肾损伤的一种早期标志物,在诊断及早期治疗干预中可能发挥潜在的作用.本文在此对脓毒症诱导的AKI发病机制、早期诊断及生物学标志物的研究进展做一探讨.     

Elevated procalcitonin and C‐reactive protein as potential biomarkers of sepsis in a subpopulation of thrombotic microangiopathy patients

Thrombotic microangiopathy (TMA) comprises a group of microvascular thrombosis syndromes associated with multiple pathogenic factors. Deficient activity of ADAMTS13 is a pathogenic factor in a subset of TMA patients that provides a strong rationale for plasma exchange treatment. However, the subset of TMA patients with normal ADAMTS13 activity remains a heterogeneous group of patients in which the appropriate treatment is not well understood. In addition to the common forms of TMA thrombotic thrombocytopenic purpura and the hemolytic uremic syndrome, the differential diagnosis of TMA may include sepsis, autoimmune disorders, and disseminated intravascular coagulation. Optimal treatment of TMA depends on timely recognition of treatable pathogenic factors. We hypothesized that sepsis is a rapidly identifiable pathogenic factor in a subset of TMA patients. To test this hypothesis, we retrospectively measured the rapid biomarkers of sepsis C‐reactive protein (CRP) and procalcitonin (PCT), in a repository of pretreatment plasma samples from 61 TMA patients treated with plasma exchange. Levels were analyzed in 31 severely ADAMTS13‐deficient and 30 ADAMTS13‐normal patients. None of the 31 patients with severe deficiency of ADAMTS13 had elevated PCT. However, 11 of 30 (37%) non‐ADAMTS13‐deficient patient samples were strongly positive for PCT. These patient samples also had a >10‐fold higher median CRP level than patients with normal PCT. We conclude that rapid assays may help identify sepsis in a subset of TMA patients. J. Clin. Apheresis, 2009. © 2009 Wiley‐Liss, Inc.     

The value of C-reactive protein in emergency medicine

C-reactive protein (CRP) is a commonly used tool in emergency department (ED), especially in febrile and infectious patients. It was identified in 1930 and was subsequently classified into an “acute phase protein”, an early indicator of infectious or inflammatory situations in the ED, CRP must be a diagnostic reference and no single value can be indicated to rule in or rule out a specific diagnosis or disease. CRP is a comprehensively assisted tool for evaluation and diagnosis of tissue damage (rheumatologic diseases, stroke, cancer, pancreatitis, burn injury, sepsis and gout) and infection (urinary tract infection, pelvic inflammatory disease, meningitis and lung infection). It can be used for treatment monitoring and severity evaluation in pneumonia, pancreatitis, pelvic inflammatory disease (PID), and urinary tract infections (UTI). Otherwise, it also plays the role of prognostic indicator of acute coronary syndrome. C-reactive protein adds little to the diagnosis of pneumonia, urinary tract infections, and pancreatitis. A single CRP value should not straightly make the decision to treat these patients. That is, CRP has no role in diagnosing these clinical entities, and a normal CRP level should never delay antibiotic coverage in ED. Faster and more interpretable tools such as image studies (X-ray, sonography and computed tomography) are available to help diagnose suspected cases of aortic dissection, appendicitis, cholecystitis, pancreatitis, pneumonia and stroke in ED.     

Cord blood plasma reference intervals for potential sepsis markers: pro-adrenomedullin, pro-endothelin, and pro-atrial natriuretic peptide

Objectives

To establish reference values in cord blood of the following new sepsis markers: pro-adrenomedullin (MR-proADM), pro-endothelin (CT-proET-1), and pro-atrial natriuretic peptide (MR-proANP).

Methods

MR-proADM, CT-proET-1, MR-proANP, and procalcitonin (PCT) were measured in cord blood of newborn infants by Time Resolved Amplified Cryptate Emission (TRACE) technology. The inclusion criteria in the control group (n = 194) was the absence of any clinical sign or risk factor of sepsis. A group of 73 newborn infants presenting with risk factors of sepsis at delivery was also studied.

Results

The median values (reference interval) of CT-proET-1, MR-pro-ADM, and MR-proANP measured in cord blood plasma were 72 pmol/L (39–115), 0.84 nmol/L (0.5–1.38), and 163 pmol/L (76–389), respectively. The PCT reference interval was not significantly different from that previously described in cord blood serum.

Conclusions

The reference intervals established will serve as a starting point for further clinical investigations aimed to elucidate the potential prognostic/diagnostic value of these markers in neonatal sepsis management.     

宏基因组学第二代测序技术对比传统实验室微生物培养在脓毒症病原学诊断中的优势

目的通过对宏基因组学第二代测序技术(mNGS)获得的病原体与实验室培养结果进行对比,了解mNGS在脓毒症病原学诊断中的优势及其临床指导意义。方法将入选的脓毒症患者的标本(肺泡灌洗液、痰液、血液、脑脊液、胸水、腹水、分泌物等)同时送检mNGS和实验室细菌培养,对结果进行对比分析,评价mNGS在脓毒症病原学诊断方面的临床价值。结果mNGS的阳性率为78.9%;细菌培养的阳性率为40.4%(P<0.05)。通过mNGS共检出致病病原体57种,其中细菌31种,真菌16种,病毒7种,非典型病原体3种;细菌培养共检出病原体24种,其中细菌18种,真菌6种。以培养结果为金标准,mNGS的敏感度为76.2%,特异度为29.8%,阳性预测值为42.3%,阴性预测值为64.8%。根据病原学结果的抗生素调整将患者分为三组:按mNGS调整为mNGS组、经验性调整为经验组、按培养结果调整为传统培养组。mNGS组ICU住院时间更短(P<0.05),培养组降钙素原下降更明显(P<0.05)。结论mNGS在感染性疾病病原体的诊断方面较传统微生物培养时间更短,阳性率更高,在少见病原体、罕见病原体诊断方面有显著优势,可缩短患者ICU住院时间。     

A retrospective study of 130 consecutive multiple trauma patients in an intensive care unit

A retrospective study of 130 multiple trauma patients admitted to an intensive care unit is presented. Overall mortality was 33% for a mean ISS of 39.4. Craniocerebral trauma, multiple organ failure, sepsis and ARDS are the main causes of death, although there is no statistical difference for these between survivors and non-survivors. There is a good correlation between ISS and mortality (r=0.86). Patients developing MOF, sepsis and ARDS have significantly higher ISS. Mortality from complications such as sepsis, MOF, ARDS and aspiration pneumonia seems more related to age.     

游离钙和氧合指数联合快速序贯器官衰竭评分在识别成人脓毒症中的诊断效能

目的研究游离钙(iCa)和氧合指数(PaO₂/FiO₂)联合快速脓毒症相关序贯器官衰竭评分(qSOFA)在识别成人脓毒症患者中的诊断效能。方法回顾性分析2019年10月至2021年3月就诊于东部战区总医院抢救室的147例脓毒症患者及158例主要诊断为非脓毒症的感染性疾病患者,收集患者临床资料(包括iCa、PaO₂/FiO₂、qSOFA等指标),通过倾向性评分匹配(PSM)校正患者年龄、性别、感染部位等混杂因素,得到脓毒症组(n=93)和非脓毒症组(n=93)患者,比较PSM前后两组间的临床资料,将匹配后数据集(n=186)作为训练集,采用Logistic回归分析感染性疾病患者发生脓毒症的独立危险因素,通过受试者工作特征曲线下面积(AUC)进行诊断效能分析,比较新发低钙血症、PaO₂/FiO₂、qSOFA及三者联合模型在识别成人脓毒症患者中的诊断效能,将原数据集(n=305)作为验证集代入联合模型进行验证,并比较联合模型与脓毒症相关序贯器官衰竭评分(SOFA)间的差异和一致性。结果PSM前后脓毒症患者iCa、PaO₂/FiO₂均低于非脓毒症组(PSM前:Z=-5.138,Z=-7.743;PSM后:Z=-3.505,Z=-4.817,P<0.001),qSOFA分值高于非脓毒症组(PSM前:Z=-7.089;PSM后:Z=-4.149,P<0.001),iCa与降钙素原(PCT)、C-反应蛋白(CRP)、白细胞介素-6(IL-6)、SOFA及急性生理与慢性健康状况评分系统Ⅱ(APACHEⅡ)呈负相关(r=-0.338、-0.243、-0.271、-0.281、-0.269,P<0.05),联合模型在训练集(n=186)中识别成人脓毒症患者的AUC为0.777,95%CI为0.711~0.835,敏感度为74.19%,特异度为73.12%,阳性似然比为2.76,阴性似然比为0.35,在验证集(n=305)中识别成人脓毒症患者的AUC为0.836,95%CI为0.790~0.876,敏感度为77.55%,特异度为77.85%,阳性似然比为3.50,阴性似然比为0.29,联合模型在训练集及验证集中的AUC大于新发低钙血症、PaO₂/FiO₂及qSOFA分值(P<0.001),与SOFA进行McNemar检验提示P=0.904、一致性检验Kappa值为0.554(P<0.001)。结论新发低钙血症、PaO₂/FiO₂、qSOFA分值与感染性疾病患者发生脓毒症有回归关系,其中新发低钙血症是独立危险因素,与iCa、PaO₂/FiO₂及qSOFA单独使用相比,三者联合模型在识别成人脓毒症中的诊断效能更高。     

Plasma hepatocyte growth factor is increased in early-phase sepsis

To elucidate the involvement of hepatocyte growth factor (HGF) in systemic inflammatory response syndrome (SIRS) and sepsis, we investigated the plasma levels of HGF, as well as those of various proinflammatory and anti-inflammatory cytokines, in 50 patients who visited our emergency department (ED). The patients were divided into four groups, depending on the existence of SIRS and infection: group 1 (G1), no infection and no SIRS; group 2 (G2), infection and no SIRS; group 3 (G3), no infection and SIRS; and group 4 (G4), infection and SIRS (e.g., sepsis). We found that plasma HGF levels in G4 were significantly higher than those in the groups without infection (G1 and G3). However, the correlations between HGF and other cytokines were comparatively low compared with those between any other pairs of cytokines, suggesting independent regulation of HGF production in vivo. High plasma HGF was significantly correlated with the presence of infection and with serum total bilirubin (TB) level on multivariate logistic regression analysis. Considering HGFs known functions, we speculated that high plasma HGF levels may indicate the occurrence or necessity for tissue protection and regeneration after acute systemic insults in sepsis.     

创伤弧菌脓毒症大鼠肝组织因子和组织因子途径抑制物的基因表达及抗生素的影响

目的 研究创伤弧菌(VV)脓毒症大鼠肝组织的组织因子(TF)和组织因子途径抑制物(TFPI)基因表达及抗生素头孢哌酮钠联用乳酸左旋氧氟沙星对其的影响.方法 110只雄性SD大鼠随机(随机数字法)分为正常对照组(NC组,10只)、创伤弧菌脓毒症组(VV组,分5个哑组,每亚组10只)、创伤弧菌脓毒症药物干预组(AA组,分5个亚组,每亚组10只).构建创伤弧菌脓毒症模型及药物干预模型.RT-PCR检测大鼠肝组织TF mRNA和TFPI mRNA的基因表达水平.应用SPSS 12.0进行t检验、方差分析等处理.结果 与NC组相比,VV组染菌后2 h,6 h,9 h,12 h,16 h TF mRNA表达均明显升高(P<0.05),其中染菌6 h表达最高;从组染菌后9 h,12 h的TF mRNA仍明显高于NC组(P<0.05),后逐渐减少.VV组与AA组的肝组织TFPI mRNA与NC组相比,均无明显改变(P>0.05).与相同时间点的VV组相比,AA组16 h TF mRNA明显降低(P相似文献