创伤患者血浆降钙素原与创伤严重程度全身性感染器官衰竭及死亡率之间关系的研究

目的分析比较创伤患者血浆降钙素原(PCT)水平和全身炎症反应综合征(SIRS)、感染、多器官功能障碍综合征(MODS)的发生率和严重程度,并评估PCT对这些创伤后并发症的预测价值.方法对急诊抢救和入住重症监护病房(ICU)的机械性创伤患者在创伤严重程度、感染性并发症的发生、器官功能不全及死亡率等方面进行回顾性分析,在入院当天和第1、3、5、7、10、14和21天分别采集血标本,采用免疫发光法检测血浆PCT.结果机械性创伤导致的血浆PCT升高与创伤严重程度相关,在第1～3天达到峰值,并在21 d内逐渐下降.与没有发生SIRS的患者相比,发生SIRS患者的血浆PCT水平升高显著(P＜0.05).在创伤后第1天,创伤后病情平稳的患者血浆PCT水平为1.0±0.3μg/L,而伴有全身性感染、多器官功能不全患者的血浆PCT水平分别为7.0±3.2、5.5±2.6μg/L,且其在创伤早期血浆PCT浓度最高,并维持在高水平约10～14 d.创伤后3 d内血浆PCT水平升高预示严重的SIRS、全身性感染和MODS的发生(P＜0.0001).结论PCT水平升高可以作为一项对创伤患者发生全身性感染和MODS敏感的和有预测意义的指标,常规监测血浆PCT有助于早期认识创伤后并发症.因此,PCT可以作为一个有价值的指标来监测高危创伤患者的炎症状态.     

Relationship between injury severity and lactate levels in severely injured patients

Objective To determine the correlation of blood concentration of lactate and severity of injury and survival in severely injured patients.Design and setting A prospective study of severely injured patients admitted directly from an emergency surgical unit to a surgical intensive care unit with an Injury Severity Score (ISS) of 16 points or more. The study was conducted over 30 months.Patients 98 severely injured subjects aged between 16 and 82 years with ISS range from 16 to 75 points, overall 25.5% mortality.Interventions Blood lactate concentrations were measured once on admission, twice daily during the first 2 days and once daily during the next 3 days. ISS, Revised Trauma Score, Shock Index, and Trauma and Injury Severity Score were calculated for each subject.Measurements and results Of 98 severely injured patients 91 had elevated blood lactate concentration (over 2.0 mmol/l). Regression analyses demonstrated that injury severity, as measured by ISS, can be predicted from lactate concentration on admission, while survival, either actual or predicted by Trauma and Injury Severity Score higher than 0.5, can be predicted from lactate concentration after 12 h. We also found that patients with Shock Index higher than 0.9 had significantly higher lactate levels during the first 36 h than those with values less than 0.9.Conclusions This study confirmed the relationship between blood lactate levels and injury severity as well as the prognostic value of blood lactate level for survival of severely injured patients.     

Relationship between neopterin and granulocyte elastase plasma levels and the severity of multiple organ failure

In a series of 56 patients (24 uncomplicated postoperative and 32 septic patients), neopterin and elastase alpha 1 protease inhibitor complex (E-alpha 1 PI) plasma levels were measured daily. The clinical course of each patient was evaluated with the Multiple Organ Failure (MOF) score according to Goris. Neopterin could differentiate between septic and nonseptic patients (p less than .001), and E-alpha 1 PI between septic nonsurvivors and nonseptic patients only (p less than .01). In septic patients, acute pulmonary insufficiency was indicated by elevated E-alpha 1 PI values (greater than or equal to 400 micrograms/L) 1 day before mechanical ventilation was performed with a sensitivity of 81% and a specificity of 82%. Defining a patient with MOF whose score was greater than or equal to 5 as a high-risk septic patient, a comparison neopterin greater than or equal to 40 nmol/L and E-alpha 1 PI greater than or equal to 400 micrograms/L, measured 1 day before the evaluation of an MOF score of greater than or equal to 5 yielded a sensitivity of 91% and a specificity of 99% when patients fulfilled both criteria. We conclude that neopterin and E-alpha 1 PI might be useful parameters for the diagnosis of septicemia and monitoring of the clinical course in septic patients. Moreover, they might indicate the possible central role of macrophage and PMN activation in the development of MOF.     

Relationship between injury severity and serum tau protein levels in traumatic brain injured rats

Background

Although serum tau protein levels increase following TBI, the time course is unknown. The aim of the present study was to determine whether serum tau protein levels increased in both a severity-dependent and time-dependent manner in an experimental model of rat traumatic brain injury (TBI).

Methods

A total of 24 Sprague-Dawley rats were subjected to varying grades of TBI using a contusion injury model on the right parietal cortex. Enzyme-linked Immunoabsorbent Assay (ELISA) analysis for serum was performed at 15 min pre-injury, 1, 6, 24, 48, and 168 h post-injury. Immunoblotting for serum tau protein, neurological evaluation and histological observation were also performed.

Results

Tau protein levels rapidly increased after 1 h in both mild and severe TBI groups (p < 0.001), and declined after 6 h. In the sham-operated group, tau protein levels did not change significantly after TBI. Tau protein levels were severity-dependent at 1 and 6 h after TBI. The levels were higher in the severe TBI group than in the mild TBI group at 1 h (p < 0.001) and 6 h (p < 0.001).

Conclusions

Serum tau protein levels were severity-dependent and time-dependent at 1 and 6 h after TBI. However, the serum tau protein may not be a useful marker 24 h after TBI.     

心力衰竭患者低钠血症及与神经内分泌激素的关系

目的 对心衰患者治疗中出现的低钠血症及与血浆激素的关系等有关因素进行分析。方法 156例患者均测定入院时血钠浓度，并于入院后第二天清晨空腹抽血，用放射免疫法测定血浆心钠素(ANP)和肾素(RENIN)浓度。观察不N程度心衰患者的血钠浓度与患者基本情况及ANP浓度的关系。结果 提示年龄、心衰程度、心脏病的种类、药物的使用等均可对低钠血症的形成产生影响，ANP浓度增高者低钠血症数高于ANP浓度正常组。心衰患者治疗前的ANP浓度和血钠浓度间成负相关。结论 提示心衰时神经内分泌的激活是低钠的一个重要因素。有低钠血症者预后较差，病死率明显增高。     

Predictors of mortality and multiple organ failure in children with sepsis

Objectives: To assess the markers of perfusion which best discriminate survivors from non-survivors of childhood sepsis and to compare the information derived from gastric tonometry with conventionally measured haemodynamic and laboratory parameters. Design: Prospective clinical study of children with sepsis syndrome or septic shock. Setting: Paediatric intensive care unit in a tertiary referral centre. Patients: 31 children with sepsis syndrome or septic shock. Interventions: A tonometer was passed into the stomach via the orogastric route. Measurements and main results: The following data were recorded at admission, 12, 24 and 48 h: heart rate, mean arterial pressure, arterial pH, base deficit, arterial lactate, gastric intramucosal pH (pHi) and DCO₂ (intramucosal carbon dioxide tension minus arterial partial pressure of carbon dioxide). The principal outcome measure was survival. The secondary outcome measure was the number of organ systems failing at 48 h after admission. There were 10 deaths and 21 survivors. No variable discriminated survival from death at presentation. Blood lactate level was the earliest discriminator of survival. Using univariate logistic regression, lactate discriminated survivors from those who died at 12 and 24 h after admission, but not at 48 h (p = 0.049, 0.044 and 0.062, respectively). The area under the receiver operating characteristic (ROC) curve for lactate was 0.81, 0.88 and 0.89 at 12, 24 and 48 h, respectively. At 12 h after admission, a blood lactate level > 3 mmol/l had a positive predictive value for death of 56 % and a lactate level of 3 mmol/l or less had a positive predictive value for survival of 84 %. At 24 h a lactate level > 3 mmol/l had a positive predictive value for death of 71 % and a level of 3 mmol/l or less had a positive predictive value for survival of 86 %. No other variable identified non-survivors from survivors at 12 h. Gastric tonometry could only be done on 19 of the 31 children, of whom 8 died and 11 survived. In these 19 children, DCO₂ measured at 24 h, but not at 12 or 48 h, distinguished those who died from those who survived (p = 0.045 and p = 0.20, respectively). The area under the ROC curve for DCO₂ measured at 24 h as a predictor of survival was 0.71. Neither the absolute value of pHi nor the trend of change in pHi at any time in the first 48 h identified survivors in this series. The mean arterial pressure distinguished survivors from non-survivors at 24 and 48 h (area under ROC curve = 0.80 and 0.78, respectively). The base deficit and heart rate did not identify non-survivors from survivors at any time in the first 48 h. Conclusions: Blood lactate level was the earliest predictor of outcome in children with sepsis. In this group of patients, gastric tonometry added little to the clinical information that could be derived more simply by other means. Received: 19 September 1996 Accepted: 20 February 1997     

Interleukin-18 plasma levels are increased in patients with sepsis compared to severely injured patients.

Interleukin-18 (IL-18) appears to play a critical role in cytokine-induced organ failure during endotoxemia in animal models. Therefore, plasma samples from patients with severe trauma and sepsis were examined for the presence of IL-18. Significantly elevated plasma IL-18 concentrations were found in patients with sepsis compared to severely injured patients and healthy humans. Septic patients who died and patients with septic shock exhibited higher levels of IL-18 than survivors and septic patients without shock. In addition, septic patients with gram-positive infections had significantly higher IL-18 plasma levels than patients with gram-negative infection. These findings were confirmed by whole blood assay from healthy humans where Staphylococcus aureus markedly (P < 0.05) increased the release of IL-18 in whole blood ex vivo, while endotoxin was ineffective. Although obtained from a small patient group, these results suggest that IL-18 production may discriminate between gram-positive and gram-negative sepsis, and that increased IL-18 appearance may be associated with an adverse outcome in septic patients.     

脓毒症患者肾损伤程度与肾损伤分子-1表达水平的相关性研究

目的 探讨脓毒症患者肾损伤程度与尿液肾损伤分子-1(Kim-1)表达水平的相关关系,为脓毒症急性肾损伤(AKI)的早期诊断和预防提供简便、可靠的循证医学依据.方法 65例入住ICU的脓毒症患者,根据肾损伤程度,按AKIN诊断和分期标准,分为非AKI组(A组,n=36),轻度AKI组(B组,n=13),中重度AKI组(C组,n=16).另外选取20例健康体检者作为健康对照组(D组,n=20).采集患者静脉血和尿液,用ELISA法检测尿Kim-1表达水平,酶法测定血肌酐(Scr)水平,并计算肌酐清除率(Ccr),分析Kim-1表达水平与肾损伤程度之间的关系;绘制受试者工作特征曲线(ROC),计算曲线下面积(AUC),评价Kim-1对脓毒症AKI的诊断价值.结果 与A组及D组比较,B、C两组尿Kim-1水平均有明显升高(P均<0.05);其中C组较B组升高更明显(P<0.01);各组Kim-1的表达水平与Ccr水平呈负相关(r=-0.792);Kim-1的AUC为0.814(P<0.01).结论 脓毒症AKI患者尿液Kim-1的表达水平较正常人或脓毒症非AKI患者显著增加,其增加幅度与AKI的严重程度呈显著正相关,Kim-1可以作为检测脓毒症AKI的敏感指标.     

The clinical value of procalcitonin and neopterin in predicting sepsis and organ failure after major trauma

We examined whether procalcitonin (PCT) or neopterin (NT) are useful in predicting sepsis, multiple organ failure (MOF), or death after multiple trauma (MT). In a prospective clinical study, a total of 137 consecutive trauma patients (mean age 39 years, median injury severity score [ISS] 27 points) and 34 healthy volunteers were enrolled. Blood samples were collected on arrival in the emergency room until day 28 after trauma. Plasma NT was detected by enzyme-linked immunoassay and PCT plasma levels were determined using an immunoluminometric assay. The incidence of sepsis was 65%, MOF 48%, and death in hospital within 28 days 11%. After adjustment for age, gender, and ISS, PCT and NT levels during the first 2 days after injury were unable to differentiate between patients who developed sepsis or not. On the contrary, patients who developed MOF had higher PCT plasma levels on day 0 (0.60 vs. 0.15 ng/mL), and on days 1 and 2 combined (1.95 vs. 0.32 ng/mL). This difference remained significant in multivariate logistic regression (P = 0.01) and additional subgroup analyses for early and late MOF (P = 0.048 and 0.002). For NT, smaller differences were observed (4.39 vs. 3.68 nmol/L, and 7.20 vs. 5.79 nmol/L), which lost significance in multivariate analysis. On the basis of PCT, ISS, and age, a MOF prediction rule was developed and had a good predictive power (area under the curve: 0.77; P < 0.001). These findings demonstrate that high plasma concentrations of PCT in the early posttraumatic phase are an independent predictor of MOF but not of sepsis.     

颅脑损伤患者血浆D-二聚体含量与伤情、预后的相关性

目的 :探讨D -二聚体 (DD)含量与颅脑损伤病人伤情、预后的相关性。方法 :应用D -二聚体定量测定的方法 ,检测 5 5例不同伤情的颅脑损伤病人血浆中D -二聚体的含量 ,探讨DD含量与格拉斯哥昏迷分级 (GCS)、格拉斯哥预后分级 (GOS)及脑损伤病理类型的关系。结果 :患者组DD含量明显高于对照组 ;DD含量与GCS、GOS呈负相关 ,而与脑损伤病理类型无关。结论 :血浆DD的定量测定有助于早期、准确地判断伤情与预后。     

动态检测血清降钙素原水平对多发伤患者伤情判断的临床意义

目的　探讨血清降钙素原 (PCT)水平的动态变化对多发伤患者伤情判断的意义。方法　对急诊抢救和入住重症监护病房 (ICU)的多发伤患者 96例在入院第 1、3、5、7、10、14和 2 1天分别采集静脉血标本 ,采用免疫发光法检测血清PCT ,以判断PCT水平变化与多发性创伤严重程度和预后之间的关系。结果　多发伤患者在创伤后血PCT水平明显升高 ,各创伤严重程度评分 (ISS)分值区段内的创伤患者PCT水平有显著差异 (P <0 0 5 ) ,随着ISS评分值的增高 ,不同时段PCT水平亦升高 ,二者之间存在正相关性 ,而PCT与年龄无关。结论　动态检测多发伤患者外周血PCT的水平变化可以作为判断多发伤伤情的有效指标之一     

Relationship between alcohol use disorders,cortisol concentrations,and cytokine levels in patients with sepsis

Introduction  

Patients with alcohol use disorders (AUD) are at increased risk of developing sepsis and have higher mortality. AUD are associated with higher cortisol and anti-inflammatory cytokine profile. Higher cortisol increases risk of death in septic patients. The relationship between AUD and cortisol in septic patients is unknown. We aimed to study this relationship and postulated that AUD would be associated with higher cortisol and anti-inflammatory cytokine profile.     

血清降钙素原与多器官功能障碍综合征严重程度相关性的临床研究

目的 研究血清降钙素原(PCT)水平与多器官功能障碍综合征(MODS)严重程度的相关性。 方法 对61例MODS患者(其中感染组40例,非感染组21例)采用微量双夹心免疫发光法测定血清PCT 水平,并记录其急性生理学与慢性健康状况Ⅱ(APACHE Ⅱ)评分和Marshall评分,采用线性回归分析方法分 析血清PCT水平与APACHEⅡ评分的相关性。结果 MODS患者血清PCT水平呈不同程度升高;感染组血 清PCT[13．01(2．73,64．79)μg／L]、APACHEⅡ评分[(17．50±5．35)分]与Marshall评分[(6．38±2．46)分] 明显高于非感染组(1．50(0,2．98)μg／L、(14．67±3．01)分和(4．62±2．01)分,P<0．05或P<0．0013;感染组 与非感染组血清PCT水平与APACHEⅡ评分不相关(r=0．175,P=0．281;r=0．071,P=0．759),全部 MIDDS患者血清PCT水平与APACHEⅡ评分也无明显相关性(r=0．229,P=0．076);全部MODS患者血清 PCT水平与Marshall评分显著相关(r=0．514,P<0．001),但感染组的r值更高(r=0．535,P<0.001),非感 染组血清PCT水平与Marshall评分不相关(r=0．003,P=0．991)。结论 检测血清PCT对判断感染导致的 MODS患者病情严重程度具有重要的临床价值。     

86例新生儿败血症血清降钙素原和C反应蛋白的水平研究

目的探讨血清降钙素原（procalcitonin,PCT）和C反应蛋白（c—reactive protein,CRP）检测在诊断新生儿败血症中的作用。方法采用固相免疫色谱法和免疫比浊法分别测定新生儿败血症患儿的PCT、CRP浓度,并与白细胞（WBC）计数作比较。结果与对照组相比,败血症患儿中PCT和CRP水平明显升高（P〈0．01）,而WBC计数在两组中差异无统计学意义（P〉0．05）;PCT和CRP水平与患儿病情的严重程度呈正相关。结论PCT与CRP均可作为早期识别新生儿败血症及其严重性的重要指标,PCT水平检测对早期诊断与估计预后有重要意义。     

降钙素原、C 反应蛋白与急性胰腺炎严重程度和预后的关系

目的：探讨降钙素原（PCT）、C 反应蛋白（CRP）与急性胰腺炎（AP）严重程度和预后的相关性。方法回顾性分析106例急性胰腺炎（AP）的降钙素原、C 反应蛋白水平,其中重症急性胰腺炎（SAP）45例,轻症急性胰腺炎（MAP）61例。分析它们与其他生化指标、AP 病情程度及患者预后的相关性。结果SAP 组患者血清 PCT 及 CRP 水平分别为（7．86±2．38）μg/L 和（148．26±16．46）mg/L,明显高于 MAP 组的（5．22±2．13）μg/L 和（47．62±9．89）mg/L（P ＜0．01）。AP 患者血清 PCT 水平与 CRP 水平呈正相关（r ＝0．316,P ＜0．01）,且两者与24 h APACHE II 评分、Ranson 评分、Balthazar CT 评分均呈正相关（P ＜0．05或＜0．01）。结论检测 PCT 与 CRP 水平有助于判断 AP 病情发展和预测预后。     

Prognostic value of mortality in emergency department sepsis score, procalcitonin, and C-reactive protein in patients with sepsis at the emergency department

The prognostic value of procalcitonin (PCT) in patients with sepsis at the emergency department (ED) has not been evaluated. We conducted a prospective observational study to compare the prognostic value of PCT on sepsis and compared with a validated score, Mortality in Emergency Department Sepsis (MEDS) score, and C-reactive protein (CRP) in the setting of ED of an urban, university-based medical center. Five hundred twenty-five consecutive adult patients admitted to the ED fulfilling the American College of Clinical Pharmacists/Society of Critical Care Medicine Consensus Conference definition of sepsis were prospectively enrolled. Serum PCT and CRP were evaluated for each patient. Clinical characteristics and laboratory results on ED admission were recorded using a standardized form. Each patient was followed for at least 30 days. The main outcome was early (5-day) and late (6- to 30-day) mortality. The median age of the study sample was 64.0 (interquartile range, 47-76) years old, and the overall 30-day mortality rate was 10.5%. The c-statistic in the prediction of early mortality was 0.89 for MEDS, 0.76 for PCT, and 0.68 for CRP. The c-statistic in the prediction of late mortality was 0.78 for MEDS, 0.70 for PCT, and 0.63 for CRP. Overall, MEDS score has the best discriminative capability among the three tested markers. Under the best cutoff value, PCT was the most sensitive, and MEDS score was the most specific marker. We suggest further combining the information on PCT and MEDS score to enhance the accuracy in predicting ED sepsis mortality.     

重度脓毒症凝血功能紊乱与病情严重度及预后的关系

目的 探讨重度脓毒症凝血功能紊乱与病情严重度及预后的关系.方法 将2002年11月至2005年3月收住全国20家三级医院脓毒症并发急性器官功能不全患者694例分为死亡组和生存组,分析比较两组患者主要凝血指标的差异及主要凝血指标异常与病情严重度（APACHE-Ⅱ评分）的关系.结果 （1）死亡组患者与凝血功能相关的主要指标：血小板明显低于存活组（P＜0.05）,D-dimer明显高于生存组（P＜0.05）,凝血酶元时间（PT）、部份凝血活酶时间（APTT）、TT均较生存组延长（P＜0.05）.（2）血小板下降、血小板下降与D-dimer同时升高,APTT和FDP异常患者的APACHE-Ⅱ评分明显高于生存组（P＜0.05）.结论 与凝血功能相关的主要指标：血小板、D-dimer、PT、APTT、TT的检测对判断重度脓毒症的预后及评估病情严重度有一定指导意义.