C-reactive protein used as an early indicator of infection in patients with systemic inflammatory response syndrome

Objective To assess the diagnostic value of a single determination of serum C-reactive protein as a marker of sepsis in critically ill patients.Design Prospective, observational study.Setting Intensive care unit of a university hospital.Patients and participants One hundred twenty-five adult patients with systemic inflammatory response syndrome (SIRS) (55 patients without evidence of infection and 70 patients with the diagnosis of sepsis confirmed by documented infection). Twenty-five patients with non-complicated acute myocardial infarctions (AMI) and 50 healthy volunteers were used as controls.Interventions None.Measurements and results Serum C-reactive protein concentration was measured within the first 24 h of SIRS onset. Healthy subjects, AMI and non-infectious SIRS patients showed lower C-reactive protein median values ([(0.21 [95% confidence intervals (95% CI), 0.21–0.4] mg/dl, 2.2 [95% CI, 2.1–4.9] mg/dl and 1.7 [95% CI, 2.4–5.5] mg/dl, respectively) than patients with sepsis (18.9 [95% CI, 17.1–21.8]), p<0.001. The presence of severe sepsis (r_s=0.27; p=0.03), SOFA score (r_s=0.25; p=0.03) and arterial lactate (r_s=0.24; p=0.04) correlated significantly with C-reactive protein concentrations in sepsis cases. The best threshold value for C-reactive protein for predicting sepsis was 8 mg/dl (sensitivity 94.3%, specificity 87.3%). The area under the receiver-operating characteristic curve for C-reactive protein was 0.94 (95% CI, 0.89–0.98).Conclusions Determination of serum C-reactive protein can be used as an early indicator of infection in patients with SIRS.Supported in part by Red Respira (isciii-RTIC C03/11), CIRIT SGR 2001/414 and Distinció a la Recerca Universitaria (JR).     

Urokinase-type plasminogen activator receptor as a predictor of poor outcome in patients with systemic inflammatory response syndrome

BACKGROUND:

Urokinase-type plasminogen activator (uPA) and urokinase-type plasminogen activator receptor (uPAR) are known as important factors, which mediate a variety of functions in terms of vascular homeostasis, inflammation and tissue repair. However, their role in systemic inflammatory response syndrome (SIRS) has been less well studied. This study aimed to test the hypothesis that the abnormalities of fibrinolysis and degradation of extracellular matrix mediated by uPA and uPAR are directly related to the patients with SIRS. We therefore analyzed their role and clinicopathological significance in patients with SIRS.

METHODS:

A case-control study was conducted with 85 patients who were divided into two groups according to the diagnostic criteria of SIRS: SIRS group (n=50) and non-SIRS group (n=35). The SIRS group was divided into MODS group (n=26) and non-MODS group (n=24) by their severity, and survival group (n=35) and non-survival group (n=15) by their prognosis. Another 30 healthy adults served as normal controls. uPA and uPAR in plasma were detected by commercial enzyme-linked immunosorbent assay (ELISA) kits.

RESULTS:

The plasma level of uPA was lower in the SIRS group than in the non-SIRS group and controls (P<0.001 and P<0.001). It was lower in sepsis patients and the MODS group than in the non-sepsis patients and the non-MODS patients (all P<0.05). However, there was no difference in uPA level between survivors and non-survivors (P>0.05). The plasma level of uPAR increased in the SIRS group compared with the non-SIRS group and controls (P<0.001 and P<0.001). There was a significant elevation of uPAR in sepsis patients, MODS patients and non-survivors as compared with non-sepsis patients, non-MODS patients and survivors respectively (all P<0.05). Plasma uPAR levels were positively correlated with APACHE II score (r=0.575, P<0.001) and SOFA score (r=0.349, P=0.013). AUCs for the prediction of SIRS mortality were 0.67 and 0.51, respectively, for uPA and uPAR.

CONCLUSION:

uPAR could be a predictor of poor outcome in patients with SIRS.KEY WORDS: Systemic inflammatory response syndrome, Multiple organ dysfunction syndrome, Urokinase-type plasminogen activator, Urokinase-type plasminogen activator receptor     

Oxidative stress in critically ill patients with systemic inflammatory response syndrome

OBJECTIVE: To evaluate whether critically ill patients with systemic inflammatory response syndrome, on admission to an intensive care unit, had more severe oxidative stress than those without this syndrome. DESIGN: A prospective, cohort study. SETTING: A mixed medical and surgical adult intensive care unit with 12 beds. PATIENTS: A total of 68 consecutive patients admitted to the intensive care unit. INTERVENTIONS: Venous blood samples were routinely obtained within 24 hrs of admission. MEASUREMENTS AND MAIN RESULTS: Patients' plasma total antioxidant capacity, the lipid peroxidation products malondialdehyde and 4-hydroxynonenal, reduced sulfhydryl groups, and nitrites/nitrates were measured by spectrophotometric technique at admission to the intensive care unit. Myeloperoxidase (enzyme-linked immunosorbent assay) and polymorphonuclear elastase (immuno-activation assay) were also measured on admission to the intensive care unit. The patients with criteria of systemic inflammatory response syndrome (n = 20) had higher Acute Physiology and Chronic health Evaluation III scores (determined by collecting the worst value within 24 hrs after admission to the intensive care unit) and plasma concentrations of lipid peroxidation products and nitrites/nitrates and lower plasma concentration of reduced sulfhydryl groups and plasma total antioxidant capacity than patients without the syndrome (n = 48). Moreover, the markers for leukocyte activation, myeloperoxidase and polymorphonuclear elastase, presented higher concentrations in the plasma of patients with systemic inflammatory response syndrome. CONCLUSIONS: Patients admitted to the intensive care unit with criteria of systemic inflammatory response syndrome had a more severe oxidative stress than patients without this syndrome.     

Sweet's syndrome associated with systemic inflammatory response syndrome

Septic shock is characterised by infection causing a systemic inflammatory response, end-organ failure and acute circulatory collapse. Treatment consists of antimicrobial therapy and the supportive management of multi-organ failure. We report a case of what we believed to be septic shock due to pyelonephritis in a patient whose condition continued to deteriorate despite conventional treatment until the diagnosis of Sweet's syndrome was made. Once she was started on high dose steroids, her condition improved and she made a full recovery. We believe this to be the first case of a severe systemic inflammatory response syndrome associated with Sweet's syndrome. Received: 20 January 1998 Accepted: 12 June 1998     

Periplaneta americana extract used in patients with systemic inflammatory response syndrome

BACKGROUND: Periplaneta americana extract is recognized to have a positive effect on gastrointestinal mucosa. This study aimed to investigate the effects of periplaneta americana extract on immune function, nutrition status and gastrointestinal complications of early enteral nutrition patients with systemic inflammatory response syndrome (SIRS).METHODS: Patients with SIRS were randomly divided into two groups: treatment and control groups. All patients in the two groups received conventional therapy including enteral nutrition, but periplaneta americana extract, an additional Chinese medicine, was given to the patients in the treatment group. At the beginning of treatment (0 day) and 1, 3, and 7 days after treatment, the levels of immunoglobulin (IgA), total lymphocyte count (TLC), total protein (TP) and prealbumin (PA) were respectively tested in patients' venous blood. The incidences of bloating, diarrhea, aspiration pneumonia and high blood sugar at 7 days after treatment were recorded. The mortality of the patients in 28 days was recorded.RESULTS:At 3 and 7 days after treatment, the levels of IgA and TLC in the treatment group were higher than those in the control group (P<0.05). At 7 days after treatment, the levels of TP and PA in the treatment group were higher than those in the control group (P<0.05). The incidences of bloating and diarrhea in the treatment group were lower than those in the control group, the differences were significant (P<0.05). The mortality of treatment group was lower than that of the control group (P>0.05).CONCLUSION: Periplaneta americana extract could reduce gastrointestinal complications and improve immune function and nutritional status in patients with systemic inflammatory response syndrome.     

胱抑素C在急性胰腺炎并发全身炎症反应综合征致多器官功能障碍综合征患者中的变化

目的：观察胱抑素 C(cystatin-C,Cys-C)在急性胰腺炎(acute pancreatitis,AP)并发全身炎症反应综合征(systemic inflammatory response syndrome,SIRS)致多器官功能障碍综合征(multiple organ dysfunction syndrome, MODS)患者中的变化。方法 AP 患者178例,根据其并发 SIRS、MODS 情况分为3组：AP 组127例、SIRS 组30例、MODS 组21例。同时,收集健康体检者30例作为正常对照组。测定所有待测者血清 Cys-C、降钙素原(procalcitonin,PCT)、超敏 C 反应蛋白(hypersensitive C-reactive protein,hs-CRP)水平,观察 Cys-C 水平与 AP 并发SIRS、MODS 情况,以及其与血清 hs-CRP、PCT 水平的相关性。结果与对照组比较,观察组血清 Cys-C、PCT、hs-CRP 水平均明显升高(P <0.01)。与 AP 组比较,SIRS、MODS 组升高更为明显,以 MODS 组更为突出(P <0.05或P <0.01)。相关性分析表明,血清 Cys-C 水平与 PCT、hs-CRP 呈正相关。结论 Cys-C 与炎症反应关系密切,参与了 AP 并发 SIRS、MODS,并具有重要作用。     

Serum albumin in systemic inflammatory reaction syndrome

A group of patients with pyoinflammatory surgical disease, which showed a strong correlation between the serum concentration of albumin and the number of signs of a systemic inflammatory reaction (SIR), was examined. It was found that the more number of such signs the patient had, the less blood concentration of albumin was: the linear correlation coefficient averaged -0.78 (p < 0.01) in the group. In the natural development of the disease, the larger number of signs of SIR (negative changes) is followed by decreased albumin concentrations and their reduction (positive changes) leads to an increase and even complete restoration of albumin concentrations. With a fatal outcome, there is a much greater drop in the serum concentration of albumin, which is inconsistent with the magnitude of criteria of SIR. The possible reasons for a reduction in blood albumin concentration and for ineffective correction of hypoalbuminemia in sepsis are discussed.     

肾功能多指标联测在SIRS中早期肾功一能损害的诊断与预测价值

目的：动态监测肾功能多指标联检、观察全身炎症反应综合征（SIRS）至多脏器功能障碍综合征（MODS）时肾功能的变化,肾脏损害部位及程度,寻找一个安全、可靠、简易易推广的早期诊断急性肾功衰竭的方法。方法：选择我院急诊ICU符合SIRS标准56例,其中29例发生急性肾功能衰竭。采用放射免疫法测定血内皮素（ET）、尿微量蛋白系列：尿白蛋白（ALB）、尿免疫球蛋白G（IgG),尿转铁蛋白（TRF）、α1－微球蛋白（α1－MG）、β2－微球蛋白（β2－MG）并与常规尿蛋白、血BUN、Cr进行比较,并计算排钠指数。结果：肾功多指村联测总阳性率及单项指标阳性率均高于血BUN、Cr常规尿蛋白折阳性率。差异有显著意义,P＜0．01。尿微量蛋白系列的变化可出现在SIRS期早于传统生化指标和常规尿蛋白的测定。结论：肾功能多指标动态监测可作为判断SIRS期至MODS早期肾功能状态的又一临床指标。对指导临床、防治MODS的发生,评估预后有一定的实用价值。     

263例烧伤后全身炎性反应综合征临床分析

目的：探讨烧伤后全身炎性反应综合征（SIRS）的诊断、治疗以及对多脏器功能失常综合征（MODS）转归的影响。方法：根据美国胸科医生学会（ACCP）和危重病医学会（SCCM）制定的标准诊断，同时参照APACHEⅡ评分系统、烧伤严重程度、全身感染情况等确定SIRS的严重程度。治疗方法分为烧伤休克的治疗、全身治疗和创面治疗3部分进行。结果：263例中，轻、中度SIRS135例（51．3％）；重度SIRS128例（48．7％），APACHEⅡ评分均＞10分。发生各种严重并发症41例（15．6％），其中并发MODS18例，占并发症发生率的43．9％；死亡19例（7．22％），128例重度SIRS中死亡17例，占死亡总数的89.5%。结论：严重烧伤后由于二次打击因素的存在,SIRS发生率高，与MODS的发病和预后密切相关。高度重视SIRS向MODS转变过程中的高危因素，阻断或消弱二次打击是防治SIRS最有力的措施。     

Clopidogrel-induced systemic inflammatory response syndrome

Clopidogrel bisulfate, a widely used inhibitor of platelet aggregation, is considered at least as safe as aspirin. We describe a patient who developed a systemic inflammatory response syndrome consisting of high fever, tachycardia, cellulitis-like rash, impaired liver function, and mild leukopenia after receiving clopidogrel before coronary angiography and stent implantation. The reaction resolved promptly after withdrawal of the drug and recurred shortly after a rechallenge dose was administered, thus making the diagnosis of a clopidogrel-induced reaction highly probable. Recognition of this clopidogrel-induced syndrome is extremely important, both for rapid discontinuation of the offending drug and for avoidance of unnecessary drug therapy or invasive procedures.     

Peripheral hemophagocytosis: An early indicator of advanced systemic inflammatory response syndrome/hemophagocytic syndrome

Peripheral hemophagocytosis (PHP) is seen in patients with hemophagocytic syndrome (HPS), a clinical status in which activated macrophages play a role in its pathogenesis. The inflammatory state, systemic inflammatory response syndrome (SIRS), is also associated with activated macrophages. However, the link between HPS and SIRS and the clinical implications of PHP remain to be determined. In the present work, we examined the clinical utility and impact of the detection of PHP and the link between HPS and SIRS. We studied the clinical and laboratory profiles of 322 SIRS patients (174 men; mean age, 68 +/- 22 years; range, 16-99 years) who visited an urban hospital specializing in respiratory, cardiovascular, digestive, renal diseases, general surgery, and orthopedics in Japan. Peripheral hemophagocytosis was detected in 40 (23 men; mean age, 81.3 +/- 8.7 years; range, 63-98 years) of 322 patients on 3 +/- 2 days after SIRS diagnosis as determined with a "blunt-edged-smear" method differing from the conventional "feather-edged smear" method. The incidence of advanced SIRS and ensuing death in the SIRS+ PHP- group (37 and 21 of 40, respectively) was significantly greater than in the SIRS+ PHP- group (82 and 17 of 282) (P < 0.01). The duration from SIRS diagnosis to recovery in 19 SIRS+ PHP- surviving patients (26 +/- 18 days) was longer than that in 19 age-matched SIRS+ PHP- surviving patients who initially presented comparable clinical profiles (6 +/- 3 days) (P < 0.001). Bone marrow analysis in all 7 patients having PHP and SIRS showed no HPS initially (<3% hemophagocytes), but all subsequently developed HPS at 7 +/- 1 days after the diagnosis, confirmed by the presence of 9% +/- 13% hemophagocytes in the bone marrow. Electron microscopic and immunohistochemical analyses revealed that PHP was derived from hemophagocytes in the bone marrow. The present data strongly suggest that PHP detection could serve as an early indicator for advanced SIRS and/or HPS and that the use of the blunt-edged method is preferable for PHP detection.     

Elevation in interleukin 13 levels in patients diagnosed with systemic inflammatory response syndrome

Objective To examine plasma levels and circadian rhythm of interleukin 13 (IL-13), tumour necrosis factor (TNF) α and total serum cortisol in the systemic inflammatory response syndrome (SIRS). Design and setting Prospective observational study in a 12-bed medical-surgical ICU of a 500-bed university hospital. Patients Ten patients with SIRS and eight controls. Measurements Arterial blood was sampled hourly for 24 h for measurement of plasma IL-13, TNF- α, cortisol and white blood cell count (WCC) differential within 24 h of development of SIRS. Results There were significantly higher plasma IL-13 levels in SIRS patients than in controls (1282 vs. 713 pg/ml). IL-13 was significantly higher in patients with a diagnosis of sepsis than in those with non-infectious causes of SIRS (2080 vs. 515 pg/ml). In SIRS the elevation in IL-13 was associated with higher TNF-α and reduced WCC. A circadian rhythm was observed in plasma IL-13 secretion. No distinct circadian rhythm was noted for TNF- α, and the normal circadian rhythm of serum cortisol was lost. Conclusions The anti-inflammatory cytokine IL-13 is elevated in early SIRS. Its plasma level exhibits a circadian rhythm and may be modulated in part by TNF-α. SIRS patients have disruption of the normal circadian rhythm of serum cortisol.     

血乳酸和D-二聚体测定在全身炎症反应综合征中的意义

目的　探讨血乳酸 (LA)和D -二聚体 (D -dimer)在全身炎症反应综合征 (SIRS)时的变化、相关性及与预后的关系。方法　满足SIRS诊断标准的住院病人 10 0例为SIRS组 ,并按满足 2项、3项、4项标准分为S1、S2 、S3 亚组 ,按照预后分为生存组和死亡组 ;不满足SIRS诊断标准的急诊病人 5 0例为非SIRS组 ;健康正常人 5 0例为对照组。分别测定LA和D -dimer。结果　SIRS组LA和D -dimer均高于非SIRS组及对照组 (P <0 .0 1) ,SIRS组LA和D -dimer在S3 亚组高于S1亚组 (P <0 .0 5 ) ,死亡组高于生存组 (P <0 .0 5 ) ,SIRS组LA与D -dimer呈明显正相关 (P <0 .0 1) ,LA和D -dimer均与预后呈负相关 ,经检验 ,D -dimer与预后呈明显负相关 (r=- 0 .2 90 3,P<0 .0 1)。结论　LA、D -dimer在SIRS病人明显升高 ,二者呈正相关 ,D -dimer可能是SIRS预后的标记物。     

全身炎症反应综合征中血浆尿激酶型纤溶酶原激活物及其受体的表达

目的 探讨uPA,uPAR与D-D,IL-6及TNF-α之间的关系及其在SIRS中的作用.方法 采用前瞻性、临床病例对照研究,病例的收集均来源于武汉市中心医院2008年1月至2010年1月年龄＞55岁的就诊患者,标本的采集均为清晨空腹静脉血清,检测全身炎症反应综合征( SIRS)患者血中尿激酶型纤溶酶原激活物(uPA)及其受体(uPAR)、D-二聚体(D-D)、白细胞介素6(IL-6)和肿瘤坏死因子(TNF-α)含量.按SIRS诊断标准分为SIRS组:50例来源于重症医学科;非SIRS组35例来源于内科病房;另选30例体检科体检者作为健康对照组,均需排除:(1)孕产妇;(2)恶性肿瘤;(3)转入ICU后7d内死亡;(4)心肺复苏术后;(5)既往有血液系统疾病;(6)入住ICU时即有SIRS的患者.采用双抗体夹心酶联免疫吸附法(ELISA)测定血中uPA,uPAR,D-D,IL-6及TNF-α含量.数据均采用SPSS 17.0统计学软件进行分析:正态分布的计量资料以均数±标准差(-x±s)表示,独立样本t检验进行分析;非正态分布的计量资料以中位数表示,Mann-Whitney秩和检验;相关性分析采用Spearman秩相关检验;以24h血uPA、uPAR、IL-6和TNF-α作受试者工作特征曲线(ROC曲线),比较SIRS患者血uPA,uPAR,IL-6和TNF-α含量诊断MODS的应用价值.结果 SIRS组患者血uPA,uPAR,D-D,IL-6及TNF-α含量较非SIRS组和健康对照组均显著升高(均P＜0.01).uPA与IL-6、TNF-α不相关,uPAR与IL-6,TNF-α呈正相关(分别为r=0.395,P=0.004;r=0.606,P＜0.01).以uPA,uPAR,IL-6及TNF-α诊断MODS做ROC曲线,ROC曲线下面积(AUROC)分别为0.59,0.76,0.86,0.83.结论 uPA和uPAR参与了SIRS患者凝血功能障碍的过程,但在SIRS中起作用的途径机制并不完全相同.uPAR在SIRS向MODS的发展过程中起着一定作用.     

全身炎症反应综合征患者血浆血管活性因子变化及临床意义

目的 探讨肿瘤坏死因子－α（ＴＮＦ－α）去甲肾上腺素（ＮＥ）,内皮素（ＥＴ）,肾上腺髓质素（ＡＤＭ）在全身炎症反应综合征（ＳＩＲＳ）病理过程中的作用。方法 检测３８例不同类型的ＳＩＲＳ（创伤,创伤性休克,感染性休克）患者及１２例健康对照组血浆ＴＮＦ－α,ＮＥ,ＥＴ,ＡＤＭ水平。结果 创伤组,创伤性休克组,感染性休克组与正常对照组血浆ＴＮＦ－α,ＮＥ,ＥＴ,ＡＤＭ浓度相比均明显增加,尤以感染性休克组     

全身炎症反应综合征患者致炎因子与抗炎因子的变化及相关性研究

目的 观察全身炎症反应综合征（SIRS）患者血浆中致炎因子肿瘤坏死因子－α（TNF-α）、白介素－6（IL－6）和抗炎因子转化细胞生长因子－β（TGF-β）、白介素－10（IL－10）的变化规律及其相关性。方法 符合SIRS诊断48例，分别在入院后第1、8小时和第2、3、4天清晨空腹抽肘静脉血3mL，测定TNF－α、IL－6、TGF－β和IL－10，并设对照组。结果 TNF－α和IL－6各监测点均比对照组显著升高（P＜0．05，P＜0．01），TGF－β和IL－10入院后第小时与对照组比较无显著差异，第8小时以后各监测点均比对照组显著升高（P＜0．05，P＜0．01），TNF－α和IL－6峰值出现早于TGF－β和IL－10，致炎因子与抗炎因子具有显著的相关性。结论 拮抗炎症因子的同时提高机体免疫功能，达到致炎因子与抗炎因子的平衡是治疗SIRS的新思路。     

全身炎症反应综合征患者凝血功能的研究

Objective To study the change of coagulation function in the patients of systemic inflammatory response syndrome (SIRS) , and to provide evidences on anticoagulation therapy. Methods All of the patients in ICU were divided into two groups: SIRS (30 patients) and non-SIRS(25 patients). Thirty healthy adults were recruited as controls. Prothrombin time (PT), thrombin time (TT), activated partial thromboplastin time (APTT) , fibrinogen(FIB),levels of platelet (PLT) and D-dimer were measured in all patients and healthy adults. Results The levels of PT, APTT,TT.DD in the SIRS group((16.48 ± 1. 57) s, (22. 67 ± 1. 48) s, (43. 56 ±4.33)s and (2.25 ±0.18)mg/L respectively) were significantly higher than those in the non-SIRS group((12. 83 ± 1.23)s, (17. 05 ±1. 97)s,(33. 34 ±2. 38)s and(0. 58 ±0. 15)mg/L respectively)and the control group ((12. 04 ±0. 98) s,(16. 88 ±1. 37)s,(29. 84 ±1.98)s and (0.43 ±0. 11)mg/L respectively) (P <0. 05). The levels of PLT,FIB in the SIRS group((110. 69 ±50. 23) × 109/L and(2. 05 ±0. 33) g/L, respectively) were significantly lower than those in the non-SIRS group((180. 58 ±45. 70) × 109/L and(3. 54 ±0. 29)g/L,respectively)and the control group ((204. 95 ± 46. 83) × 109/L and (3. 78 ± 0. 54) g/L, respectively) (P < 0. 05). Conclusions The dysfunction of coagulation exits in SIRS. Coagulation system abnormity might play an important role in the development of SIRS.