降钙素原对脓毒症患者病情及预后的临床价值

目的：探讨降钙素原（procalcitonin，PCT）对脓毒症患者病情及预后的临床价值，及其与急性生理学与慢性健康状况Ⅱ评分（APACHEⅡ评分）的相关性。方法回顾性分析2013年1月1日至2014年12月31日收住本院急诊科（包括普通病房及急诊重症监护室 EICU）、感染科的109例脓毒症患者的临床资料（包括入院24 h 内 PCT 值、白细胞计数 WBC 及中性粒细胞百分比Neut％、APACHEⅡ评分等）。据患者病情严重程度（脓毒血症组、严重脓毒症组和脓毒性休克组）、临床结局（存活组和死亡组）及多器官功能障碍综合征 MODS （MODS 组和非 MODS 组）不同进行分组，比较各组中各指标差异，分析 PCT 与 APACHEⅡ评分两者之间的相关性，评价 PCT、APACHEⅡ评分和 APACHEⅡ评分＋PCT 在评估患者预后及多器官功能障碍综合征中的价值，及分析 PCT 对脓毒症患者预后的独立效应及脓毒症患者预后的影响因素。结果脓毒血症组中 PCT 值、APACHEⅡ评分均低于严重脓毒症组和脓毒性休克组，严重脓毒症组均低于脓毒性休克组，三组之间差异均有统计学意义（P ＜0.05）。脓毒血症组中 WBC 明显低于脓毒性休克组（P ＜0.05）。死亡组较存活组中的 APACHEⅡ评分显著升高，差异有统计学意义（P ＜0.01），而 PCT 值、WBC、Neut％在两组间则差异无统计学意义。非 MODS 组中 APACHEⅡ评分、WBC、Neut％、PCT 值均显著低于 MODS 组（均 P ＜0.05）。PCT 与 APACHEⅡ评分之间呈显著正相关关系（rs ＝0.403，P ＜0.01）。通过绘制 PCT、APACHEⅡ评分、APACHEⅡ评分＋PCT 三者的受试者工作曲线（ROC）来评估脓毒症患者预后情况，得出三者的 ROC 曲线下面积（AUC）分别为0.617、0.899、0.917，而APACHEⅡ评分、APACHE Ⅱ评分＋PCT 的预后评估价值均较 PCT 高（均 P ＜0.01），且 PCT、APACHEⅡ评分的截断值（cut-off）、灵敏度、特异度分别为（3.40 ng／mL、88.24％、38.04％）和（20分、94.12％、81.52％）。同样 PCT、APACHEⅡ评分、APACHEⅡ评分＋PCT 三者评估脓毒症患者多器官功能障碍综合征的 AUC 分别为0.824、0.796、0.871，PCT 分别与 APACHEⅡ评分、APACHEⅡ评分＋PCT 间差异无统计学意义，且 PCT、APACHEⅡ评分的截断值、灵敏度、特异度分别为（7.26 ng／mL、88.24％、63.79％）和（17分、64.71％、87.93％）。PCT 对脓毒症患者预后的 COR、AOR 分别为1.008、1.014，性别与 APACHEⅡ评分是影响脓毒症患者预后的独立危险因素。结论 PCT 值、APACHEⅡ评分能评估脓毒症患者病情，三者间均呈正相关关系。APACHEⅡ评分、APACHEⅡ评分＋PCT 较 PCT 能更好评估患者预后，且 PCT 不能作为预后评估的独立指标；而 PCT、APACHEⅡ评分、APACHEⅡ评分＋PCT 对脓毒症患者多器官功能障碍综合征的评估效能均较好。PCT 研究需考虑混杂因素，性别与 APACHEⅡ评分是脓毒症患者预后的两个独立危险因素。

The clinicalvalue of procalcitoninin the condition and prognosis of patients with sepsis

Objective To explore the clinical value of procalcitonin (PCT)in the disease severity and prognosis of patients with sepsis,and the relationship between PCT and acute physiology and chronic health evaluation Ⅱscore (APACHEⅡscore).Methods Clinical data (including the value of PCT,the count of the white blood cell WBC and the percent of neutrophils percentage Neut%,APACHEⅡ score,et al,within 24 hours after admission)of 109 sepsis patients admitted to the emergency department (including the general ward and emergency intensive care unit EICU)and infections department of our hospital from January 1st 2013 to December 31st 2014 were retrospectively analyzed.The patients were divided into several groups according to the patients condition (the sepsis group,the severe sepsis group and the septic shock group),the clinical outcomes (the survival group and the dead group ),and multiple organ dysfunction syndrome MODS (the MODS group and the non-MODS group),comparing the differences of all markers in each group;to analyze the correlation between PCT and APACHEⅡ score;to assess the value of PCT,APACHE Ⅱ score and APACHE Ⅱ score +PCT for prognosis and multiple organ dysfunction syndrome of patients with sepsis;to have a understanding of the independent effect of PCT on the prognosis andthe factors of prognosis in patients with sepsis.Results The value of PCT,APACHEⅡ score in sepsis group was lower than the severe sepsis group and the septic shock group,also the severe sepsis was lower than the septic shock group,and each group was significantly different (P <0.05).Compared with the septic shock group,the count of WBC of sepsis group was significantly lower (P <0.05).Also the dead group compared with the survival group,the APACHEⅡ score was significantly increased (P <0.01),but the values of PCT,WBC,Neut% were not significantly different.The values of APACHEⅡ score,WBC, Neut%,PCT in the non-MDOS group were significantly lower than those in the MODS group (all P <0.05).The relationship between the values of PCT and APACHEⅡ score was significantly correlated (rs=0.403,P <0.01 ).Using the receiver operating characteristic curve (ROC ) for evaluating the prognosis,the area under curve (AUC)of PCT,APACHE Ⅱ score and the PCT +APACHE Ⅱ score respectively were 0.617,0.899,0.917,and the last two were significantly better (all P <0.01),also the cut-off,sensitivity and specificity of PCT,APACHE Ⅱ score were respectively (3.40 ng/mL, 88.24%,38.04%),(20 scores,94.12%,81.52%).As the same to evaluating MODS,the AUC of PCT,APACHEⅡ score and APACHE Ⅱ score +PCT respectively were 0.824,0.796,0.871,the assessed value between PCT and APACHEⅡ score,between PCT and APACHEⅡ score +PCT were not significantly different;also the cut-off,sensitivity and specificity of PCT,APACHEⅡ score respectively were (7.26 ng/mL,88.24%,63.79%), (17 scores,64.71%,87.93%).The COR and AOR of PCT for the prognosis were respectively 1.008,1.014,and gender and APACHE Ⅱ score were the two independent risk factors for the prognosis in patients with sepsis.Conclusions The value of PCT and APACHEⅡ score could evaluate the severity of illness in sepsis patients,and the three were positive correlations.APACHEⅡ score,APACHEⅡ score +PCT had a significantly higher prognostic value than PCT,and PCT could not be a independent marker.But for assessing the MODS in patients with sepsis,the assessed value of PCT,APACHEⅡ score,APACHEⅡ score +PCT were medium.Gender and APACHEⅡ score were the two independent risk factors for the prognosis in patients with sepsis.