尿源性脓毒血症严重程度的相关因素分析
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摘要
目的回顾分析临床白细胞(WBC)、中性粒细胞百分比(N%)、血小板(PLT)、纤维蛋白原(FIB)、D-二聚体(D-Dimer)、白细胞介素-6(IL-6)、降钙素原(PCT)、C反应蛋白(CRP)等炎性指标,与尿源性脓毒血症严重程度的相关性,为临床早期诊治尿源性脓毒血症提供临床参考及指导。方法回顾分析2013年1月～2018年4月我院泌尿外科收治尿源性脓毒血症患者的临床资料70例。根据2014版(中国泌尿外科疾病诊断治疗指南)感染性休克和脓毒血症的临床诊断标准分组:A组(脓毒症组)22例;B组(低血压+严重脓毒血症组)12例;C组(感染性休克组)17例;D组(难治性感染性休克组)19例;比较患者的WBC、N%、PLT、FIB、D-Dimer、IL-6、PCT、CRP的差异;应用Logistic回归分析炎性指标与脓毒血症的相关性,评价炎性指标对病情严重程度的相关影响。结果 (1)不服从正态分布的炎性指标进行Kruskal-Wallis检验表明:N%、PLT、D-Dimer、PCT在尿脓毒血症严重程度组别上的P<0.05,差异有统计学意义;CRP符合正态分布及方差齐,单因素方差分析后提示CRP在脓毒血症不同组别上的P>0.05,差异无统计学意义;(2)Kruskal-Wallis事后检验两两比较:N%在A-B、A-C、A-D组之间差异有统计学意义;PLT在AC、A-D组之间差异有统计学意义;D-Dimer在A-C组之间差异有统计学意义;PCT在A-B、A-C、A-D组之间差异有统计学意义;比较炎性指标不同组别的中位数结果提示:PLT数量随脓毒血症严重程度加重而减少,PCT随脓毒血症严重程度升高而上升;N%随脓毒血症严重程度升高而上升;(3)炎性指标的有序Logistic回归提示:PCT的P=0.000,回归系数为0.186;N%显著性检验P=0.035,回归系数为0.047;PLT显著性检验P=0.003,回归系数为-0.012,差异有统计学意义。结论 PCT血清波动与尿源性脓毒血症病情严重程度呈正相关;PLT与尿源性脓毒血症严重程度呈负相关;N%随脓毒血症病情加重而变化,PCT、PLT、N%动态联合检测可以作为脓毒血症患者严重程度的参考指标指导临床治疗。
Objective To analyze the association of the clinical inflammatory indices with the severity of urinary sepsis.Methods We reviewed the clinical data of 70 patients with urinary sepsis treated in our hospital between January, 2013 and April, 2018. All the patients were diagnosed in line with the Guidelines for Diagnosis and Treatment of Urological Diseases in China(2014 edition), including 22 patients with sepsis, 12 with hypotension and severe sepsis, 17 with septic shock, and 19 with critical septic shock. White blood cell count(WBC), neutrophil percentage(N%), platelets(PLT), fibrinogen(FIB), Ddimer, interleukin-6(IL-6), procalcitonin(PCT) and C-reactive protein(CRP) were examined in all the cases and compared among the 4 groups. The correlations of these inflammatory markers with the severity of sepsis were analyzed using logistic regression analysis. Results The 4 groups of patients showed significant differences in N%, PLT, D-dimer, and PCT(P<0.05)but not in CRP(P>0.05). Kruskal-Wallis Pairwise comparisons showed that the N% and PCT in patients with sepsis differed significantly from those in the other 3 groups; platelets in patients with sepsis differed significantly from those in patients with septic shock and critical septic shock; D-dimer differed significantly between patients with sepsis and those with septic shock.Among the 4 groups, the median levels of PLT decreased and PCT and N% increased with the worsening of sepsis. Logistic regression analysis indicated that PCT(r=0.186, P=0.000), N%(r=0.047, P=0.035) and PLT(r=-0.012, P=0.003) were significantly correlated with the severity of sepsis in these patients. Conclusion PCT, PLT and N% are all significantly correlated with the severity of sepsis, and their combined detection can be informative for assessing the severity of sepsis to facilitate clinical decisions on treatment.
Objective To analyze the association of the clinical inflammatory indices with the severity of urinary sepsis.Methods We reviewed the clinical data of 70 patients with urinary sepsis treated in our hospital between January, 2013 and April, 2018. All the patients were diagnosed in line with the Guidelines for Diagnosis and Treatment of Urological Diseases in China(2014 edition), including 22 patients with sepsis, 12 with hypotension and severe sepsis, 17 with septic shock, and 19 with critical septic shock. White blood cell count(WBC), neutrophil percentage(N%), platelets(PLT), fibrinogen(FIB), Ddimer, interleukin-6(IL-6), procalcitonin(PCT) and C-reactive protein(CRP) were examined in all the cases and compared among the 4 groups. The correlations of these inflammatory markers with the severity of sepsis were analyzed using logistic regression analysis. Results The 4 groups of patients showed significant differences in N%, PLT, D-dimer, and PCT(P<0.05)but not in CRP(P>0.05). Kruskal-Wallis Pairwise comparisons showed that the N% and PCT in patients with sepsis differed significantly from those in the other 3 groups; platelets in patients with sepsis differed significantly from those in patients with septic shock and critical septic shock; D-dimer differed significantly between patients with sepsis and those with septic shock.Among the 4 groups, the median levels of PLT decreased and PCT and N% increased with the worsening of sepsis. Logistic regression analysis indicated that PCT(r=0.186, P=0.000), N%(r=0.047, P=0.035) and PLT(r=-0.012, P=0.003) were significantly correlated with the severity of sepsis in these patients. Conclusion PCT, PLT and N% are all significantly correlated with the severity of sepsis, and their combined detection can be informative for assessing the severity of sepsis to facilitate clinical decisions on treatment.
引文
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[20]Li M F,Li X L,Fan K L,et al.Platelet desialylation is a novel mechanism and a therapeutic target in thrombocytopenia during sepsis:an open-label,multicenter,randomized controlled trial[J].Journal of Hematology&Oncology,2017,10(1):104.
[21]Greco E,Lupia E,Bosco O,et al.Platelets and Multi-Organ failure in sepsis[J].Int JMol Sci,2017,18(10):2200.
[22]Jaillon S,GaldieroMR,Del Prete DA,et al.Neutrophils in innate and adaptive immunity[J].Semin Immunopathol,2013,35(4):377-94.
[23]Cheval C,Timsit JF,Garrouste-Orgeas M,et al.Procalcitonin(PCT)is useful in predicting the bacterial origin of an acute circulatory failure in critically ill patients[J].Intensive Care Med,2000,26(Suppl 2):S153-8.
[24]Liu B,Ding X,Yang J.Effect of early goal directed therapy in the treatment of severe sepsis and/or septic shock[J].Curr Med Res Opin,2016,32(11):1773-82.
[25]Suárez-Santamaría M,Santolaria F,Pérez-Ramírez A,et al.Prognostic value of inflammatory markers(notably cytokines and procalcitonin),nutritional assessment,and organ function in patients with sepsis[J].Eur Cytokine Netw,2010,21(1):19-26.
[26]Castelli GP,Pognani C,Meisner M,et al.Procalcitonin and Creactive protein during systemic inflammatory response syndrome,sepsis and organ dysfunction[J].Crit Care,2004,8(4):R234-42.
[27]Oliveira CF,Botoni FA,Oliveira CR,et al.Procalcitonin versus Creactive protein for guiding antibiotic therapy in sepsis:a randomized trial[J].Crit CareMed,2013,41(10):2336-43.
[2]Kaukonen KM,Bailey M,Pilcher D,et al.The systemic inflammatory response syndrome criteria and their differential association with mortality[J].J Crit Care,2018,46:29-36.
[3]Zhao R,Dong S.Clinical value of serum endocan and procalcitonin in early diagnosis and prognosis evaluation of sepsis[J].Zhonghua Wei Zhong Bing Ji JiuYi Xue,2017,29(4):321.
[4]Keshary A,Badgett RG.Reassessment of a meta-analysis of procalcitonin-guided antibiotic therapy for lower respiratory tract infections[J].Lancet Infect Dis,2018,18(2):140.
[5]陈山,魏金星,陈斌,等.泌尿系感染诊断治疗指南[M].北京:人民卫生出版社,2013:424-34.
[6]Uzzan B,Cohen R,Nicolas P,et al.Procalcitonin as a diagnostic test for sepsis in critically ill adults and after surgery or trauma:a systematic review and meta-analysis[J].Crit Care Med,2006,34(7):1996-2003.
[7]Becker KL,Snider R,Nylen ES.Procalcitonin assay in systemic inflammation,infection,and sepsis:clinical utility and limitations[J].Crit CareMed,2008,36(3):941-52.
[8]Napolitano LM.Sepsis 2018:definitions and guideline changes[J].Surg Infect(Larchmt),2018,19(2):117-25.
[9]Giamarellos-Bourboulis EJ,MegaA,Grecka P,et al.Procalcitonin:a marker to clearly differentiate systemic inflammatory response syndrome and sepsis in the critically ill patient[J].Intensive Care Med,2002,28(9):1351-6.
[10]Meisner M,Tschaikowsky K,Palmaers T,et al.Comparison of procalcitonin(PCT)and C-reactive protein(CRP)plasma concentrations at different SOFA scores during the course of sepsis andMODS[J].Crit Care,1999,3(1):45-50.
[11]Lin KH,Wang FL,Wu MS,et al.Serum procalcitonin and C-reactive protein levels as markers of bacterial infection in patients with liver cirrhosis:a systematic review and meta-analysis[J].Diagn Microbiol Infect Dis,2014,80(1):72-8.
[12]Ghorbani G.Procalcitonin role in differential diagnosis of infection stages and non infection inflammation[J].Pak J Biol Sci,2009,12(4):393-6.
[13]赵磊,臧学峰,陈炜.血中炎性指标水平与细菌性血流感染所致脓毒症患者病情严重程度的相关性分析[J].中华危重病急救医学,2015,27(6):448-53.
[14]刘阳桦,吴敏.细菌性血流感染所致脓毒症患者凝血-炎症生物标志物水平变化的临床意义[J].中国病原生物学杂志,2017,12(3):270-3.
[15]保勇,史梦,喻华,等.检测血清降钙素原对感染性疾病及脓毒症的诊断价值[J].实用医院临床杂志,2012,9(1):94-6.
[16]尹承芬,李彤,高心晶,等.降钙素原对成人脓毒症诊断准确性的Meta分析[J].中华危重病急救医学,2015,27(9):743-9.
[17]Schroeder S,Hochreiter M,Koehler T,et al.Procalcitonin(PCT)-guided algorithm reduces length of antibiotic treatment in surgical intensive care patients with severe sepsis:results of a prospective randomized study[J].LangenbeckArch Surg,2009,394(2):221-6.
[18]Liew YX,Chlebicki MP,Lee W,et al.Use of procalcitonin(PCT)to guide discontinuation of antibiotic use in an unspecified sepsis is an antimicrobial stewardship program(ASP)[J].Eur J Clin Microbiol Infect Dis,2011,30(7):853-5.
[19]Schultz MJ,Determann RM.PCT and sTREM-1:the markers of infection in critically ill patients[J].Med Sci Monit,2008,14(12):RA241-7.
[20]Li M F,Li X L,Fan K L,et al.Platelet desialylation is a novel mechanism and a therapeutic target in thrombocytopenia during sepsis:an open-label,multicenter,randomized controlled trial[J].Journal of Hematology&Oncology,2017,10(1):104.
[21]Greco E,Lupia E,Bosco O,et al.Platelets and Multi-Organ failure in sepsis[J].Int JMol Sci,2017,18(10):2200.
[22]Jaillon S,GaldieroMR,Del Prete DA,et al.Neutrophils in innate and adaptive immunity[J].Semin Immunopathol,2013,35(4):377-94.
[23]Cheval C,Timsit JF,Garrouste-Orgeas M,et al.Procalcitonin(PCT)is useful in predicting the bacterial origin of an acute circulatory failure in critically ill patients[J].Intensive Care Med,2000,26(Suppl 2):S153-8.
[24]Liu B,Ding X,Yang J.Effect of early goal directed therapy in the treatment of severe sepsis and/or septic shock[J].Curr Med Res Opin,2016,32(11):1773-82.
[25]Suárez-Santamaría M,Santolaria F,Pérez-Ramírez A,et al.Prognostic value of inflammatory markers(notably cytokines and procalcitonin),nutritional assessment,and organ function in patients with sepsis[J].Eur Cytokine Netw,2010,21(1):19-26.
[26]Castelli GP,Pognani C,Meisner M,et al.Procalcitonin and Creactive protein during systemic inflammatory response syndrome,sepsis and organ dysfunction[J].Crit Care,2004,8(4):R234-42.
[27]Oliveira CF,Botoni FA,Oliveira CR,et al.Procalcitonin versus Creactive protein for guiding antibiotic therapy in sepsis:a randomized trial[J].Crit CareMed,2013,41(10):2336-43.