降钙素原在心脏术后感染性与非感染性全身炎症反应综合征的鉴别诊断价值

Procalcitonin for the differential diagnosis of infectious and non-infectious systemic inflammatory response syndrome after cardiac operation

目的 评价降钙素原（PCT）对于早期鉴别心脏术后感染性与非感染性全身炎症反应综合征（SIRS）的诊断价值.方法 对2011年4月1日至2013年3月31日期间因心脏手术后入住东京医科齿科大学（日本）医学部附属医院重症监护病房（ICU）符合SIRS诊断的142例患者的临床资料进行回顾性分析,根据国际“拯救脓毒症宣言”2012年指南标准,将患者分为感染组（47例）和非感染组（95例）.感染组患者包括脓毒症11例,严重脓毒症12例,感染性休克24例.对患者临床资料进行比较,并绘制受试者工作特征曲线（ROC曲线）,评估PCT、C-反应蛋白（CRP）、白细胞计数（WBC）鉴别感染性与非感染性疾病的诊断价值,以及诊断脓毒症的严重程度.结果 感染组PCT、CRP、WBC明显高于非感染组[PCT（μg/L）：2.80（1.24,10.20）比0.10（0.06,0.21）,Z=-9.020,P=0.001; CRP （mg/L）：158.0 （120.0,199.0）比58.0（25.0,89.0）,Z=-7.264,P=0.001;WBC（×109/L）：15.5（11.0,22.6）比9.3（7.2,12.6）,Z=-5.792,P=0.001].PCT、CRP、WBC诊断脓毒症的临界值分别为0.47 μg/L、119.5 mg/L、10.85×109/L,三者相比较,PCT对脓毒症诊断具有最高敏感度（91.5％）及特异度（93.7％）.脓毒症组、严重脓毒症组、感染性休克组WBC比较差异无统计学意义[×109/L：12.40（9.10,24.20）、13.30（9.93,16.93）、20.40（13.45,28.60）,x2=5.638,P=0.060],而PCT、CRP差异具有统计学意义[PCT（μg/L）：1.37 （0.72,1.85）、3.16（0.48,13.24）、3.68 （1.67,20.96）,x2=7.422,P=0.024; CRP （mg/L）：120.0 （74.0,180.0）、135.7（81.7,181.3）、171.1（151.5,306.0）,x2=9.524,P=0.009].对于诊断严重脓毒症,PCT优于CRP,但对感染性休克无诊断效力.PCT诊断严重脓毒症临界值为2.28 μg/L时的敏感度为66.7％,特异度为90.9％; CRP诊断感染性休克临界值为149.5 mg/L时的敏感度为83.3％,特异度为66.7％.结论 与WBC、CRP等炎症指标比较,血清定量PCT测定在心脏术后感染性并发症早期诊断中具有更好的预测价值,以PCT≥0.47 μg/L为诊断脓毒症的临界值.

Objective To assess the value of procalcitonin （PCT） for the differential diagnosis between infectious and non-infectious systemic inflammatory response syndrome （SIRS） after cardiac operation.Methods Patients diagnosed with SIRS after cardiac surgery and admitted to Department of Cardiovascular Surgery of Tokyo Medical and Dental University Graduate School between April 1st,2011 and March 31st,2013 were retrospectively studied.A total of 142 patients with SIRS were included,and they were divided into infectious group （n =47） or non-infectious group （n =95） according to the diagnostic criteria of the Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock：2012 （SSCG2012）.The patients with infectious SIRS were included,and there were 11 with sepsis,12 with severe sepsis without shock,and 24 with septic shock respectively.The clinical data of patients were compared,and the receiver operating characteristic curve （ROC curve） was plotted to assess the diagnostic value of infection and non-infectious diseases for PCT,C-reactive protein （CRP） and white blood cell count （WBC）,as well as the diagnosis of the severity of sepsis.Results PCT,CRP,and WBC were significantly higher in the infectious SIRS group than those in the non-infectious SIRS group [PCT （μg/L）：2.80 （1.24,10.20） vs.0.10 （0.06,0.21）,Z=-9.020,P=0.001; CRP （mg/L）：158.0 （120.0,199.0） vs.58.0 （25.0,89.0）,Z=-7.264,P=0.001; WBC （× 109/L）：15.5 （11.0,22.6） vs.9.3 （7.2,12.6）,Z=-5.792,P=0.001].PCT had the highest sensitivity （91.5％） and specificity （93.7％） for differential diagnosis,with a cut-off value for infectious SIRS of 0.47 μg/L,and the cut-offvalue of CRP and WBC were 119.5 mg/L and 10.85 × 109/L,respectively.There was no significant difference in WBC among sepsis group,severe sepsis group,and septic shock group [× 109/L：12.40 （9.10,24.20）,13.30 （9.93,16.93）,20.40 （13.45,28.6）,x2=5.638,P=0.060],while PCT,CRP had significant difference [PCT（μg/L）：1.37 （0.72,1.85）,3.16 （0.48,13.24）,3.68 （1.67,20.96）,x2=7.422,P=0.024; CRP （mg/L）：120.0（74.0,180.0）,135.7 （81.7,181.3）,171.1 （151.5,306.0）,x2=9.524,P=0.009].PCT was more reliable than CRP in diagnosing severe sepsis without shock,but it was ineffective for diagnosing septic shock.The cut-off value of PCT for diagnosing severe sepsis without shock was 2.28 μg/L,and the sensitivity was 66.7％,specificity was 90.9％.Cut-off value of CRP for the diagnosis of septic shock was 149.5 mg/L,with the sensitivity of 83.3％,and the specificity of 66.7％.Conclusions PCT was a useful marker for the diagnosis of infectious SIRS after cardiac operation as compared with WBC and CRP.The optimal PCT cut-off value for diagnosing infectious SIRS was 0.47 μg/L.