全身炎症反应综合征患者心率变异性及血甲状腺激素和皮质醇变化与预后关系的研究

Relationship between heart rate variability and serum levels of thyroid hormones, cortisol and prognosis in patients with systemic inflammatory response syndrome

目的探讨全身炎症反应综合征（SIRS）患者自主神经活动与下丘脑一垂体一肾上腺轴的关系，筛查判断SIRS预后的有用指标。方法对受试者进行急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分和多器官功能障碍综合征（MODS）评分，同时进行24h动态心电图连续监测。用频域和时域两种方法分析SIRS患者的心率变异性（HRV）；用放射免疫分析法测定血清甲状腺激素和皮质醇（COR）浓度，分析两者的相关性。结果①与非SIRS组比较，SIRS组APACHEⅡ评分、MODS评分均明显升高（P均〈0．01）；SIRS组中死亡组两种评分均较生存组明显升高（P均〈0．01）。②与正常对照组比较，非SIRS组、SIRS组HRV各项指标均明显降低（P均〈0．05），而SIRS组较非SIRS组降低更明显（P〈0．05）；SIRS死亡组HRV较生存组明显下降（P〈0．01）。多元逐步回归分析，患者预后与全部正常NN间期标准差（SDNN）呈负相关，与APACHEI评分和MODS评分呈正相关（P〈0．01和P〈0．05）。预后良好的预测准确率81．1％，预后不良的预测准确率74．5％。HRV中SDNN≤55ms可作为预后的临界值，其敏感性、特异性、阳性预测值和阴性预测值最高（分别为76．2％、76．7％、90．4％和52．6％）。③与非SIRS组和正常对照组比较，SIRS患者血清三碘甲状腺原氨酸（T3）、甲状腺素（T4）、促甲状腺激素（TSH）水平降低，而COR浓度升高，T3、T4、COR浓度与患者预后有关（P〈0．05或P〈0．01）。④SIRS组血清T3、TSH与HRV呈正相关，COR浓度与HRV呈负相关（P〈0．05或P〈0．01）。⑤死亡组血清T4、T4、TSH与HRV均呈明显正相关，COR与HRV呈负相关，MODS评分与COR浓度呈正相关，COR与SDNN呈负相关（P〈0．05或P〈0．01）。结论神经内分泌调节系统对SIRS严重程度、器官功能的预后有重要影响。SDNN、COR浓度、APACHEⅡ和MODS评分，可作为评价STRS患者预后的有用指标．

Objective To explore the relationship of autonomic nerve system regulation function in patients with systemic inflammatory response syndrome （SIRS） to hypothalamo- pituitary- adrenal axis and to find useful markers to predict the prognosis of patients with SIRS. Methods Acute physiology and chronic health evaluation Ⅱ（APACHE Ⅱ ） and multiple organ dysfunction syndrome （MODS） scores were obtained and heart rate variability （HRV） was analyzed with both time -domain and frequency -domain methods. The serum levels of thyroid hormone and cortisol （COR） were measured by radio -immunoassay. Results （1）The patients with SIRS showed significantly higher APACHE Ⅱ scores and MODS scores but lower HRV when compared with the non- SIRS patients and control group （P〈0. 05 or P〈0.01）. In addition, in the SIRS group, the non - survivors were found to have statistically higher APACH I and MODS scores as well as lower HRV than the survivors （all P〈0.01）. （2）Multiple regression analysis revealed that there was a negative correlation between the outcome of the patients and standard differentiation of NN interval （SDNN）, and there was a positive correlation between the outcome of the patients and APACHII and MODS scores （P〈 0. 01 and P〈0.05）. The correction rates of prediction in good or bad outcome were 81.1% and 74.5%, respectively. SDNN≤55 ms may be the prognostic threshold value, and the sensitivity, specification, positive and negative prediction values were 76.2%, 76. 7%, 90.4% and 52.6% respectively. （3）The patients with SIRS showed lower thyroid hormone levels of triiodothyronine （T3）, tetraiodothyronine （T4）, thyroid stimulating hormone （TSH）, and higher concentration of COR compared with the non - SIRS patients and healthy controls, and they were correlated with the prognosis of the patients （P〈0.05 or P〈0.01）. （4）In the SIRS group there were positive correlations between concentrations of T3, TSH and HRV, and opposite results were also obtained between the HRV and the concentration of COR, showing negative correlation （P〈0.05 or P〈0.01 ）. （5）In the death group, there were positive correlations between concentrations of T3, T4, TSH and HRV （P〈0.01 or P〈0.05）. Also in this group, there were positive correlations between MODS scores and COR, but negative correlation between COR and SDNN （P 〈 0. 05 or P 〈 0. 01）. Conclusion Evidently the neuroendocrine system exerts significant influences on the severity of disease, function of organs and prognosis. SDNN, concentration of COR, APACHE Ⅱ and MODS scores were the useful indexes to evaluate the prognosis of the patients with SIRS.