多发伤患者血清胆碱酯酶与急性期蛋白的相关性

Relationship between serum cholinesterase and acute-phase proteins in patients with multiple trauma BA

目的探讨多发伤患者血清胆碱酯酶（ChE）与急性期蛋白（APP）变化的相关性，比较它们在反映病情严重度和判断预后中的价值。方法为前瞻性观察研究。选择2005年10月至22）（／7年10月在伤后24h内收住浙江大学医学院附属第二医院急诊监护室的多发伤患者共81例。排除标准：（1）有慢性肝病、有机磷接触、活动性肺结核或肿瘤病史；（2）伤前有主要脏器感染；（3）存在肝脏损伤；（4）年龄〈18周岁者。其中男57例，女24例；年龄（46±18）岁，损伤严重度评分（34．0±11．9）。另选择76例本院健康体检者作为对照，其中男53例，女23例；年龄（44±16）岁。排除标准同患者组。2组性别、年龄构成均具可比性。患者组在伤后第1、3、7天抽取静脉血常规方法检测血清ChE活性、血清白蛋白（ALB）、前白蛋白（PAB）、转铁蛋白（TRF）、C反应蛋白（CRP），同时记录急性生理和慢性健康评分Ⅲ（APACHEⅢ）。对照组以同样方法测定血清ChE、ALB、PAB、TRF、CRP，并采用t检验或秩和检验分别与患者组各时点相比较。采用单因素重复方差分析患者组血清ChE及各APP指标在伤后的动态变化情况，采用Pearson相关分析法分析血清ChE与各APP的相关性及它们与APACHEⅢ的相关性。根据患者转归分为存活和死亡2组，采用t检验或秩和检验比较组间各指标的差异，通过Logistic回归分析比较它们在预后判断中的价值。结果患者伤后各时点血清ChE、ALB、PAB、TRF均比各对照组显著降低，CRP则明显升高，其中血清ChE活性都比对照组下降超过25％（42．3％～50．2％），并与PAB、TRF一样呈下降趋势；血清ChE活性在各时点与AH3、PAB、TRF都显著正相关，与CRP第3、7天负相关。患者APACHEⅢ在各时点与血清ChE、TRF均显著负相关，与ALB仅第1天负相关，与PAB仅第1、7天负相关，与CRP仅第7天正相关；各时点死亡组血清ChE活性和TRF都显著低于存活组，而死亡组ALB仅在第7天、PAB仅在第1天和第7天显著低于存活组，CRP仅在第7天显著高于存活组，Logistic回归分析提示仅血清ChE和PAB是判断预后的独立因素。结论血清ChE可视为负急性期蛋白的一种，在反映多发伤病情严重度和预测患者转归中的综合价值要优于其他主要APP。

Objective To investigate the relationship between serum cholinesterase（ChE） and acute-phase proteins in patients with multiple trauma, then to evaluate their significance to judge prognosis. Method It＇ s a prospective observation study. Patients with multiple trauma admitted to emergency intensive care unit, Second Affiliated Hospital, Zhejiang Universieg, school of medicihe within 24 h after trauma from Oct. 2005 to Oct. 2007 were enrolled. And those with chronic liver disease, touching orgnaophosphorus, active tuberculosis, tumor, infection of major organ before trauma, liver injury or age 〈 18 year were excluded. Among 81 patients, 57 were male and 24 female. The average age was （46± 18） years, and the average injury severity score was （34.0±11.9） .Seventy six healthy were selected as controls, 53 male and 23 female, with an average age of （44 ± 16） years. The exclusion standards were the same as those in patients. Both groups had same gender proportion and age. Serum ChE and acute-phase proteins（APP） including albumin（ALB）, prealbunfin（PAB）, transferrin（TRF）, C-reactive protein（CRP） in patients were detected at 1, 3, 7 d after trauma. The acute physiology and chronic health evaluation Ⅲ （ APACHE Ⅲ ） was recorded simultaneously. Serum ChE, ALB, PAB, TRF, CRP in the controls were also detected. All of these indexes in the controls were compared with thoses in patients by t test or rank sum test. The dynamic changes of serum ChE and APPs in patients were analyzed by one way repeated measures ANOVA. The relationships between serum ChE and those APPs and the relationships between APACHE Ⅲ and these indexes were analyzed by Pearson correlation analysis. We also compared these indexes between patients with different outcomes by t test or rank sum test. The values of serum ChE and those APPs to judge prognosis were evaluated by logistic regression analysis. Results Patients had lower serum ChE, ALB, PAB, TRF and higher CRP than the healthy at 1, 3, 7 d post trauma. Serum ChE activity in patients was reduced over 25% （42.3%- 50.2%） than that in the healthy, and showed a tendency to decrease after trauma, which resembled PAB and TRF. Serum ChE was positively correlated with ALB, PAB and TRF at 1, 3, 7 d, and negatively correlated with CRP at 3, 7 d. At 1, 3, 7 d post trauma, APACHEⅢ in patients was negatively correlated with serum ChE and TRF, but negatively correlated with ALB only at 1 d, and negatively correlated with PAB only at 1,7 d, and positively correlated with CRP only at 7 d. Non-survivors had lower serum ChE activity and TRF than survivors at 1,3, 7 d after trauma, but had lower ALB only at 7 d after trauma and had lower PAB only at 1,7 d after trauma than survivors, and had higher CRP than survivors only at 7 d after trauma. Logistic regression analysis showed serum ChE and PAB were the only two independent risk factors to judge prognosis. Conclusions Serum ChE may be included as negative acute-phase protein, and is better than other APPs in reflecting injury severity and prognosis in patients with multiple trauma.