脓毒症患者早期血浆皮质醇水平变化及其临床意义研究

Early Plasma Cortisol Changes in Septic Patient and Its Value

目的探讨脓毒症患者早期血浆皮质醇水平的变化及其对脓毒症患者病情危重程度的判断价值。方法选取2011年9月—2012年3月天津医科大学总医院急救中心收治的81例脓毒症患者为脓毒症组,另选取同期非脓毒症患者40例为对照组。脓毒症患者根据预后分为存活组67例和死亡组14例。采用单因素和多因素Logistic回归,分析影响脓毒症患者预后的危险因素,绘制受试者工作特征(ROC)曲线并计算曲线下面积,分析血浆皮质醇对脓毒症患者预后的判断价值。结果 (1)脓毒症组与对照组患者血浆皮质醇、乳酸(LAC)、血糖(GLU)、白细胞计数(WBC)、肌酐(Cr)、C反应蛋白(CRP)、促肾上腺皮质激素(ACTH)、肿瘤坏死因子α(TNF-α)、白介素(IL)-10水平比较,差异均有统计学意义(P<0.05);两组降钙素原(PCT)、血氧分压(PaO2)、血小板计数(PLT)水平比较,差异均无统计学意义(P>0.05)。(2)脓毒症死亡组与存活组患者血浆皮质醇水平、急性生理和慢性健康状况评分系统Ⅱ(APACHEⅡ评分)、LAC、GLU、PaO2比较,差异均有统计学意义(P<0.05)。(3)Spearman's相关分析显示,脓毒症患者血浆皮质醇水平与ACTH、PCT、TNF-α、APACHEⅡ评分均呈正相关(r值分别为0.403、0.186、0.403和0.360,P<0.05),与IL-10水平呈负相关(r=-0.375,P<0.05)。血浆ACTH水平与TNF-α呈正相关(r=0.251,P<0.05),与IL-10水平呈负相关(r=-0.229,P<0.05)。(4)Logistic回归分析,皮质醇、APACHEⅡ评分、LAC、PaO2与脓毒症患者预后有回归关系。皮质醇的ROC曲线下面积为0.893。结论脓毒症患者早期表现为高皮质醇、高TNF-α、低IL-10水平者预后较差。早期血浆皮质醇水平变化对脓毒症患者病情危重程度和预后的判断有价值。

Objective To investigate early plasma cortisol （COR） changes in septic patients and its value in judging the severity of the disease. Methods 81 patients admitted to the emergency center of Tianjin Medical University General Hospital from September 2011 to March 2012 were selected as sepsis group, and another 40 non - sepsis patients from the same period were selected as control group. The patients were further divided into survival group （67 cases） and death group （14 cases）, and the observation indicators of the two groups were compared. Logistic regression analysis was performed to analyze risk factors influ- encing prognosis. ROC was drawn and the area under ROC curve was calculated. The value of the ROC in predicting prognosis was analyzed. Results （1） The levels of COR, LAC, GLU, WBC, Cr, CRP, ACTH, TNF-α and IL- 10 between sepsis group and control group showed statistically significant differences （P 〈 0.05）, but the levels of PCT, PaO2 and PLT showed no statistically significant difference （P 〉 0. 05 ） . （ 2 ） The levels of COR, APACHE Ⅱ score, LAC, GLU and PaO2 between death group and survival group showed statistically significant differences （ P 〈 0. 05 ） . （ 3 ） Spearman＇ s correlation analysis showed that the COR level of septic patients was positively correlated with ACTH, PCT, TNF - α and APACHE H （ r = 0. 403, 0. 186, 0. 403 and 0. 360, P 〈0.05）, but was negatively correlated with IL - 10 （r = -0. 375, P 〈0. 05） . The ACTH level was positively correlated with TNF -α （ r = 0. 251, P 〈 0.05 ）, but was negatively correlated with IL - 10 （ r = - 0. 229, P 〈 0. 05） . （4） Logistic regression analysis showed that COR, APACHE Ⅱ score, LAC and PaO2 were independent factors for the prognosis of septic patients, and the area under ROC was 0. 893. Conclusion The early manifestations of sepsis are high levels of COR and TNF -α, and patients with low level of IL - 10 usually have bad prognosis. Early COR changes are of good value for the prediction of sepsis severity and prognosis.