重症患儿粪弹性蛋白酶-1的变化及其临床意义

Clinical study of the fecal elastase-1 levels in critically ill children

目的 通过测定重症患儿粪弹性蛋白酶-1 （FE-1）,探讨FE-1与胰酶、脓毒症及疾病严重程度之间的关系.方法 分析2013年7月至2014年3月湖南省儿童医院PICU收治的402例重症患儿,入住PICU 24 h内留取成形大便标本,根据FE-1质量分数分组：＞200μg/g为胰腺外分泌功能正常组（A组,n =300）,（100～200）μg/g为轻中度胰腺外分泌功能不全组（B组,n =52）,＜100 μg/g为重度胰腺外分泌功能不全组（C组,n=50）.分析各组与胰酶变化、脓毒症及其严重程度,及其与休克、器官功能障碍个数、PCIS评分、SOFA评分、APACHEⅡ评分之间的关系.计数资料采用x2检验.计量资料非正态分布或方差不齐,以中位数和四分位数[M（P25,P75）]表示,行非参数检验,有统计学意义时行多个样本两两比较的秩和检验.相关性采用Spearman相关分析.结果 （1）A、B两组间血脂肪酶升高差异有统计学意义（P＜0.O1）.（2）非脓毒症患儿288例,脓毒症114例,两组FE-1水平差异具有统计学意义（P＜0.05）.脓毒症患儿分为一般脓毒症组、严重脓毒症组、脓毒性休克组,与非脓毒症组四组间FE-1差异具有统计学意义（P＜0.01）. （3）A、B、C三组患儿在脓毒症与非脓毒症所占比例分别为65.79％vs.78.13％,15.79％ vs.11.80％,18.42％ vs.10.07％,B、C组在脓毒症中所占比例高于非脓毒症且逐渐升高.（4） FE-1质量分数的总体趋势随脓毒症严重程度而降低,非脓毒症组与一般脓毒症组,严重脓毒症组与脓毒性休克组两两比较差异无统计学意义（P＞0.05）,其余组两两比较差异均具有统计学意义（P＜0.01）.（5）三组间休克、器官功能障碍个数、MODS≥3个、PCIS评分、SOFA评分、APS评分比较差异均有统计学意义（P＜0.05）.随着FE-1质量分数降低,器官功能障碍个数、SOFA评分、APS评分呈升高趋势（rst=-0.194,P=0.000;rs2=-0.348,P=0.000;rs3=-0.176,P=0.000）,PCIS评分呈下降趋势（rs4=0.185,P=0.000）.结论 胰腺外分泌功能受损与脓毒症存在相关性,这种胰腺功能障碍在轻症脓毒症患者可能并不显著,但随脓毒症严重程度加重或病情严重程度加重其发生率逐渐升高.

Objective To determine the fecal elastase-1 （FE-1） in critically ill children in order to investigate the relationships between FE-1 and trypsin,sepsis as well as the severity of the disease.Methods Totally 402 critically ill children admitted in pediatric intensive care unit （PICU） of Hunan Children＇ s Hospital from July 2013 to March 2014 were studied.The formed stool of patients was collected during the first 24 h after admission.Subjects were divided to 3 groups according to FE-1 concentration：＞ 200 μg/g for normal pancreatic exocrine function （group A,n =300）,100-200 μg/g for mild to moderate exocrine pancreatic insufficiency （group B,n =52）,＜ 100 μg/g for severe pancreatic exocrine insufficiency （group C,n =50）.The analyses of the relationships between FE-1 and pancreatic enzymes,sepsis severity,shock,the number of organ dysfunction,PCIS （pediatric critically ill score）,SOFA score,and APACHE Ⅱ score were carried out.Chi-squared test was used for data statistics.The median and four percentile interval were used for the measurement data of abnormal distribution or non-neat variance,the rank sum test of each two of multiple samples compared each other was used for non-parametric test,only when it was statistically significant,and the Spearman method of correlation analysis was used for correlation analysis.Results （1） There was significant difference in serum lipase between group A and group B （P ＜ 0.01）.（2） There was statistical difference in FE-1 level between sepsis group and non-sepsis group （P ＜ 0.05）.Children with sepsis were divided into three groups according to the severity of sepsis：mild sepsis group,severe sepsis group and septic shock group.There were significant difference in FE-1 level among different severities of sepsis groups and as well as non-sepsis group （P ＜ 0.01）.（3） The proportions of FE-1 in septic children of A,B and C groups in comparison with those in non-septic children of three groups were 65.79％ vs.78.13％,15.79％ vs.11.80％,18.42％ vs.10.07％,respectively.The proportions of FE-1 in septic children of B and C groups escalated were higher than those in children without sepsis.（4） The general trend in FE-1 concentrations varied along with the severity of sepsis.There were no significant differences in FE-1 concentration between non-sepsis group and mild sepsis group,and between severe sepsis group and septic shock group,but other paired comparisons between the four groups had statistical significant （P ＜0.01）.（5） Along with FE-1 level decreased,the number of organ dysfunction,SOFA score,APS score （This is a part of APACHE Ⅱ score and other part,CPS,is excluded） increased and PCIS score decreased （rs1 =-0.194,P =0.000; rs2 =-0.348,P =0.000; rs3 =-0.176,P =0.000; rs4 =0.185,P =0.000）.Conclusions Pancreatic exocrine function damage is associated with sepsis,the pancreatic dysfunction in patients with mild sepsis may not be significant,but its incidence increases gradually with the development of sepsis or with the deterioration of the disease.