血清胆碱酯酶含量对重症肺炎患者病情和预后的评估价值

The value of determination of serum cholinesterase levels in judgment of severity and prognosis in patients with severe pneumonia

目的探讨血清胆碱酯酶（S-ChE）含量对重症肺炎患者病情严重程度及预后的评估价值。方法回顾性分析中山大学附属第一医院普内科和佛山市第三人民医院神经内科2011年5月至2015年5月收治的住院时间超过24h的成人重症肺炎患者的临床资料，根据住院期间是否死亡将患者分为存活组和死亡组。收集患者人重症加强治疗病房（ICU）24h内各项临床指标和急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分、多器官功能障碍综合征（MODS）评分、英国胸科协会改良肺炎评分（CURB-65）及S-ChE含量。采用二元logistic回归分析筛选出影响重症肺炎患者预后的独立危险因素，绘制受试者工作特征曲线（ROC）并寻找其最佳截断点，比较其对重症肺炎患者病情和预后的评估价值。结果共纳入86例重症肺炎患者，存活组46例，死亡组40例。单因素分析显示，死亡组S-ChE含量（kU／L：2．748±0．826比4．489±1．360，t’=7．274，P=0．000）、动脉血氧分压[PaO2（mmHg，1mmHg=0．133kPa）：52．55±18．29比60．83±16．65，t=2．196，P=0．031]、氧合指数（mrnHg：114．20±48．01比167．10±69．68，t’-=4．229，P=0．000）、二氧化碳结合力[CO2-CP（mmol／L）：22．85±5．44比26．00±7．63，t’=2．225，P=0．029]均明显低于存活组，而体温（℃：38．67±1．18比37．74±1．18，t=-3．627，P=0．000）、脉搏（次／min：130．65±15．72比107．26±19．61，t’=-6．133，P=0．000）、合并慢性肺病患者比例[45．0％（18／40）比13．0％（6／46），x^2=10．860，P=0．001]、吸入氧浓度[TiO2：0．495（0．410，0．600）比0．380（0．290，0．500），Z=-3．265，P=0．001]、APACHEⅡ评分（分：25．80±5．07比16．39±5．12，t=-8．540，P=0．000）、CURB-65评分[分：3（3，4）比2（1，2），Z=-5．562，P=0．000]、MODS评分（分：8．15±2．49比4．35±2．01，t=-7．832，P=0．00）、国际标准化比值[INR：1．22（1．08，1．31）比1．07（1．00，1．10），Z=-4．231，P=0．000]、活化部分凝血活酶时间[APTT（s）：33．80（32．13，38．75）比28．50（25．70，36．00），Z=-3．482，P=0．000]均明显高于存活组。二元logistic回归分析显示，S-ChE含量、APACHEⅡ评分、MODS评分是影响重症肺炎患者预后的独立危险因素[S-ChE：优势比（OR）=0．084，95％可信区间（95％CI）=0．017—0．424，P=0．003；APACHEⅡ评分：OR=1．675，95％CI=1．098-2．556，P=0．017；MODS评分：OR=2．189，95％CI=1．262-3．800，P=0．005]；其判断重症肺炎预后的ROC曲线下面积（AUC）分别为0．874±0．036、0．889±0．033和0．884±0．035（两两比较均P〉0．05）。S-ChE含量的截断值为3．372kU／L时判断重症肺炎患者死亡危险陛的敏感度、特异度、阳性预测值、阴性预测值分别为80．0％、78．0％、76．19％和81．82％，APACHEⅡ评分的截断值为19．5分时分别为95．0％、70．0％、73．08％和94．12％，MODS评分的截断值为6．5分时分别为70．0％、91．0％、87．50％和77．78％。若以S-ChE含量联合APACHEⅡ评分判断重症肺炎患者死亡危险性，其敏感度、特异度、阳性预测值、阴性预测值分别为100％、92．0％、93．75％、100％，若以S-ChE含量联合MODS评分来判断，则4个指标均为100％，两种联合评价的敏感度、特异度、阳性预测值和阴性预测值均高于单用S-ChE、APACHEⅡ评分或MODS评分评价。结论S-ChE含量可以作为重症肺炎患者病情和预后评估有效而简便的指标，S-ChE含量与APACHEⅡ评分或MODS评分联合应用可明显提高对重症肺炎患者死亡危险性的预测价值。

Objective To investigate the value of serum cholinesterase （S-ChE） levels in judgment of severity and prognosis in patients with severe pneumonia. Methods The clinical data of patients with severe pneumonia, who were admitted to the Department of Internal Medicine in the First Affiliated Hospital of Sun Yat-sen University, or the Department of Neurology in the Third People＇s Hospital of Foshan from May 2011 to May 2015, whose hospital time was longer than 24 hours, were retrospectively analyzed. They were divided into survival group and death group according to the final outcome. Lab data, acute physiology and chronic health evaluation Ⅱ （APACHE Ⅱ） score, multiple organ dysfunction syndrome （MODS） score, the improved pneumonia score of British Thoracic Society （confusion, uremia, respiratory, blood pressure, age 65 years, CURB-65）, and S-ChE levels of all patients were collected after they were hospitalized into the intensive care unit （ICU） within 24 hours. Independent risk factors for prognosis were analyzed by binary logistic regression analysis, and receiver operating characteristic curve （ROC） was plotted. Best truncation point analysis was used to compare their estimated value for prognosis of patients with severe pneumonia. Results Eighty-six patients with severe pneumonia were studied. Among them 46 patients survived, and 40 patients died. By the single factor analysis, the following lab data in the death group were found significantly lower than those in the survival group： S-ChE levels （kU/L： 2.748±0.826 vs. 4.489±1.360, t＇ = 7.274, P = 0.000）, arterial partial pressure of oxygen [PaO2 （mmHg, 1 mmHg = 0.133 kPa）： 52.55 ±18.29 vs. 60：83 ±16.65, t = 2.196, P = 0.031], oxygenation index （mmHg： 114：20±48.01 vs. 167.10 ± 69.68, t＇ = 4.229, P = 0.000）, and carbon dioxide combining power [CO2-CP （mmol/L）： 22.85±5.44 vs. 26.00±7.63, t＇ = 2.225, P = 0.029]. The following clinical data were significantly higher in the death group than those in the survival group, namely body temperature （℃ ： 38.67± 1.18 vs. 37.74±1.18, t = -3.627, P = 0.000）, pulse （bpm： 130.65±15.72 vs. 107.26±19.61, t＇ = -6.133, P = 0.000）, the ratio of concomitant chronic lung disease [45.0% （18/40） vs. 13.0% （6/46）, x^2 = 10.860, P = 0.001], fraction of inspired oxygen [TiO2： 0.495 （0.410, 0.600） vs. 0.380 （0.290, 0.500）, g = -3.265, P = 0.001], APACHE Ⅱ score （25.80±5.07 vs. 16.39±5.12, t =-8.540, P = 0.000）, CURB-65 score [3 （3, 4） vs. 2 （1, 2）, Z = -5.562, P = 0.000], MODS score （8.15±2.49 vs. 4.35 ±2.01, t = -7.832, P = 0.000）, international normalized ratio [INR： 1.22 （1.08, 1.31） vs. 1.07 （1.00, 1.10）, Z = -4.231, P = 0.000], and activated partial thromboplastin time [APTT （s）： 33.80 （32.13, 38.75） vs. 28.50 （25.70, 36.00）, Z = -3.482, P = 0.000]. Binary logistic regression analysis showed that, S-ChE levels, APACHE Ⅱ score and MODS score were found to be the independent risk factors for prognosis in the patients with severe pneumonia, respectively [S-ChE： odds ratio （OR） = 0.084, 95% confidence interval （95%CI） = 0.017-0.424, P = 0.003; APACHE Ⅱ score： OR = 1.675, 95%CI = 1.098-2.556, P = 0.017; MODS score： OR = 2.189, 95%CI = 1.262-3.800, P = 0.005]. The area under ROC （AUC） for S-ChE levels, APACHE Ⅱ score and MODS score were 0.874 ±0.036, 0.889 ± 0.033 and 0.884 ± 0.035, respectively （all P 〉 0.05 as compared between any two means）. At the best truncation points of S-ChE levels, APACHE Ⅱ score and MODS score were 3.372 kU/L, 19.5 score, and 6.5 score respectively. The sensitivity, specificity, positive predictive value and negative predictive value in predicting death risk in patients with severe pneumonia were （80.0%, 78.0%, 76.19% and 81.82%）, （95.0%, 70.0%, 73.08% and 94.12%） and （70.0%, 91.0%, 87.50%, 77.78%）, respectively. If S-ChE levels was combined with APACHEⅡ score or combined with MODS score, the sensitivity, specificity, positive predictive value and negative predictive value [S-ChE levels combined APACHE Ⅱ score： 100%, 92.0%, 93.75% and 100%; S-ChE levels combined MODS score： all 100%] were higher than single power of S-ChE levels, APACHEⅡ score or MODS score. Conelusilons S-ChE levels can be considered as an effective and practical index to estimate the severity and prognosis in patients with severe pneumonia. The combined application of S-ChE levels and APACHE Ⅱ score or MODS score can obviously improve the prognostic power in patients with severe pneumonia.