动态监测血清前肾上腺髓质素对呼吸机相关性肺炎预后的评估价值

The predictive value of serum proadrenomedullin by dynamic monitoring in the prognosis of ventilator-associated pneumonia

目的：探讨血清前肾上腺髓质素（Proadrenomedullin, pro-ADM）对呼吸机相关性肺炎（ventilator-associated pneumonia, VAP）预后的评估价值。方法将52例VAP患者根据28 d病情预后分为生存组和死亡组。所有患者在临床确诊VAP第1、3、5天采用双抗体夹心法测定血清pro-ADM浓度，运用受试者工作特征曲线分析pro-ADM对VAP的预后价值。结果在第1、3和5天，死亡组患者的pro-ADM浓度[（4.18±1.78）nmol/L、（4.51±1.88）nmol/L和（5.15±1.89）nmol/L]高于生存组患者[（3.19±1.39）nmol/L、（2.98±1.35）nmol/L和（1.65±0.88）nmol/L]（P＜0.05）。随时间变化，死亡组血清pro-ADM浓度呈升高趋势（P＜0.001），而生存组呈下降趋势（P＜0.001）。绘制受试者工作特征曲线计算pro-ADM在第1、3和5天预测VAP患者28 d死亡的曲线下面积分别是0.664（95%CI 0.520-0.789）、0.746（95%CI 0.606-0.856）和0.966（95%CI 0.874-0.997）。在第5天，以pro-ADM＞3.13 nmol/L作为截断值，pro-ADM预测VAP预后的敏感度和特异度分别是86.7%和94.6%。结论血清pro-ADM浓度动态升高提示VAP患者预后不佳，血清pro-ADM的监测可能用于VAP预后的评估。

Objective To evaluate the prognostic value of patients with ventilator-associated pneumonia by dynamic monitoring for serum proadrenomedullin（pro-ADM）levels. Methods A prospective observational cohort study including consecutive patients with VAP was conducted. According to the survival situation within the 28 days of ICU, the patients were divided into death group and survival group. The levels of serum pro-ADM were measured by sandwich ELISA on 1st, 3rd and 5th days. The prognostic value of pro-ADM in VAP was assessed by receiver operating characteristic （ROC） curve. Results The serum pro-ADM level of the patients in the death group on 1st day[（4.18±1.78） nmol/L], 3rd day[（4.51 ± 1.88）nmol/L]and 5th day[（5.15 ± 1.89）nmol/L]were significantly higher than those in the survival group[（3.19±1.39）nmol/L,（2.98±1.35）nmol/L and（1.65±0.88）nmol/L, respectively]（all P〈0. 05）. The serum pro-ADM level of the patients in the death group showed a trend of increase（P〈0.001）, while the survival group declined（P〈0.001）. For prognosis of VAP, the areas under the curve for pro-ADM on 1st, 3rd and 5th days were 0.664（95%CI 0.520-0.789）, 0.746（95%CI 0.606-0.856）and 0.966（95%CI 0.874-0.997）, respectively. When the cutoff value of pro-ADM was set above 3.13 nmol/L on the 5th day, the sensitivity and the specificity for predicting the prognostic value of patients with VAP were 86.7%and 94.6%. Conclusion Serum level of pro-ADM may be used as a marker to predict the prognostic value of patients with VAP early. The increased pro-ADM indicates a poor prognosis of VAP.