降钙素原在小儿体外循环心脏术后早期的自然变化规律及其影响因素

Changes and its influencing factors of procalcitonin in pediatric cardiac surgery under cardiopulmonary bypass

目的探索降钙素原(procalcitonin,PCT)在小儿体外循环(cardiopulmonary bypass,CPB)心脏术后早期的自然变化规律及其影响因素。方法采用观察性临床研究方法,对2018年6月—2019年12月阜外医院小儿心脏外科中心重症监护病房(pediatric intensive care unit,PICU)收治的年龄3岁以下、先天性心脏病(先心病)手术风险矫正评分(risk adjustment of congenital heart surgery,RACHS)2~5级、CPB下手术、无术前感染或炎性疾病的患儿,连续测定术前至术后第7 d的PCT、C-反应蛋白(c-reactive protein,CRP)、白细胞(white blood cell,WBC)计数,同时行痰培养和胸部X线片检查,对体温>38℃的患儿行血培养,对伤口化脓的患儿行伤口分泌物培养。统计术后7 d内感染及并发症情况,根据术后7 d内有无感染和并发症将入组患儿分为4组:感染+并发症组、单纯感染组、单纯并发症组以及正常组。结果最终选择住PICU≥4 d的患儿为研究对象,共429例患者入选,其中男268例、女161例,年龄8.0(0.7,26.0)个月。包括单纯感染组145例、单纯并发症组38例、正常组230例以及感染+并发症组16例。小儿CPB心脏术后PCT、CRP、WBC均较术前明显升高,其中CRP、WBC在术后第2 d达到高峰,一直持续到术后第7 d仍高于正常。PCT在术后第1 d达到高峰,一般在术后第5 d降至正常。年龄、体重、RACHS评分、CPB及主动脉阻断时间均与术后早期PCT浓度有一定程度相关性。单纯感染组、单纯并发症组及正常组之间两两比较,年龄、体重、RACHS评分、CPB及主动脉阻断时间等基础资料差异无统计学意义。其中单纯感染组与正常组术后第3~7 d的PCT浓度差异具有统计学意义(P<0.01),单纯并发症组与正常组术后第1~7 d的PCT浓度差异均有统计学意义(P<0.01),单纯感染组与单纯并发症组术后第1~5 d的PCT浓度差异有统计学意义(P<0.05)。结论小儿CPB心脏术后WBC、CRP、PCT均明显升高,从其动态变化趋势看,三者相比,PCT更能预警术后早期感染或并发症的存在。影响小儿CPB心脏术后早期PCT浓度的因素包括年龄、体重、RACHS评分、CPB和主动脉阻断时间、感染以及并发症。

Objective To explore the natural changes of procalcitonin(PCT)in the early period after pediatric cardiac surgery with cardiopulmonary bypass(CPB).Methods A prospective and observational study was done on patients below 3 years of age,who underwent cardiac surgery involving CPB,with the risk adjustment of congenital heart surgery(RACHS)score of 2 to 5 and free from active preoperative infection or inflammatory disease.Blood samples for measurement of PCT,C-reactive protein(CRP)and white blood cell(WBC)were taken before surgery and daily for 7 days in postoperative period.Infections and complications within 7 days after operation were investigated.According to the presence or absence of infection and complications within 7 days after operation,the enrolled children were divided into an infection+complications group,a simple infection group,a simple complication group,and a normal group.Results Finally,429 children with PICU stay≥4 days were enrolled,including 268 males and 161 females,with a median age of 8.0(0.7,26.0)months.There were 145 children in the simple infection group,38 children in the simple complication group,230 children in the normal group and 16 children in the infection+complications group.The levels of PCT,CRP and WBC were significantly higher after CPB.CRP and WBC peaked on the second postoperative day(POD)and remained higher than normal until POD7.PCT peaked on POD1 and would generally decrease to normal on POD5 if without infection and complications.Age,body weight,RACHS scores,the duration of CPB and aortic cross-clamping time were correlated with PCT level.There was a statistical difference in PCT concentration between the simple infection group and the normal group on POD 3-7(P<0.01)and a statistical difference between the simple complication group and the normal group on POD 1-7(P<0.01).A statistical difference was found between the simple infection group and the simple complication group in PCT on POD 1-5(P<0.05).Conclusion WBC,CRP and PCT significantly increase after CPB in pediatric cardiac surgery patients.The factors influencing PCT concentration include age,weight,RACHS scores,CPB and aortic cross-clamping time,infection and complications.