[摘]目 探讨血清胆碱酯酶(SChE)前白蛋白(PAB)载脂蛋白A1(Apo A1)急性生理学慢性健康状况系统Ⅱ(APACHEⅡ)评分重症肺炎预评估作方法 选择2015年3月2017年3月院接诊70例重症肺炎患者作研究象根APACHEⅡ评分<20分A组APACHEⅡ评分≥20分B组较两组器官功障碍综合征(MODS)发生率死亡率根否发生MODS分MODS组非MODS组根28d转情况分死亡组存活组较组间血清SChEPABApo A1APACHEⅡ评分差异结果 A组MODS发生率死亡率均明显低B组[1724(529)vs4390(1841)1034(329)vs4146(1741)](P<005)MODS组血清SChEPABApo A1明显低非MODS组[(284±033)kUL vs(453±040)kUL(11845±1520)mgL vs(20461±1792)mgL(060±011)gL vs(115±021)gL]APACHEⅡ评分明显高非MODS组[(2691±274)分vs(1958±204)分]较均具显著差异(P<005)死亡组血清SChEPABApo A1明显低存活组[(275±031)kUL vs(446±029)kUL(10986±1573)mgL vs(18451±1685)mgL(059±012)gL vs(112±018)gL]APACHEⅡ评分明显高存活组[(2895±240)分vs(1858±197)分]较均具显著差异(P<005)Logistic回分析结果中显示SChEPABApo A1APACHEⅡ评分均影响重症肺炎预独立危险素(OR0082013700961798P均<005)结 血清SChEPABApo A1APACHEⅡ评分重症肺炎预均具良评估价值
关键词重症肺炎胆碱酯酶前白蛋白载脂蛋白A1急性生理学慢性健康状况系统Ⅱ评分
Evaluation of prognosis of severe pneumonia by serum SChE PAB Apo A1 and APACHE II score
[Abstract] Objective To study the evaluation of prognosis of severe pneumonia by serum cholinesterase(SChE) prealbumin(PAB) apolipoprotein A1(Apo A1) and Acute physiology and chronic health scoring system II (APACHE II) score Methods 70 patients of severe pneumonia who received therapy from March 2015 to March 2017 in our hospital were selected as research objects According to the APACHE score<20 divided into A group APACHE score≥20 were divided into B group the incidence of multiple organ dysfunction syndrome (MODS) and mortality were compared between the two groups depending on whether MODS occurred divided into MODS and non MODS groups according to the prognosis after 28d the patients were divided into the death group and the survival group the differences of serum SChE PAB Apo A1 and APACHE II scores between the two groups were compared Results The incidence of the MODS and mortality in Agroup were significantly lower than those in group B[1724(529)vs4390(1841) 1034(329)vs4146(1741)] (P<005) the serum SChE PAB Apo A1 in MODS group were significantly lower than those in non MODS group[(284±033)kUL vs(453±040)kUL (11845±1520)mgL vs(20461±1792)mgL (060±011)gL vs(115±021)gL] the APACHE score was higher than those in non MODS group[(2691±274)score vs(1958±204)score] the difference was statistically significant(P<005) the serum SChE PAB Apo A1 in death group were significantly lower than those in survival group[(275±031)kUL vs(446±029)kUL (10986±1573)mgL vs(18451±1685)mgL (059±012)gL vs(112±018)gL]the APACHE score was higher than those in survival group[(2895±240) score vs(1858±197) score] the difference was statistically significant(P<005) the Logistic regression analysis showed that the scores of SChE PAB Apo A1 and APACHE II were independent risk factors for the prognosis of severe pneumonia(OR0082 0137 0096 1798 Pall<005) Conclusion The serum SChE PAB Apo A1 and APACHE II scores have a good evaluation value in the prognosis of severe pneumonia
Key words Severe pneumonia Cholinesterase Prealbumin Apolipoprotein A1 Acute physiology and chronic health scoring system II score
重症肺炎床较常见呼吸系统急重症患者通常需入住ICU该病进展迅速常会器官造成累易导致感染性休克全身炎症反应综合征(SIRS)等严重甚出现器官功障碍综合征(MODS)等严重影响预[1]较学者认选择效指标评估重症肺炎病情严重程度疾病预中十分关键早期指导医师进行合理干预[23]研究称重症肺炎患者中血清胆碱酯酶(SChE)表达呈降低状态死亡患者中表达更低目前国外该指标重症肺炎预评估价值相关报道较少[4]外重症肺炎发生发展程中体较急性时相反应蛋白均会出现明显改变中前白蛋白(PAB)载脂蛋白A1(Apo A1)作重急性时相蛋白指标助判断疾病危重程度[56]急性生理学慢性健康状况系统Ⅱ(APACHEⅡ)评分极危重症患者中种应广泛评分标准分数越高提示患者病死率越高[7]研究通观察血清SChEPABApo A1APACHEⅡ评分重症肺炎中预评估作期床早期判断疾病治疗提供参考现报道
1资料方法
11 般资料
选择2015年3月2017年3月院接诊70例重症肺炎患者中男41例女29例年龄28~75岁均(5086±589)岁社区获性肺炎57例医院获性肺炎13例研究起点患者入住综合ICU日期研究终点28d病情转转出ICU痊愈出院死亡研究已获伦理委员会批准实施
重症肺炎诊断标准[8]标准:①需进行机械通气②感染性休克需进行血收缩剂治疗次标准:①氧合指出≤250mmHg(10mmHg133kPa)②呼吸频率≥30次min③病变肺炎造成累④定障碍意识障碍⑤白细胞<40×109L1⑥血板<100×109L1⑦氮质血症⑧体温<36℃⑨血压低需进行强力液体复苏符合项标准三项次标准确诊
纳入标准:①符合重症肺炎诊断标准②床资料完整③患者家属知情意研究排标准:①需采取量茶酚胺类药物②期服免疫抑制剂激素类药物③合肝肾功严重障碍呼吸系统疾病恶性肿瘤等④中途放弃治疗死亡者出院者
12 研究方法
根APACHEⅡ评分[9]<20分A组APACHEⅡ评分≥20分B组根否发生MODS分MODS组非MODS组根28d转情况分死亡组存活组
13血清SChEPABApo A1检测方法
纳入研究次日抽取3ml空腹静脉血离心提取血清治愈冷冻箱储存备检测采武汉市百斯康医疗设备限公司生产全动生化分析仪GF2280型免疫浊法测定PABApo A1试剂盒购该公司速率法检测血清SChE操作程严格参仪器试剂盒说明书
13 统计学分析
spss180软件包处理计量资料均数±标准差(±s)表示组间较独立样t检验计数资料χ2检验Logistic回分析影响重症肺炎预危险素P<005表示差异具统计学意义
2 结果
21 APACHEⅡ评分患者MODS发生率死亡率较
A组MODS发生率死亡率均明显低B组(P<005)见表1
表1APACHEⅡ评分患者MODS发生率死亡率较(例)
Table 1 Comparison of the incidence of MODS and mortality between the different APACHE II scores (n )
组
例数
MODS发生率
死亡率
A组
29
5(1724)
3(1034)
B组
41
18(4390)
17(4146)
χ2值
5473
8060
P值
0019
0005
22 MODS组非MODS组血清SChEPABApo A1APACHEⅡ评分较
MODS组血清血清SChEPABApo A1明显低非MODS组APACHEⅡ评分明显高非MODS组(P<005)见表2
表2 MODS组非MODS组血清SChEPABApo A1APACHEⅡ评分较(±s)
Table 2 Comparison of Serum SChE PAB Apo A1 and APACHE II scores were compared between the MODS group and the non MODS group (±s)
组
例数
SChE(kUL)
PAB(mgL)
Apo A1(gL)
APACHEⅡ评分(分)
MODS组
23
284±033
11845±1520
060±011
2691±274
非MODS组
47
453±040
20461±1792
115±021
1958±204
t值
17534
19815
11766
12579
P值
0000
0000
0000
0000
23 转患者血清SChEPABApo A1APACHEⅡ评分较
死亡组血清SChEPABApo A1明显低存活组APACHEⅡ评分明显高存活组(P<005)见表3
表3转患者血清SChEPABApo A1APACHEⅡ评分较(±s)
Table 3 Comparison of serum SChE PAB Apo A1 and APACHE II scores between the different outcomes (±s)
组
例数
SChE(kUL)
PAB(mgL)
Apo A1(gL)
APACHEⅡ评分(分)
死亡组
20
275±031
10986±1573
059±012
2895±240
存活组
50
446±029
18451±1685
112±018
1858±197
t值
21856
17054
12108
18673
P值
0000
0000
0000
0000
24重症肺炎预危险素Logistic回分析
否死亡作变量SChEPABApo A1APACHEⅡ评分作变量Logistic回分析结果中显示SChEPABApo A1APACHEⅡ评分均影响重症肺炎预独立危险素(P<005)见表3
表4重症肺炎预危险素Logistic回分析
Table 4 The Logistic regression analysis of the risk factors in the severe pneumonia prognosis
指标
β值
OR值
95CI
P值
SChE
2435
0082
0019~0418
<005
PAB
2895
0137
0025~0375
<005
Apo A1
2179
0096
0041~0389
<005
APACHEⅡ评分
0583
1798
1085~2753
<005
3 讨
重症肺炎指具严重中毒症状发症肺炎呼吸系统疾病危重症该病引发致死率极高相关文献报道社区获性肺炎医院获性肺炎病死率分20~6030~70[10]年抗菌药物断研发进展已取较满意成效该病发病率死亡率居高[11]效评估重症肺炎患者预采取时干预措施显极重
SChE属丝氨酸脂酶家族种肝脏合成假性胆碱酯酶相分子含量300000半衰期约11d年报道指出SChE面积脑梗死早期脓毒症发伤MODS等危重症患者预评估中发挥着重作表达越低提示病情程度越危急[1213]研究结果显示发生MODS死亡患者中血清SChE表达明显未发生MODS存活患者低作影响重症肺炎预独立危险素提示血清SChE表达判断重症肺炎疾病严重程度评估预中具积极意义莫新等[14]报道显示血清SChE判断重症肺炎死亡危险性阳性预测值阴性预测值敏感度特异度分7619818280007800
PAB肝脏合成血中分泌负性急性时相蛋白表达肝细胞合成分泌蛋白质功进行反应急性炎症反应程中类炎症子损伤组织器官中便包括肝细胞外损伤肝血窦皮细胞降低PAB表达研究称机体发生感染时PAB表达急剧降低感染状态缓解表达升高[15]BouharrasEl Idrissi H等[16]报道显示SIRS患者中血清PAB表达明显健康群低疾病越严重患者血清PAB表达越低肝细胞损伤程度越严重器官功障碍间存着密切关系研究结果中显示发生MODS死亡患者中血清PAB表达明显未发生MODS存活患者低影响重症肺炎预独立危险素通分析降低原肝细胞炎症损害间相关
Apo A1高密度脂蛋白结构蛋白仅脂质代谢抗动脉粥样硬化中起调节作抗炎程中种负急性时相蛋白炎症程中环节起抑制作发挥抗炎保护机制Johansson P等[17]研究分析炎症反应程中肿瘤坏死子(TNF)α白介素(IL)6等量释放令肝细胞分泌载脂蛋白力降低致血清Apo A1表达降低令难发挥保护作引发细胞子释放失控林化等[18]报道显示炎症时血清Apo A1降低成失控全身炎症反应诱发MODS重环节研究显示发生MODS死亡患者中血清Apo A1表达明显未发生MODS存活患者低评估疾病预中发挥着重作显示血清Apo A1降低反应机体炎症程度增加继增加MODS发生率死亡率
APACHEⅡ评分目前国外评估危重患者疾病严重程度中应广泛评分系统该评分系统实时解疾病进展情况治疗效果等[1920]艺等[21]通分析MODS患者床资料发现APACHEⅡ评分预测价值明显优MODS评分Khalid I等[22]研究显示APACHEⅡ评分危重症患者ICU停留时间死亡时间间均具密切关系研究结果显示APACHEⅡ评分≥20分重症肺炎患者中发生MODS死亡患者明显更高发生MODS死亡患者中APACHEⅡ评分明显未发生MODS存活患者高重症肺炎预间呈正相关进步显示APACHEⅡ评分评估重症肺炎患者预中具积极意义
4 结
综述血清SChEPABApo A1APACHEⅡ评分均作评估重症肺炎预独立危险素检测助解疾病进展预床加强患者类指标检测时调整治疗方案降低死亡率
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