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中华损伤与修复杂志(电子版) ›› 2018, Vol. 13 ›› Issue (03) : 176 -181. doi: 10.3877/cma.j.issn.1673-9450.2018.03.005

所属专题： 文献；

论著

休克期降钙素原水平与重度烧伤患者烧伤严重程度及预后的相关性研究
刘兆兴1, 张改巾1, 王鑫1, 申传安1,†()   
  1. 1. 100048　北京，解放军总医院第一附属医院烧伤整形科
  • 收稿日期:2018-03-13 出版日期:2018-06-01
  • 通信作者: 申传安
  • 基金资助:
    国家自然科学基金面上项目(81373140); 全军后勤科研计划重点项目(BWS14J048)

Correlation study of serum procalcitonin levels with severity and prognosis in severe burn patients during shock period

Zhaoxing Liu1, Gaijin Zhang1, Xin Wang1, Chuan′an Shen1,†()   

  1. 1. Department of Burns and Plastic Surgery, First Hospital Affiliated to the People′s Liberation Army General Hospital, Beijing 100048, China
  • Received:2018-03-13 Published:2018-06-01
  • Corresponding author: Chuan′an Shen
  • About author:
    Corresponding author: Shen Chuan′an, Email:
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引用本文：

刘兆兴, 张改巾, 王鑫, 申传安. 休克期降钙素原水平与重度烧伤患者烧伤严重程度及预后的相关性研究[J]. 中华损伤与修复杂志(电子版), 2018, 13(03): 176-181.

Zhaoxing Liu, Gaijin Zhang, Xin Wang, Chuan′an Shen. Correlation study of serum procalcitonin levels with severity and prognosis in severe burn patients during shock period[J]. Chinese Journal of Injury Repair and Wound Healing(Electronic Edition), 2018, 13(03): 176-181.

目的

分析重度烧伤患者休克期血清降钙素原(PCT)水平，探讨其在病情评估及预后判断中的意义。

方法

回顾性分析解放军总医院第一附属医院烧伤整形科2014年1月至2017年1月收治的201例重度烧伤患者的病例资料，收集患者年龄、性别、致伤原因、烧伤面积、预后结局等基本资料，记录患者休克期血清PCT值、血常规、肝功能、肾功能、血气分析等实验室检查结果。采用Spearman相关系数分析PCT水平与烧伤指数、预后结局及其他临床参数的相关性。根据烧伤指数将纳入病例分组层化分析，比较不同烧伤程度中生存患者与病死患者PCT水平的差异性。对数据行t检验、Mann-Whitney U检验，绘制受试者工作特征(ROC)曲线，Kaplan-Meier法和Log-rank检验，分析PCT对死亡的预测效果。

结果

相关性分析中，与PCT有相关性的临床参数为白细胞计数(r＝0.350，P<0.01)、血糖(r＝0.258，P<0.01)、肌酐(r＝0.284，P<0.01)、尿素氮(r＝0.216，P<0.01)、总胆红素(r＝0.372，P<0.01)、序贯性器官衰竭评估(SOFA)评分(r＝0.681，P<0.01)、白蛋白(r＝－0.154，P＝0.029)、脑钠肽(r＝0.151，P＝0.032)、氧合指数(r＝0.173，P＝0.014)、烧伤指数(r＝0.693, P<0.01)。分组层化分析中，烧伤指数<60的患者仅有1例死亡，予以排除；54例烧伤指数≥60的特大面积烧伤患者PCT对死亡预测的ROC曲线下面积为0.782(95%CI为0.637～0.927，P<0.01)，2.394 ng/mL为血清PCT的最佳阈值，其预测死亡的敏感度为85.0%，特异度为79.4%。Kaplan-Meier生存分析显示，PCT≤2.394 ng/mL与PCT>2.394 ng/mL的90 d生存率分别为90%和29%，差异有统计学意义(Log-rank＝23.95，P<0.01)。

结论

PCT可作为重度烧伤患者早期判断病情严重程度及预后的参考指标，为临床救治提供依据。

关键词: 烧伤, 疾病严重程度指数, 预后, 降钙素原, 休克期
Objective

To analyze the level of serum procalcitonin (PCT) in severe burn patients during shock period, and to evaluate its clinical significance.

Methods

This was a retrospective cohort study of total 201 severe burn patients admitted to Department of Burns and Plastic Surgery, First Hospital Affiliated to the Chinese People′s Liberation Army General Hospital from January 2014 to January 2017. The basic data of patients′ age, gender, cause of injury, area of burn and prognosis were collected, and the laboratory examination results of serum PCT, routine blood test, liver and kidney function and blood gas analysis were recorded during shock period. Spearman rank correlation were used to analyze the relationship between PCT level and clinical parameters. The difference of PCT level between survivors and non-survivors was evaluated among the subgroups divided by burn size. Data were processed with t test and Mann-Whitney U test. Receiver operating characteristic(ROC) curve analysis was performed to evaluate the diagnostic value of PCT level for predicting mortality in burn patients. The Kaplan-Meier method and Log bank test were used for survival analysis.

Results

There were significant correlations between leucocyte count(r=0.350, P<0.01), blood glucose (r=0.258, P<0.01), creatinine(r=0.284, P<0.01), urea nitrogen(r=0.216, P<0.01), total bilirubin (r=0.372, P<0.01), sequential organ failure assessment (SOFA) score(r=0.681, P<0.01), albumin (r=-0.154, P=0.029), brain natriuretic peptide(r=0.151, P=0.032), oxygenation index(r=0.173, P=0.014), burn index(r=0.693, P<0.01) and PCT level during shock period. Only 1 patient died of burn index less than 60. The area under the ROC curve of PCT level for predicting death for 54 patients with burn index more than 60 was 0.844(95%CI 0.637-0.927, P<0.01), and the best threshold value was 2.394 ng/mL, with sensitivity of 85.0% and specificity of 79.4%. Survival analysis revealed that the survival rates were 90% and 29%, after 90 days in the patients with PCT levels ≤ 2.394 ng/mL and in those with>2.394 ng/mL, respectively(Log-rank=23.95, P<0.01).

Conclusion

PCT level during shock period can be a useful biomarker for predicting severity and prognosis in severe burn patients.

Key words: Burns, Severity of illness index, Prognosis, Procalcitonin, Shock period
表1 201例重度烧伤患者基本资料
参数 数值
年龄(岁，M) 35(1～84)
年龄段(例) ?
? ≤14岁 34
? 15～60岁 141
? >60岁 26
性别(男/女，例) 145/56
致伤原因(例) ?
? 火焰烧伤 125
? 热液烫伤 49
? 化学烧伤 3
? 热压伤 2
? 电烧伤 11
? 蒸汽烫伤 2
? 烧冲复合伤 9
合并吸入性损伤(例，有/无) 95/106
烧伤总面积[%TBSA，M(P25～P75)] 53.4(30.0～99.0)
烧伤指数[M(P25～P75)] 46.4(15.7～98.3)
病死率[例(%)] 21(10.4)
表2 重度烧伤患者休克期PCT水平与部分临床参数的相关性分析
参数 r值 P值
体温 0.066 0.394
心率 0.080 0.261
平均动脉压 0.077 0.278
氧合指数 0.173 0.014
白细胞计数 0.350 <0.01
血小板计数 0.047 0.503
血钠 0.041 0.562
血钾 －0.083 0.242
血糖 0.258 <0.01
肌酐 0.284 <0.01
尿素氮 0.216 <0.01
总胆红素 0.372 <0.01
白蛋白 －0.154 0.029
胆碱酯酶 0.032 0.648
脑钠肽 0.151 0.032
SOFA评分 0.681 <0.01
APACHE Ⅱ评分 0.143 0.067
表3 重度烧伤患者休克期PCT水平与烧伤指数、预后结局的相关性分析
PCT水平(ng/mL) 例数 烧伤指数[M(P25～P75)] 预后结局
病死 病死率(%)
≤0.50 80 28.33(22.42～33.33) 0 0
0.50～1.00 46 37.33(31.25～46.67) 2 4.35
1.00～2.00 32 60.00(41.25～76.67) 1 3.13
2.00～5.00 24 68.33(46.04～79.58) 8 33.33
5.00～10.00 8 78.67(46.67～89.92) 3 37.50
10.00～20.00 7 78.33(66.67～92.67) 5 71.43
>20.00 4 68.50(32.50～97.75) 2 50.00
r值 ? 0.693 0.428
P值 ? <0.01 <0.01
表4 不同烧伤严重程度生存患者与病死患者休克期PCT水平比较
烧伤指数 合计[n＝201，M(P25～P75)] 生存患者[n＝180，M(P25～P75)] 病死患者[n＝21，M(P25～P75)] Z值 P值
例数 PCT(ng/mL) 例数 PCT(ng/mL) 例数 PCT(ng/mL)
≤20 4 0.14(0.10～0.23) 4 0.14(0.10～0.23) 0 ? ? ?
20～40 96 0.38(0.20～0.68) 96 0.38(0.20～0.68) 0 ? ? ?
40～60 47 0.85(0.44～1.70) 46 0.84(0.44～1.48) 1 3.57 ? ?
60～80 27 2.10(1.26～4.54) 21 1.69(1.19～2.57) 6 4.42(2.81～12.24) －2.566 0.010
>80 27 2.31(1.42～6.67) 13 1.79(1.24～2.16) 14 6.05(2.32～13.72) －2.475 0.013
表5 烧伤指数≥60的特大面积烧伤患者中生存患者与病死患者休克期相关临床参数比较(±s)
患者类型 例数 烧伤指数 白细胞计数(×109/L) 血小板计数(×109/L) 血钠(mmol/L) 血钾(mmol/L)
生存患者 34 75.9±10.5 25.8±10.9 247.7±111.7 139.7±21.8 3.9±0.5
病死患者 20 87.7±10.2 30.3±13.9 238.3±118.9 140.3±7.9 4.0±1.1
t值 ? －4.040 －1.301 0.292 －0.107 －0.213
P值 ? <0.01 0.199 0.771 0.915 0.833
患者类型 例数 血糖(mmol/L) 肌酐(μmol/L) 总胆红素(μmol/L) SOFA评分(分) APACHE Ⅱ评分(分)
生存患者 34 13.3±5.6 72.7±28.7 30.3±14.4 10.2±3.7 19.8±4.2
病死患者 20 15.0±8.1 97.4±41.4 36.3±18.9 13.8±3.4 21.3±2.6
t值 ? －0.877 －2.587 －1.333 －2.295 0.930
P值 ? 0.384 0.014 0.188 0.012 0.261
图1 54例烧伤指数≥60的特大面积烧伤患者休克期PCT、烧伤指数、SOFA评分预测死亡的ROC曲线
图2 54例烧伤指数≥60的特大面积烧伤患者Kaplan-Meier生存分析，Log-rank＝23.95，P<0.01
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