脓毒症相关凝血功能障碍患者发病及预后危险因素分析

秦苏徽; 顿士娟

doi:10.16766/j.cnki.issn.1674-4152.002225

脓毒症相关凝血功能障碍患者发病及预后危险因素分析

doi: 10.16766/j.cnki.issn.1674-4152.002225

秦苏徽,
顿士娟^,

蚌埠医学院第一附属医院重症医学科，安徽蚌埠 233004

基金项目:

安徽高校自然科学研究重点项目 KJ2019A0351

安徽高校自然科学研究重点项目 KJ2018A0244

详细信息

通讯作者:
顿士娟，E-mail：844812845@qq.com

中图分类号: R631.2
计量
- 文章访问数: 132
- HTML全文浏览量: 22
- PDF下载量: 19
- 被引次数: 0
出版历程
- 收稿日期: 2021-09-27
- 网络出版日期: 2022-03-02

Analysis of risk factors for the pathogenesis and prognosis of patients with sepsis-associated coagulopathy

QIN Su-hui,
DUN Shi-juan^,

Department of Critical Care Medicine, the First Affiliated Hospital of Bengbu College, Bengbu, Anhui 233004, China

摘要

摘要: 目的通过分析脓毒症相关凝血功能障碍(sepsis-associated coagulopathy，SAC)发病及影响预后的危险因素，为临床上预防脓毒症凝血功能障碍的发生、改善预后提供思路。方法收集蚌埠医学院第一附属医院重症医学科2020年1月—2021年6月收治的57例脓毒症患者，根据是否符合脓毒症相关凝血功能障碍诊断标准，将患者分成对照组(诊断脓毒症但凝血功能尚正常者，36例)和观察组(符合脓毒症凝血功能障碍诊断者，21例)，死亡组(11例)和存活组(46例)。收集研究对象的一般资料、血清降钙素原(procalcitonin, PCT)、活化部分凝血活酶时间(activated partial thromboplastin time, APTT)、纤维蛋白原(fibrinogen, FIB)，通过比较临床资料分析脓毒症凝血病发病及预后的危险因素。结果观察组与对照组年龄和性别比较差异无统计学意义(均P>0.05)，观察组血清PCT、APTT水平明显高于对照组[33.46(23.11, 63.25) ng/mL vs. 6.85(2.35, 8.77) ng/mL; 37.40(32.15, 45.15) s vs. 29.50(25.75, 33.50) s]，FIB水平明显低于对照组[(2.90±0.95)g/L vs. (5.01±1.08)g/L]，差异有统计学意义(均P < 0.05)。死亡组和存活组相比，年龄、性别和APTT差异无统计学意义(均P>0.05)，死亡组血清PCT水平明显升高[44.73(7.48, 63.90) ng/mL vs. 7.78(3.56, 14.86) ng/mL]，FIB水平明显低于存活组[(3.28±1.45)g/L vs. (4.46±1.37)g/L]，差异有统计学意义(均P < 0.05)；多元logistic回归分析提示，PCT升高(OR=1.275，95% CI：1.049~1.550)、FIB下降(OR=0.124，95% CI：0.023~0.676)是SAC发病的危险因素，PCT升高(OR=0.918，95% CI：0.859~0.981)是SAC预后的危险因素(均P < 0.05)。结论在临床中，当血清PCT水平升高、FIB水平降低时需警惕SAC的发生，对于确诊SAC的患者PCT水平的持续升高可能提示不良预后。
- 脓毒症相关凝血功能障碍 /
- 降钙素原 /
- 纤维蛋白原
Abstract: Objective To analyse the onset of sepsis-associated coagulopathy (SAC) and the risk factors affecting prognosis, provide ideas for preventing the occurrence of sepsis coagulopathy and improve prognosis. Methods A total of 57 patients with sepsis, who were admitted to the Department of Critical Care Medicine of the First Affiliated Hospital of Bengbu Medical College from January 2020 to June 2021, were included. On the basis of the diagnostic criteria for sepsis coagulopathy, the patients were divided into the control group (diagnosed sepsis; the coagulation function is normal, 36 cases), the observation group (21 cases meet the diagnosis of coagulation dysfunction in sepsis), the death group (11 cases) and the survival group (46 cases). The general information of the research subjects, serum procalcitonin (PCT), activated partial thromboplastin time (APTT) and fibrinogen (FIB) was collected, and the pathogenesis and prognosis of sepsis coagulopathy was analysed by comparing the two groups of clinical data risk factors. Results No statistically significant difference in age and gender was found between the observation group and control group (P>0.05). The levels of serum PCT and APTT in the observation group were significantly higher than those in the control group [33.46(23.11, 63.25) ng/mL vs.6.85(2.35, 8.77) ng/mL; 37.40(32.15, 45.15) s vs. 29.50(25.75, 33.50) s]. In addition, the FIB level decreased significantly [(2.90±0.95) g/L vs. (5.01±1.08) g/L], and the difference was statistically significant (all P < 0.05). There was no significant difference in age、gender and APTT between the death group and the survival group (all P>0.05).The serum PCT levels in death group was significantly higher than those in the survival group [44.73(7.48, 63.90) ng/mL vs. 7.78(3.56, 14.86) ng/mL], and the FIB level decreased significantly [(3.28±1.45) g/L vs. (4.46±1.37) g/L], and the difference was statistically significant (all P < 0.05). Factor logistic regression analysis indicated that the increase in PCT (OR=1.275, 95% CI: 1.049-1.550) and the decrease in FIB (OR=0.124, 95% CI: 0.023-0.676) were considered as risk factors for SAC, and the increase in PCT (OR=0.918, 95% CI: 0.859-0.981) was considered as a risk factor for the prognosis of SAC (all P < 0.05). Conclusion In clinical practice, when the serum PCT level increases and the FIB level decreases, SAC may occur. The continuous increase of the PCT level in patients diagnosed with SAC may indicate a poor prognosis.
- Sepsis-associated coagulopathy /
- Procalcitonin /
- Fibrinogen

HTML全文

表 1 观察组与对照组脓毒症患者感染部位分布情况[例(%)]

组别	例数	腹腔感染	泌尿系统感染	肺部感染	软组织感染	血流感染
对照组	36	9(25.0)	7(19.4)	15(41.7)	4(11.1)	1(2.8)
观察组	21	5(23.8)	3(14.3)	9(42.8)	1(4.8)	3(14.3)
χ²值		0.010	0.017	0.008	0.110	1.217
P值		0.920	0.894	0.930	0.740	0.270

下载: 导出CSV

表 2 存活组与死亡组脓毒症患者感染部位分布情况[例(%)]

组别	例数	腹腔感染	泌尿系统感染	肺部感染	软组织感染	血流感染
存活组	46	10(21.7)	8(17.4)	21(45.7)	4(8.7)	3(6.5)
死亡组	11	4(36.4)	2(18.2)	3(27.3)	1(9.1)	1(9.1)
χ²值		0.387	0.144	0.592	0.001	0.090
P值		0.534	0.705	0.442	0.967	0.764

下载: 导出CSV

表 3 对照组与观察组脓毒症患者临床资料比较

组别	例数	性别(例)		年龄(x±s，岁)	PCT [M(P₂₅, P₇₅), ng/mL]	APTT[M(P₂₅, P₇₅), s]	FIB(x±s，g/L)
组别	例数	男性	女性	年龄(x±s，岁)	PCT [M(P₂₅, P₇₅), ng/mL]	APTT[M(P₂₅, P₇₅), s]	FIB(x±s，g/L)
对照组	36	22	14	55.69±12.77	6.85(2.35, 8.77)	29.50(25.75, 33.50)	5.01±1.08
观察组	21	9	12	61.05±8.32	33.46(23.11, 63.25)	37.40(32.15, 45.15)	2.90±0.95
统计量		1.750^a		-1.717^b	-5.426^c	-4.285^c	7.414^b
P值		0.182		0.092	＜0.001	＜0.001	＜0.001
注：^a为χ²值，^b为t值，^c为Z值。

下载: 导出CSV

表 4 存活组与死亡组脓毒症患者临床资料比较

组别	例数	性别(例)	年龄 (x±s，岁)		PCT [M(P₂₅, P₇₅), ng/mL]	APTT [M(P₂₅, P₇₅), s]	FIB (x±s，g/L)
组别	例数	男性	女性		PCT [M(P₂₅, P₇₅), ng/mL]	APTT [M(P₂₅, P₇₅), s]	FIB (x±s，g/L)
存活组	46	26	20	57.59±12.21	31.25(26.73, 36.00)	7.78(3.56, 14.59)	4.46±1.37
死亡组	11	5	6	58.00±8.71	44.73(7.48, 63.90)	37.00(30.20, 46.70)	3.28±1.45
统计量		0.438^a		-0.106^b	-3.114^c	-1.921^c	2.512^b
P值		0.508		0.916	0.002	0.055	0.015
注：^a为χ²值，^b为t值，^c为Z值。

下载: 导出CSV

表 5 脓毒症性凝血病发病危险因素logistic回归分析

项目	B	SE	Wald χ²	P值	OR值	95% CI
PCT	0.243	0.100	5.934	0.015	1.275	1.049~1.550
APTT	0.111	0.120	0.844	0.358	1.117	0.882~1.414
FIB	-2.088	0.865	5.821	0.016	0.124	0.023~0.676

下载: 导出CSV

表 6 脓毒症性凝血病预后危险因素logistic回归分析

项目	B	SE	Wald χ²	P值	OR值	95% CI
PCT	-0.086	0.034	6.377	0.012	0.918	0.859~0.981
APTT	0.055	0.048	1.280	0.258	1.056	0.961~1.161
FIB	0.119	0.322	0.137	0.711	1.127	0.600~2.116

下载: 导出CSV

参考文献(21)

[1]	SINGER M, DEUTSCHMAN C S, SEYMOUR C W, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3)[J]. JAMA, 2016, 315(8): 801-810. doi: 10.1001/jama.2016.0287
[2]	FALLON E A, BIRON GIRARD B M, CHUNG C S, et al. A novel role for coinhibitory receptors/checkpoint proteins in the immunopathology of sepsis[J]. J Leukoc Biol, 2018. DOI: 10.1002/JLB.2MIR0917-377R.
[3]	CHANG J C. Sepsis and septic shock: Endothelial molecular pathogenesis associated with vascular microthrombotic disease[J]. Thromb J, 2019. DOI: 10.1186/s12959-019-0198-4.
[4]	IBA T, LEVY J H, WARKENTIN T E, et al. Diagnosis and management of sepsis-induced coagulopathy and disseminated intravascular coagulation[J]. J Thromb Haemost, 2019, 17(11): 1989-1994. doi: 10.1111/jth.14578
[5]	谢醒文, 杨振宁, 葛鑫, 等. 脓毒症相关凝血功能障碍对脓毒症患者预后的评估价值[J]. 东南国防医药, 2020, 22(2): 161-164. doi: 10.3969/j.issn.1672-271X.2020.02.011
[6]	LYONS P G, MICEK S T, HAMPTON N, et al. Sepsis-associated coagulopathy severity predicts hospital mortality[J]. Crit Care Med, 2018, 46(5): 736-742. doi: 10.1097/CCM.0000000000002997
[7]	IBA T, UMEMURA Y, WATANABE E, et al. Diagnosis of sepsis-induced disseminated intravascular coagulation and coagulopathy[J]. Acute Med Surg, 2019, 6(3): 223-232.
[8]	SEYMOUR C W, LIU V X, IWASHYNA T J, et al. Assessment of clinical criteria for sepsis: For the third international consensus definitions for sepsis and septic shock(sepsis-3)[J]. JAMA, 2016, 315(8): 762-744. doi: 10.1001/jama.2016.0288
[9]	SCARLATESCU E, TOMESCU D, ARAM S S. Sepsis-associated coagulopathy[J]. J Crit Care Med, 2016, 2(4): 156-163. doi: 10.1515/jccm-2016-0024
[10]	LYONS P G, MICEK S T, HAMPTON N, et al. Sepsis-associated coagulopathy severity predicts hospital mortality[J]. Crit Care Med, 2018, 46(5): 736-742. doi: 10.1097/CCM.0000000000002997
[11]	张兴宇. 101例脓毒症患者病原菌分析及预后相关性因素研究[D]. 延吉: 延边大学, 2020.
[12]	李烽辉, 王颖菁, 唐钟祥, 等. 不同感染部位的脓毒症患者淋巴细胞计数、PCT及临床预后差异性分析[J]. 牡丹江医学院学报, 2021, 42(3): 112-114, 124. https://www.cnki.com.cn/Article/CJFDTOTAL-MDJB202103028.htm
[13]	魏萍, 刘小香, 朱捍君, 等. 血清降钙素原在老年细菌性肺炎诊断及严重程度评估中的作用[J]. 中华全科医学, 2018, 16(1): 54-56. https://www.cnki.com.cn/Article/CJFDTOTAL-SYQY201801018.htm
[14]	谢鸣峰. 联合检测sTREM-1、ESM-1和PCT在脓毒症早期诊断和预后临床价值[J]. 河北医学, 2019, 25(9): 1451-1455. doi: 10.3969/j.issn.1006-6233.2019.09.011
[15]	刘炳炜, 徐燕平, 席绍松, 等. SOFA评分联合PCT检测对脓毒症患者病情及其预后的临床评估价值[J]. 中华全科医学, 2021, 19(3): 391-393. https://www.cnki.com.cn/Article/CJFDTOTAL-SYQY202103016.htm
[16]	KYRIAZOPOULOU E, LIASKOU ANTONIOU L, ADAMIS G, et, al. Procalcitonin to reduce long-term infection-associated adverse events in sepsis, a randomized Trial[J]. Am J Respir Crit Care Med, 2021, 203(2): 202-210. doi: 10.1164/rccm.202004-1201OC
[17]	PATEL P, WALBORN A, RONDINA M, et al. Markers of Inflammation and Infection in Sepsis and Disseminated Intravascular Coagulation[J]. Clin Appl Thromb Hemost, 2019, 25: 1076-1089.
[18]	彭锦. 重度脓毒症患者凝血功能四项检测的临床应用分析[J]. 系统医学, 2019, 4(12): 45-47. https://www.cnki.com.cn/Article/CJFDTOTAL-XTYX201912018.htm
[19]	梁健欣, 郭舜奇. D-二聚体联合纤维蛋白原检测对脓毒症的评估价值[J]. 临床合理用药杂志, 2021, 14(15): 172-174. https://www.cnki.com.cn/Article/CJFDTOTAL-PLHY202115063.htm
[20]	马兰, 诸君, 张鑫. 老年脓毒症患者病原菌感染类型及其与血清FIB、PA、PCT表达的相关性分析[J]. 现代医学与健康研究电子杂志, 2021, 5(11): 128-131. https://www.cnki.com.cn/Article/CJFDTOTAL-XYJD202111052.htm
[21]	MATSUBARA T, YAMAKAWA K, UMEMURA Y, at el. Significance of plasma fibrinogen level and antithrombin activity in sepsis: A multicenter cohort study using a cubic spline model[J]. Thromb Res, 2019, 181(9): 17-23.