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目的 探讨血清可溶性白细胞分化抗原14亚型(sCD14-ST)对严重脓毒症、脓毒性休克患者心肌抑制(SMD)的预测价值.方法 采用前瞻性研究方法,对84例严重脓毒症、脓毒性休克患者进行脉搏指示剂连续心排血量监测(PiCCO),根据心功能指数 (CFI) 分为心肌抑制组(37例)和心肌非抑制组(47例);于入院第1天进行心脏多普勒超声检查,测量左心室射血分数(LVEF).根据28 d病死率分为生存组和死亡组.于入院第1、3、5天动态观察血清sCD14-ST、B型钠尿肽(BNP)、TNF-α、肌钙蛋白 Ⅰ (cTnⅠ)和血流动力学指标变化.两组间符合正态分布的计量资料比较采用t检验,非正态分布的计量资料采用Mann-Whitney U检验;计数资料采用χ2检验.结果 入院第1天心肌抑制组患者心脏指数(CI)、全心射血分数(GEF)和左心室收缩力指数(dPmax)均低于非抑制组,差异均有统计学意义(均P<0.01);血清sCD14-ST、TNF-α 和BNP水平均高于非抑制组,差异均有统计学意义(均P<0.01).84例脓毒症患者血清sCD14-ST水平与BNP、TNF-α呈正相关(r值分别为0.204和0.516,P值分别<0.05和0.01).第1天sCD14-ST预测脓毒症心肌抑制的受试者操作特征曲线下面积(AUC)为0.782,当其截断值为988 mg/L,其敏感度为89.2%,特异度为78.0%,预测价值低于BNP和TNF-α (均P<0.05),三者结合能够提高脓毒症心肌抑制的预测能力;Logistic回归分析发现,sCD14-ST不是脓毒症心肌抑制的独立预测因子(P>0.05).37例心肌抑制组死亡24例,病死率为64.9%,高于非抑制组的42.6%(20/47),差异有统计学意义(χ2=4.132,P=0.042).第1、3天心肌抑制组的血清sCD14-ST水平高于非抑制组,差异均有统计学意义(均P<0.01),两组均呈下降趋势.心肌抑制组死亡者的血清sCD14-ST水平高于生存者,比较差异均有统计学意义(均P<0.01).结论 脓毒症心肌抑制是严重脓毒症、脓毒性休克中的较普遍现象,高水平的sCD14-ST在一定程度上与脓毒症心肌抑制相关,但不是独立预测因子,与BNP和TNF-α联测更能提高预测能力.

Objective To evaluate the predictive value of serum presepsin (sCD14-ST) for septic myocardial depression (SMD) in patients with severe sepsis or septic shock.Methods This was a prospective cohort study.A total of 84 patients with severe sepsis or septic shock were monitored by pulse indicator continuous cardiac output (PiCCO) system and divided into myocardial depression group (cardiac function index [CFI]<4.1 L/min, n=37) and non-myocardial depression group (CFI≥4.1 L/min, n=47) according to cardiac function index (CFI).Left ventricular ejection fraction (LVEF) was measured by doppler echocardiography at admission.The patients were divided into survival group (n=40) and non-survival group (n=44) based on 28-day mortality.Serum sCD14-ST,B-type natriuretic peptide(BNP), tumor necrosis factor-α(TNF-α), cardiac troponin Ⅰ (cTnⅠ) levels and hemodynamic parameters were observed dynamically at day 1,3,5 after admission.Quantitative data with normal distribution were analyzed using t-test and abnormal distribution data were analyzed using Mann-Whitney U test.Categorical data were analyzed using χ2 test.Results The serum levels of cardiac index (CI), global ejection fraction (GEF) and left ventricular contractility index (dPmax) in myocardial depression group were all significantly lower than those in non-depression group at day 1 after admission (all P<0.01).The serum levels of sCD14-ST, TNF-α and BNP in myocardial depression group were all significantly higher than those in non-depression group (all P<0.01).Serum sCD14-ST levels in 84 septic patients were positively correlated with both BNP and TNF-α (r=0.204, P<0.05 and r=0.516, P<0.01, respectively).The area under the receiver operating characteristics curve (AUC) of sCD14-ST was 0.782 for myocardial depression in patients with sepsis, with a sensitivity of 89.2% and a specificity of 78.0% at the cut-off point of 988 mg/mL.The predictive value of sCD14-ST was inferior to BNP and TNF-α (both P<0.05).The combination of sCD14-ST, TNF-α and BNP could provide better prediction value in septic myocardial depression.Logistic regression analysis showed that serum sCD14-ST was not the in dependent predictor for septic myocardial depression (P>0.05).There were 24 cases died in myocardial depression group.The mortality of myocardial depression group was significantly higher than that of non-depression group (64.9% vs 42.6%, χ2=4.132, P =0.042).The serum levels of sCD14-ST at day 1 and day 3 in myocardial depression group were significantly higher than those in non-myocardial depression group (both P<0.01).sCD14-ST levels in both groups showed downtrend.The serum level of sCD14-ST in non-survival group was significantly higher than that in survival group (P<0.01).Conclusions Myocardial depression is common in patients with severe sepsis and septic shock.High serum level of sCD14-ST is correlated with myocardial depression to some extent, but not an independent predictor.The combination of sCD4-ST, BNP and TNF-α can improve the predictive value for myocardial depression.