摘要目的 监测脓毒性休克患儿血清降钙素原(PCT)、降钙素原清除率(PCT-C)及序贯器官衰竭评分(SOFA)差值(ΔSOFA)的动态变化,探讨PCT-C及ΔSOFA在脓毒性休克患儿病情评估及预后判断中的价值.方法 采用单中心观察性研究方法,选择2013年7月至2015年12月收住湖南省儿童医院重症监护二病房确诊为脓毒性休克的患儿274例,根据28d预后分为存活组(178例)和死亡组(96例).确诊24 h 内监测PCT并对患儿进行SOFA评分,分别监测两组患儿确诊脓毒性休克时及确诊后2 d、3 d、5 d、7 d、9 d血清PCT水平及SOFA评分,计算PCT-C及ΔSOFA.采用受试者工作特征曲线(ROC)分析上述指标在脓毒性休克患儿病情评估及预后判断中的价值.结果 存活组与死亡组比较,确诊时及确诊后2d、3dPCT水平差异均无统计学意义(P>0.05),存活组2d、3d、5d、7d、9 d PCT-C明显高于死亡组.2 d、3 d、5 d、7 d、9 d PCT-C 水平与当日 ΔSOFA 评分均呈显著正相关.9 d PCT-C、9 d ΔSOFA及确诊24 h 内 SOFA 评分预测28 d 死亡的 ROC 曲线下面积分别为0.800 (95%CI 0.69~0.91,P=0.000)、0.980(95%CI 0.78~0.95,P<0.000)与0.779(95%CI 0.66~0.89, P<0.001).9 d PCT-C预测28 d死亡的最佳截断值为38.98%,敏感度为78.90%,特异度为66.80%;9 dΔSOFA预测28 d死亡的最佳截断值为-0.5分,敏感度为89.10%,特异度为91.50%.结论 脓毒性休克患儿持续高水平的PCT 与感染控制不佳及病情恶化相关,能及时反映患儿的病情变化,持续动态观察PCT 并进行PCT-C 分析较仅关注PCT 更有价值.PCT-C及ΔSOFA评分可以作为脓毒症患儿病情发展趋势判断和疾病风险评估的指标,较低的PCT-C 及ΔSOFA对严重的感染相关并发症具有较好的警示作用并与低存活率相关.

abstractsObjective To assess the disease severity and prognosis value by observing the kinetic change of serum procalcitonin(PCT),PCT clearance rate(PCT-C) and Δsequential organ failure assessment (ΔSOFA) score in the patients with septic shock.Methods A single-center observational study was conduc-ted.A total of 274 patients with septic shock admitted into intensive care unit of Hunan Province Children′s Hospital from July 2013 to December 2015 were enrolled.The patients were divided into survival group(n=178) and nonsurvival group(n=96)according to the therapeutic outcome on day 28.The PCT and SOFA scores were estimated within 24 hours when septic shock was diagnosed.PCT-C and ΔSOFA were examined on day 2,day 3,day 5,day 7,day 9 after the septic shock was diagnosed.The diagnostic and predictive per-formance of PCT,PCT-C and ΔSOFA score were assessed by the receiver operating characteristic curve (ROC).Results There were no statistical differences on serum concentrations of PCT at 24 hour,48 hour, 72 hour between two groups.But PCT-C in survival group on day 2,day 3,day 5,day 7,day 9 were signifi-cant higher than those of nonsurvival group.The area under the ROC curve were 0.800(95%CI 0.69~0.91, P=0.000)for PCT-C on day 9,0.980(95%CI 0.78 ~0.95,P<0.000)for ΔSOFA on day 9 and 0.779 (95%CI 0.66 ~0.89,P <0.001)for SOFA score when septic shock was diagnosed. A ROC analysis identified a PCT-C on day 9 more than 38.98%(sensitivity:78.90%,specificity:66.80%) as the most accurate cut-off in predicting death.A ROC analysis identified ΔSOFA score on day 9 less than -0.5(sensi-tivity:89.10%,specificity:91.50%) as the most accurate cut-off in predicting death. Conclusion The increased levels of PCT in patients with septic shock were associated with the poor control of infection and may indicate the deterioration of septic shock,it also can reflect the activity of infection in time. Keeping observing the dynamic change of PCT and analyzing PCT-C are more useful.The PCT-C levels and ΔSOFA score may provide evidence of disease progression and be helpful in risk stratification in patients with septic shock,and lower level of PCT-C and ΔSOFA score may accompany serious infection and predict poor prognosis.