摘要目的 探讨血浆抗凝血酶Ⅲ(AT-Ⅲ)对脓毒症弥散性血管内凝血(DIC)的诊断意义及对DIC发展的可能预测作用.方法 回顾性分析2015年1月至12月入住中国医科大学附属第一医院重症医学科(ICU)所有成人患者的临床资料.根据入ICU时是否符合脓毒症诊断标准将患者分为脓毒症组与非脓毒症组;脓毒症组患者再按入ICU当日国际血栓与止血学会(ISTH)DIC评分(ISTH评分)分为显性DIC亚组(≥5分)、隐性DIC亚组(1~4分)及无DIC亚组(0分).记录患者ICU当日血常规、凝血酶原时间(PT)、纤维蛋白原(Fib)、D-二聚体、纤维蛋白原降解产物(FDP)、急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、序贯器官衰竭评分(SOFA)、ISTH评分及7 d内AT-Ⅲ水平,比较各组患者各指标的差异.采用Pearson相关法分析脓毒症患者及脓毒症DIC患者AT-Ⅲ水平与各指标的相关性;绘制受试者工作特征曲线(ROC),评价AT-Ⅲ或联合PT对脓毒症DIC的诊断效能.比较入ICU当日发生DIC与入ICU 1 d后发生DIC患者间7 d内AT-Ⅲ水平的变化趋势,明确入ICU当日发生DIC患者AT-Ⅲ水平与DIC转归之间的关系.结果 纳入445例患者中有脓毒症138例,非脓毒症307例.脓毒症患者入ICU当日诊断为显性DIC 20例,隐性DIC 115例,无DIC 3例;ICU住院期间发生显性DIC 25例,均为脓毒症患者.脓毒症组入ICU当日AT-Ⅲ活性明显低于非脓毒症组〔(55.29±13.92)%比(76.54±12.31)%,P<0.01〕;显性DIC亚组入ICU当日AT-Ⅲ活性明显低于隐性DIC亚组和无DIC亚组〔(43.85±13.00)%比(56.95±13.03)%、(68.00±16.52)%,均P<0.05〕.Pearson相关分析显示,脓毒症患者入ICU当日AT-Ⅲ与ISTH评分、PT呈显著负相关(r值分别为-0.467、-0.654,均P<0.01),其中显性DIC亚组入ICU当日AT-Ⅲ与PT呈显著负相关(r=-0.675,P=0.001).AT-Ⅲ联合PT诊断脓毒症DIC的ROC曲线下面积(AUC)大于二者单独诊断时(0.843比0.763、0.834),敏感度达90.0%,特异度达73.7%;单独应用AT-Ⅲ诊断界值为48.5%时,敏感度为78.0%,特异度为70.0%.脓毒症患者入ICU当日,ISTH评分越高,AT-Ⅲ水平越低.入ICU当日发生DIC与入ICU 1 d后发生DIC的脓毒症患者血浆AT-Ⅲ水平及其变化趋势一致,AT-Ⅲ水平均随ISTH评分的改善而呈上升趋势.结论 单独应用AT-Ⅲ或联合PT可诊断脓毒症DIC;脓毒症DIC患者血浆AT-Ⅲ水平随ISTH评分的改善呈上升趋势.

abstractsObjective To investigated the role of antithrombin Ⅲ (AT-Ⅲ) levels in the early diagnosis of disseminated intravascular coagulation (DIC) in patients with sepsis and the predictive effect of AT-Ⅲ on the development of DIC.Methods A retrospective study was conducted. Patients admitted to intensive care unit (ICU) of the First Affiliated Hospital of China Medical University from January to December in 2015 were enrolled. The patients were divided into sepsis group and non-sepsis group according to the diagnostic criteria of sepsis. In addition, sepsis patients were divided into 3 subgroups according to the international society on thrombosis and haemostasis (ISTH) scores on the first day: overt DIC (ISTH ≥ 5), non-overt DIC (ISTH 1-4) and none DIC group (ISTH = 0). Blood routine test, prothrombin time (PT), fibrinogen (Fib), D-dimer, fibrin degradation products (FDP), acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) scores, sequential organ failure assessment (SOFA) scores and ISTH scores were recorded on the first ICU day. AT-Ⅲ was recorded during 7 days. The differences were compared among these 3 groups. Correlations of AT-Ⅲ with various parameters were calculated by using Pearson correlation analysis in sepsis group and overt DIC group. Receiver operating characteristic (ROC) curves for diagnosis of DIC with AT-Ⅲ, AT-Ⅲ+PT&nbsp;were drawn to evaluate the diagnostic efficiency. The AT-Ⅲ levels of DIC patients were compared between early-onset DIC and late-onset DIC during their ICU stay. The change of AT-Ⅲ levels with time and prognosis in patients with early-onset DIC was compared between groups.Results Totally 445 patients were recruited, with 138 patients in sepsis group, and 307 in non-sepsis group. There were 20 patents diagnosed with overt DIC on the first ICU day, 115 patients non-overt DIC and 3 patients of none DIC. Twenty-five sepsis patients were diagnosed overt DIC during the ICU days. AT-Ⅲ level in sepsis patients on the first ICU day were lower than that in non-sepsis patients [(55.29±13.92)% vs. (76.54±12.31)%,P < 0.01]. Patients with overt DIC had a lower AT-Ⅲ level than non-overt DIC or none DIC patients [(43.85±13.00)% vs. (56.95±13.03)%, (68.00±16.52)%, bothP < 0.05]. It was shown by Pearson correlation analysis that AT-Ⅲ level of sepsis patients on the first ICU day was negatively correlated to ISTH score and PT (r value were -0.467, -0.654, bothP < 0.01). AT-Ⅲ level of overt DIC patient on the first ICU day was negatively correlated with PT (r = -0.675,P = 0.001). It was shown by ROC curve that area under ROC curve (AUC) of AT-Ⅲ combined with PT for diagnosis overt DIC in sepsis patients was higher than that of AT-Ⅲ or PT alone (0.843 vs. 0.763, 0.834), the sensitivity 90.0%, specificity 73.7%. The cut-off value for overt DIC diagnosis in sepsis patients of AT-Ⅲ level alone was 48.5%, sensitivity was 78.0%, specificity was 70.0%. On the first ICU day, AT-Ⅲ level was risen when ISTH score improved in patients with sepsis. There was similar change of AT-Ⅲ level between patients with early-onset DIC and late-onset DIC. AT-Ⅲ level increased with DIC improvement.Conclusion AT-Ⅲ level can be used for diagnosing sepsis-associated overt DIC independently or with a combination of PT. When ISTH score improved, AT-Ⅲ level was risen in patients with sepsis associated DIC.