目的:探讨中、重度急性呼吸窘迫综合征(ARDS)患者体外循环(CPB)心脏手术后血清降钙素原(PCT)水平的变化。并试图找出PCT的最佳截止值,以预测中度和重度ARDS的进展。
方法:回顾性分析2017年1月至2019年12月福建省立医院CPB心脏手术患者的病历资料。纳入在重症监护病房(ICU)住院超过1天并且在术后第一天有PCT值的成年患者。临床数据,如患者人口统计学,过去的历史,诊断,和纽约心脏协会(HYHA)分类,和操作模式,程序持续时间,CPB持续时间,主动脉钳夹持续时间,术中液体平衡,计算术后24小时液体平衡和血管活性-肌力评分(VIS);术后24小时C反应蛋白(CRP),收集N末端B型利钠肽前体(NT-proBNP)和PCT水平。两名临床医生根据柏林定义独立诊断ARDS,并且仅在诊断一致的患者中确定诊断。比较了中度至重度ARDS患者与无或轻度ARDS患者之间每个参数的差异。通过受试者操作特征曲线(ROC曲线)评估PCT预测中度至重度ARDS的能力。采用多因素Logistic回归分析确定中重度ARDS发生的危险因素。
结果:最终纳入了108名患者,包括37例轻度ARDS患者(34.3%),35例中度ARDS患者(32.4%),2例严重ARDS患者(1.9%),34例无ARDS患者。与无或轻度ARDS患者相比,中度至重度ARDS患者年龄较大(年龄:58.5±11.1vs.52.8±14.8,P<0.05),合并高血压比例较高[45.9%(17/37)vs.25.4%(18/71),P<0.05],手术时间更长(分钟:363.2±120.6vs.313.5±97.6,P<0.05),和更高的死亡率(8.1%vs.0,P<0.05),但VIS评分没有差异,急性肾功能衰竭(ARF)的发病率,CPB持续时间,主动脉钳夹持续时间,术中出血,输血量,两组之间的液体平衡。中重度ARDS患者术后第1天血清PCT和NT-proBNP水平明显高于无或轻度ARDS患者[PCT(μg/L):16.33(6.96,32.56)vs.2.21(0.80,5.76),NT-proBNP(ng/L):2405.0(1543.0,6456.5)与1680.0(1388.0,4667.0),均P<0.05]。ROC曲线分析显示PCT预测中重度ARDS发生的曲线下面积(AUC)为0.827[95%可信区间(95CI)为0.739~0.915,P<0.05]。当PCT临界值为7.165μg/L时,敏感性为75.7%,特异性为84.5%,用于区分发生中度至重度ARDS的患者和未发生ARDS的患者。多因素Logistic回归分析显示,年龄和PCT浓度升高是发生中重度ARDS的独立危险因素[年龄:比值比(OR)=1.105,95CI为1.037~1.177,P=0.002;PCT:OR=48.286,95CI为10.282~226.753,P<0.001]。
结论:接受CPB心脏手术的中度至重度ARDS患者的血清PCT浓度高于无ARDS或轻度ARDS患者。血清PCT水平可能是预测中度至重度ARDS发展的有希望的生物标志物。截止值为7.165μg/L
OBJECTIVE: To explore the changes of serum procalcitonin (PCT) level in patients with moderate and severe acute respiratory distress syndrome (ARDS) after cardiac surgery under cardiopulmonary bypass (CPB), and try to find out the best cut-off of PCT to predict the progression to moderate and severe ARDS.
METHODS: Medical records of patients undergoing cardiac surgery with CPB in Fujian Provincial Hospital from January 2017 to December 2019 were retrospectively analyzed. Adult patients who were admitted in intensive care unit (ICU) for more than 1 day and had PCT values on the first postoperative day were enrolled. Clinical data such as patient demographics, past history, diagnosis, and New York Heart Association (HYHA) classification, and the operation mode, procedure duration, CPB duration, aortic clamp duration, intraoperative fluid balance, calculation of 24 hours postoperative fluid balance and vasoactive-inotropic score (VIS); 24 hours postoperative C-reactive protein (CRP), N-terminal B-type natriuretic peptide precursor (NT-proBNP) and PCT levels were collected. Two clinicians independently made the diagnosis of ARDS according to the Berlin definition, and the diagnosis was established only in patients with a consistent diagnosis. The differences in each parameter were compared between patients with moderate to severe ARDS and those without or with mild ARDS. Analysis of the ability of PCT to predict moderate to severe ARDS was evaluated by receiver operator characteristic curve (ROC curve). Multivariate Logistic regression was conducted to determine the risk factors of the development of moderate to severe ARDS.
RESULTS: 108 patients were finally enrolled, including 37 patients with mild ARDS (34.3%), 35 patients with moderate ARDS (32.4%), 2 patients with severe ARDS (1.9%), and 34 patients without ARDS. Compared with patients with no or mild ARDS, patients with moderate to severe ARDS were older (years old: 58.5±11.1 vs. 52.8±14.8, P < 0.05), with a higher proportion of combined hypertension [45.9% (17/37) vs. 25.4% (18/71), P < 0.05], longer operative time (minutes: 363.2±120.6 vs. 313.5±97.6, P < 0.05), and higher mortality (8.1% vs. 0, P < 0.05), but there were no differences in the VIS score, incidence of acute renal failure (ARF), CPB duration, aortic clamp duration, and intraoperative bleeding, transfusion volume, and fluid balance between the two groups. Serum PCT and NT-proBNP levels in patients with moderate to severe ARDS at postoperative day 1 were significantly higher than those in patients with no or mild ARDS [PCT (μg/L): 16.33 (6.96, 32.56) vs. 2.21 (0.80, 5.76), NT-proBNP (ng/L): 2 405.0 (1 543.0, 6 456.5) vs. 1 680.0 (1 388.0, 4 667.0), both P < 0.05]. ROC curve analysis showed that the area under the curve (AUC) for PCT to predict the occurrence of moderate to severe ARDS was 0.827 [95% confidence interval (95%CI) was 0.739-0.915, P < 0.05]. When PCT cut-off value was 7.165 μg/L, the sensitivity was 75.7% and the specificity was 84.5%, for differentiating patients who developed moderate to severe ARDS from who did not. Multivariate Logistic regression showed that age and the elevated PCT concentration were independent risk factors for the development of moderate to severe ARDS [age: odds ratio (OR) = 1.105, 95%CI was 1.037-1.177, P = 0.002; PCT: OR = 48.286, 95%CI was 10.282-226.753, P < 0.001].
CONCLUSIONS: Patients with moderate to severe ARDS undergoing CPB cardiac surgery have a higher serum concentration of PCT than patients with no or mild ARDS. Serum PCT level may be a promising biomarker to predict the development of moderate to severe ARDS, the cut-off value is 7.165 μg/L.