2020脓毒症预防和阻断专家共识告诉你:这些血清标志物很重要!

2020-08-05 检验医学网 检验医学网

目前国际指南对于脓毒症的最新定义为,由感染引起的宿主反应失调,进而导致循环功能障碍及器官功能损害。

目前国际指南对于脓毒症的最新定义为,由感染引起的宿主反应失调,进而导致循环功能障碍及器官功能损害。

脓毒症是目前医学界面临的重大难题与挑战,随着现代医学的快速发展,对脓毒症的研究探索越来越深入,尽管多年来国际上对脓毒症采用积极的“拯救”措施,但是脓毒症的发病率和病死率仍然居高不下。我国2020年的一项针对全国44所医院ICU的研究报告显示,ICU脓毒症的发病率为20.6%,死亡率为35.5%,严重脓毒症病死率高达50%以上。

由急诊医学领域的4个学(协)会和5个相关杂志社共同探讨,及来自急诊医学、重症医学、感染病学、药学及检验医学等专业学科的40余名专家多次讨论形成了《中国脓毒症早期预防与阻断急诊专家共识》,以下简称“共识”。

共识对急性感染患者的确定识别、脓毒症高危患者的筛查、脓毒症的诊断与临床疑似、脓毒症的预防与阻断等方面作了详尽的阐述。本文重点讲述血清标志物在急诊感染的识别、脓毒症的预防与阻断中的应用。

一、急性感染患者的识别

1、根据全身表现确定感染

包括体温的变化和白细胞变化,任何体温升高或异常降低的患者都应当考虑有急性感染的可能。外周血白细胞变化是急性感染的第2个特征性变化,也有助于区别不同的感染。

2、感染生化标志物

目前常用的感染标志物包括C反应蛋白(CRP)、降钙素原(PCT)、IL-6、血清淀粉样蛋白A(SAA)以及肝素结合蛋白(HBP)。

3、根据局部症状和体征确定感染

急性感染及疑似感染的确定,如下表现可以考虑急性感染的存在:

①有急性(72h之内)发热或低体温;

②白细胞总数增高或降低;

③CRP、IL-6升高;

④PCT、SAA 及HBP升高;

⑤有明确或可疑的感染部位。

确定感染:以上①~③项中有2项加④有明确结果,可以协助确定病原体类型,或加⑤ 有明确表现可以帮助确定感染部位。

疑似感染:以上①~③项中有1项加④无确定性结果,或加⑤有可疑感染部位。

二、脓毒症高危人群筛选

越来越多研究显示脓毒症的发生与人体特定基因有关。此外年龄、基础疾病、营养不良及免疫低下也是脓毒症发生的重要因素。

研究发现,脓毒症中感染占比最大的仍是细菌,其次是病毒。肺部、腹部和泌尿道感染是引起脓毒症的常见部位。

三、脓毒症的诊断与临床疑似

1、脓毒症的诊断

第三版脓毒症定义提出当患者达到“感染+SOFA 评分≥2分”可以诊断脓毒症。(SOFA评分计算方法见下图)

2、急诊疑似脓毒症

快速序贯器官衰竭评分(qSOFA)是脓毒症3.0第三版脓毒症定义推荐的用于可疑脓毒症筛查的工具。有研究报道改良早期预警评分(MEWS)、国家早期预警评分(NEWS)和SIRS评分等早期识别评分系统在预测非ICU患者的死亡和ICU转入方面优于qSOFA。

患者临床表现:

①感染或疑似感染患者;

②qSOFA≥2;

③SOFA=1;

④NEWS评分4~6分。

急诊脓毒症临床疑似诊断标准:①项加②~④项中任意一项。

四、脓毒症的预防与阻断

对于脓毒症的预防与阻断包括及时确定高危人群、控制感染、发现及阻断细胞因子风暴、血管内皮保护及凝血调节、循环容量支持、器官功能保护等方面。

共识中提到及时发现细胞因子风暴并适时、适量地调控炎症反应对预防脓毒症发生有重要意义,而且是预防脓毒症的核心。

(1)细胞因子筛查与SIRS确定

对脓毒症高危患者以及可疑出现全身炎症反应的患者,应当进行细胞因子筛查,以确定SIRS的状态。众多研究认为主要参与SIRS和代偿性抗炎反应综合征(CARS)的因子包括:TNF-α、IL-1、IL-6、IL-12、MIF、sCD74、HMGB-1,抗炎细胞因子包括:IL-4、IL-10、IL-35、IL-37、TGF-β、IL-13 等。有证据显示,当促炎因子明显升高或出现炎症反应失衡时,即应当开始炎症调控。

因此,对于脓毒症高危感染患者,应当定期进行细胞因子监测(2~4h重复),及时发现可疑脓毒症患者。目前医院普遍检测的细胞因子是IL-6。作为IL的一种细胞因子,IL-6主要刺激参与免疫反应的细胞增殖、分化并在机体的抗感染免疫反应中起重要作用。

(2)炎症调控

当检测发现细胞因子明显升高,或炎症失衡的感染患者时,应当尽早进行炎症调控,使体内炎症反应恢复稳定平衡状态。包括糖皮质激素、非激素类抗炎药物、中药制剂、炎性介质特异性抗体的应用等。

(3)血管内皮保护与凝血调节

血管内皮损伤和微血栓形成导致组织细胞的灌注下降,被认为是器官功能障碍的直接原因。这种内皮细胞损伤及微血栓形成引发弥散性血管内凝血(DIC)。引起DIC的机制包括促凝物质上调、抗凝物质下调以及纤维蛋白溶解机制受损等。所以及时监控凝血相关指标对于预防脓毒症的发生至关重要,特别是PLT 计数。此外,血浆D-二聚体(D-dimer)也是临床常用的凝血功能参考指标,反映凝血功能激活状态。

五、总结

脓毒症起始于感染,经过细胞因子风暴、毛细血管内皮损伤、毛细血管渗漏、微血栓形成和组织灌注下降,最终导致器官功能损害。我们可以通过早期干预疾病的病理生理发展进程,实现脓毒症的阻断,进而降低脓毒症的发生率。另一方面,通过对围脓毒症期患者的合理诊治,降低脓毒症的病死率。

国赛Aristo全自动特定蛋白分析仪可以检测CRP、SAA、D-dimer等指标,有助于对感染早期的识别及反映凝血功能状态。kemilo化学发光分析仪可以同时检测PCT与IL-6两个指标,有助于对脓毒症的辅助诊断及细胞因子状态的监测,以便及时发现细胞因子风暴并适时、适量地调控炎症反应,预防脓毒症发生。

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    2020-08-05 医鸣惊人

    学习了

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