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中华危重症医学杂志(电子版)

中华危重症医学杂志(电子版) ›› 2017, Vol. 10 ›› Issue (01) : 28 -33. doi: 10.3877/cma.j.issn.1674-6880.2017.01.006

所属专题： 文献；

论著

脓毒症患者早期血小板功能变化及预后分析
张德厚1, 陈义坤2, 刘大东1,†()   
  1. 1. 212001　江苏镇江，江苏大学附属医院重症医学科
    2. 212001　江苏镇江，江苏大学附属医院急诊科
  • 收稿日期:2016-11-17 出版日期:2017-02-01
  • 通信作者: 刘大东
  • 基金资助:
    江苏省医学会急诊医学分会专项科研课题项目(2015JZKY05)

Changes of platelet function at the early phase of sepsis and its prognosis

Dehou Zhang1, Yikun Chen2, Dadong Liu1,†()   

  1. 1. Department of Internsive Care Unit, the Affiliated Hospital of Jiangsu University, Zhenjiang 212001, China
    2. Department of Emergency Medicine, the Affiliated Hospital of Jiangsu University, Zhenjiang 212001, China
  • Received:2016-11-17 Published:2017-02-01
  • Corresponding author: Dadong Liu
  • About author:
    Corresponding author: Liu Dadong, Email:
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引用本文：

张德厚, 陈义坤, 刘大东. 脓毒症患者早期血小板功能变化及预后分析[J]. 中华危重症医学杂志(电子版), 2017, 10(01): 28-33.

Dehou Zhang, Yikun Chen, Dadong Liu. Changes of platelet function at the early phase of sepsis and its prognosis[J]. Chinese Journal of Critical Care Medicine(Electronic Edition), 2017, 10(01): 28-33.

目的

探讨脓毒症患者早期血小板功能的变化对其预后的影响。

方法

收集2014年1月至2016年4月入住江苏大学附属医院ICU的脓毒症患者41例，按照病情分为脓毒症组（18例）和严重脓毒症组（23例），15例健康志愿者为对照组。比较入选患者和健康志愿者的一般情况、血常规、炎症指标、血小板功能参数，以及脓毒症患者的急性病生理学和长期健康评价（APACHE）Ⅱ评分，入住ICU总天数及28 d生存情况。采用Pearson相关性分析对血小板功能变化与脓毒症患者预后的关系进行研究；采用Logistic回归分析探讨脓毒症患者早期预后的独立危险因素。

结果

与对照组相比，两组脓毒症患者的血小板计数下降显著[（211 ± 36）× 109/L，（133 ± 16）× 109/L，（72 ± 16）× 109/L；P均< 0.05]；而白细胞计数[（6.5 ± 1.6）× 109/L，（13.6 ± 2.2）× 109/L，（22.1 ± 4.3）× 109/L]、白细胞介素6（IL-6）表达水平[（14 ± 5）pg/L，（40 ± 11）pg/L，（71 ± 13）pg/L]、前降钙素原（PCT）[（0.14 ± 0.06）ng/L，（3.87 ± 1.23）ng/L，（7.35 ± 1.41）ng/L]、血小板计数[（211 ± 36）× 109/L，（133 ± 16）× 109/L，（72 ± 16）× 109/L]、血小板黏附率[（26 ± 9）%，（56 ± 10）%，（86 ± 10）%]及聚集率[（42 ± 7）%，（66 ± 8）%，（93 ± 8）%]、P选择素阳性率[（2.2 ± 1.4）%，（15.8 ± 3.1）%，（30.4 ± 7.3）%]均显著增加（P均< 0.05）。相关性分析显示，白细胞计数、IL-6、PCT、APACHEⅡ评分和入住ICU总天数与血小板计数均呈负相关（r = -0.809、-0.834、-0.858、-0.849、-0.816，P均< 0.001），而与平均血小板体积（MPV）（r = 0.375、0.463、0.329、0.342、0.367）、血小板黏附率（r = 0.862、0.792、0.875、0.801、0.771）及聚集率（r = 0.868、0.838、0.911、0.869、0.846）、P选择素阳性率（r = 0.823、0.857、0.845、0.796、0.723）均呈正相关（P均< 0.05）。Logistic回归分析显示，年龄≥ 65岁[OR = 3.792，95%CI（1.033，13.914）]、IL-6 ≥ 200 pg/L [OR = 4.000，95%CI（1.057，15.138）]、PCT ≥ 10 ng/L [OR = 54.000，95%CI（8.038，362.755）]、血小板计数< 50 × 109/L[OR = 6.000，95%CI（1.333，26.999）]、血小板黏附率≥ 60%[OR = 4.643，95%CI（1.241，7.368）]及聚集率≥ 60%[OR = 9.917，95%CI（2.327，42.254）]、应用血管活性药物[OR = 6.000，95%CI（1.514，23.360）]均为脓毒症患者早期预后的独立危险因素（P均< 0.05）。

结论

脓毒症患者早期血小板过度活化促进了其炎症反应、增加了ICU滞留天数、降低了28 d生存情况。

关键词: 脓毒症, 血小板功能, 血小板减少症, 预后
Objective

To investigate the changes of platelet function and prognosis at the early phase of sepsis.

Methods

A total of 41 septic patients in ICU of the Affiliated Hospital of Jiangsu University from January 2014 to April 2016 were divided into the sepsis group (n = 18) and the severe sepsis group (n = 23) according to the severity of their illness. Fifteen healthy volunteers served as the control group. The general condition, hemogram, inflammatory markers, platelet parameters of all enrolled subjects, as well as the acute disease physiology and chronic health evaluation (APACHE) Ⅱ score, the ICU stay time and the 28-day survival status of septic patients were recorded and compared. Pearson correlation analysis was used to study the association between the changes of platelet function and prognosis of septic patients. Logistic regression was used to analyze the independent risk factors of early prognosis for septic patients.

Results

At early phase of sepsis, compared with the control group, the platelet count decreased significantly in the sepsis and severe sepsis groups [(211 ± 36) × 109/L, (133 ± 16) × 109/L, (72 ± 16) × 109/L; all P < 0.05]. However, the levels of WBC [(6.5 ± 1.6) × 109/L, (13.6 ± 2.2) × 109/L, (22.1 ± 4.3) × 109/L], interleukin (IL)-6 [(14 ± 5) pg/L, (40 ± 11) pg/L, (71 ± 13) pg/L] and procalcitonin (PCT) [(0.14 ± 0.06) ng/L, (3.87 ± 1.23) ng/L, (7.35 ± 1.41) ng/L], and the platelet count [(211 ± 36) × 109/L, (133 ± 16) × 109/L, (72 ± 16) × 109/L], the adhesion rate [(26 ± 9)%, (56 ± 10)%, (86 ± 10)%] and the aggregation rate [(42 ± 7)%, (66 ± 8)%, (93 ± 8)%] of platelets, the expression of P-selectin [(2.2 ± 1.4)%, (15.8 ± 3.1)%, (30.4 ± 7.3)%] significantly increased in the sepsis and severe sepsis groups (all P < 0.05). Correlation analysis showed that the platelet count had a negative correlation with WBC, IL-6, PCT, APACHE Ⅱ score, the ICU stay time (r = -0.809, -0.834, -0.858, -0.849, -0.816; all P < 0.001). However, the mean platelet volume (MPV) (r = 0.375, 0.463, 0.329, 0.342, 0.367), the adhesion rate (r = 0.862, 0.792, 0.875, 0.801, 0.771) and the aggregation rate (r = 0.868, 0.838, 0.911, 0.869, 0.846) of platelets, and the expression of P-selectin (r = 0.823, 0.857, 0.845, 0.796, 0.723) had positive correlations with those parameters (all P < 0.05). Logistic regression found that age ≥ 65 years [OR = 3.792, 95%CI (1.033, 13.914)], IL-6 ≥ 200 pg/L [OR = 4.000, 95%CI (1.057, 15.138)], PCT ≥ 10 ng/L [OR = 54.000, 95%CI (8.038, 362.755)], the platelet count < 50 × 109/L [OR = 6.000, 95%CI (1.333, 26.999)], the adhesion rate of platelets ≥ 60% [OR = 4.643, 95%CI (1.241, 7.368)], the aggregation rate of platelets ≥ 60% [OR = 9.917, 95%CI (2.327, 42.254)] and application of vasoactive drugs [OR = 6.000, 95%CI (1.514, 23.360)] were the independent risk factors of early prognosis for septic patients (all P < 0.05).

Conclusion

At the early phase of sepsis, due to the activity of overactive platelets, the inflammatory response was promoted, the ICU stay time was prolonged and the 28-day survival status was shorter.

Key words: Sepsis, Platelet function, Thrombocytopenia, Prognosis
表1 两组脓毒症患者与对照组各实验指标的比较（ ± s）
组别 例数 白细胞计数（× 109/L） IL-6（pg/L） PCT（ng/L） 血小板计数（× 109/L） MPV（fl） 血小板黏附率（%） 血小板聚集率（%） P选择素阳性率（%）
对照组 15 6.5 ± 1.6 14 ± 5 0.14 ± 0.06 211 ± 36 8.8 ± 1.0 26 ± 9 42 ± 7 2.2 ± 1.4
脓毒症组 18 13.6 ± 2.2a 40 ± 11a 3.87 ± 1.23a 133 ± 16a 8.9 ± 0.8 56 ± 10a 66 ± 8a 15.8 ± 3.1a
严重脓毒症组 23 22.1 ± 4.3ab 71 ± 13ab 7.35 ± 1.41ab 72 ± 16ab 9.1 ± 1.3 86 ± 10ab 93 ± 8ab 30.4 ± 7.3ab
F值 ? 114.805 124.681 181.989 168.584 0.253 167.942 210.142 143.319
P值 ? <0.001 <0.001 <0.001 <0.001 0.778 <0.001 <0.001 <0.001
表2 两组脓毒症患者临床特点及实验室指标的比较（例）
组别 例数 年龄≥ 65岁（是/否） 白细胞计数≥ 12 × 109/L（是/否） IL-6 ≥ 200 pg/L（是/否） PCT ≥ 10 ng/L（是/否） 血小板计数<50 × 109/L（是/否） 血小板黏附率≥ 60%（是/否）
死亡组 21 13/8 10/11 12/9 8/13 18/3 15/6
存活组 20 6/14 8/12 5/15 2/18 10/10 7/13
χ2值 ? 4.193 0.241 4.361 4.385 6.034 5.467
P值 ? 0.041 0.623 0.037 0.036 6.034 0.019
组别 例数 血小板聚集率≥ 60%（是/否） P选择素阳性率≥ 10%（是/否） APACHEⅡ评分≥ 20分（是/否） 应用血管活性药物（是/否） 多重病原菌感染（是/否）
死亡组 21 17/4 15/6 10/11 14/7 12/9
存活组 20 6/14 11/9 8/12 5/15 9/11
χ2值 ? 10.798 1.190 0.241 7.150 0.610
P值 ? 0.001 0.275 0.623 0.007 0.437
表3 脓毒症患者早期预后的危险因素分析
危险因素 回归系数 标准误 Wald值 OR值 95%CI P值
年龄≥ 65岁 1.333 0.663 4.037 3.792 1.033 ~ 13.914 0.045
IL-6 ≥ 200 pg/L 1.386 0.679 4.168 4.000 1.057 ~ 15.138 0.041
PCT ≥ 10 ng/L 1.712 0.870 16.868 54.000 8.038 ~ 362.755 < 0.001
血小板计数<50 × 109/L 1.792 0.767 5.452 6.000 1.333 ~ 26.999 0.020
血小板黏附率≥ 60% 1.535 0.673 5.202 4.643 1.241 ~ 17.368 0.023
血小板聚集率≥ 60% 2.294 0.740 9.624 9.917 2.327 ~ 42.254 0.002
应用血管活性药物 1.792 0.694 6.675 6.000 1.514 ~ 23.360 0.010
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