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1、降钙素原（ Procalcitonin ）在外科临床中的应用,普通外科 张晓圣,Company Logo,Contents,Company Logo,概 述,降钙素原(Procalcitonin，PCT)是一种由116个氨基酸组成，分子量大约为13KD的糖蛋白，是降钙素的前肽物，无降钙素样的激素活性，其分子由降钙素、下钙素和一个含57个氨基酸的N-末端碎片组成。PCT半衰期为25-30h，在体内稳定性很好，由位于11号染色体上（11P15，4）的单拷贝基因编码。,Image information in product Title Master-www.iclickart.co.kr - Im
2、age licensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used within this PowerPoint template only. You may not extract the image for any other use.,北京大学第三医院海淀院区,Company Logo,概 述,1993年，法国学者（M Asscot）第一个发现PCT在严重细菌感
3、染时显著升高，而在不是细菌感染时不升高或轻微升高。从而可以在临床上鉴别出细菌感染和非细菌感染。评价细菌感染/脓毒症及其监测的最新替代指标（2003年发表的国际脓毒症定义将PCT作为判定脓毒症的炎症指标 Crit Care Med 2003;31:1250-56 ) 。降钙素原(PCT)是近年来应用于临床的重症感染监测指标，对全身炎症反应综合征和全身性感染有较高的诊断价值。特点：不受机体免疫抑制状态的影响。,Image information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates Sl
4、ide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used within this PowerPoint template only. You may not extract the image for any other use.,北京大学第三医院海淀院区,Company Logo,概 述,PCT产生部位：正常情况下由甲状腺的髓质细胞分泌，不释放入周围循环血中，在体内很稳定，不会降解成为有激素样活性的降钙素。健康人
5、血清PCT的浓度为0.1ug/L，病理情况下，可升高至100ug/L，大部分由甲状腺以外的组织产生。研究表明，甲状腺全部切除的病人，当严重细菌感染时，血PCT水平仍然很高，其确切产生部位还不清楚（神经内分泌细胞、肺脏、肝脏中的巨噬单核cell）。PCT的代谢：至今为止未发现PCT排出的特定途径，它经肾脏排出很少。数据表明严重肾衰病人不大量升高。,Image information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr-
6、 Image licensed by affiliates Note to customers: This image has been licensed to be used within this PowerPoint template only. You may not extract the image for any other use.,北京大学第三医院海淀院区,Company Logo,概 述,Image information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates S
7、lide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used within this PowerPoint template only. You may not extract the image for any other use.,北京大学第三医院海淀院区,海淀医院：血清PCT测定采用双抗夹心免疫发光法，血清灵敏度为0.1 ng/ ml，仪器和试剂由德国柏林B.R.A. H. M.S Diagnostica公司提
8、供。 ￥：180 元（医保范围内）,Company Logo,细菌感染严重程度的判断,Image information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used within this PowerPoint template only. You
9、may not extract the image for any other use.,北京大学第三医院海淀院区,在感染疾病严重程度的发展过程中，PCT随着严重程度的不同（局部感染、脓毒血症、严重脓毒血症、脓毒性休克），呈现由低到高的浓度变化,PCT血中浓度与病程发展呈正相关对于感染程度及器官机能障碍的严重性进行准确的判断,Company Logo,概 述,Image information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart
10、.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used within this PowerPoint template only. You may not extract the image for any other use.,北京大学第三医院海淀院区,降钙素在正常人体的产生部位,细菌感染诱导降钙素原的产生部位（不确定）,Company Logo,PCT产生机理图,Image information in product Title Master-www.i
11、clickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used within this PowerPoint template only. You may not extract the image for any other use.,北京大学第三医院海淀院区,细菌与病毒感染时PCT的合成,Adapted from Chri
12、st-Crain et al. 2005区分全身性细菌感染与病毒感染的鉴别：后者0.5ng/ml,Company Logo,PCT对脓毒症诊断具有最高的敏感性和特异性,Image information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used w
13、ithin this PowerPoint template only. You may not extract the image for any other use.,北京大学第三医院海淀院区,2003年国际年会，PCT被定为脓毒血症唯一的金标准（感觉有点像做广告）,Company Logo,对外科临床诊疗的判断,Image information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr- Image license
14、d by affiliates Note to customers: This image has been licensed to be used within this PowerPoint template only. You may not extract the image for any other use.,北京大学第三医院海淀院区,PCT显著地提高了临床诊断的准确率,Harbarth S. Am J Respir Crit Care Med 2001,Company Logo,区别感染及其他原因引起的发热,Image information in product Title M
15、aster-www.iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used within this PowerPoint template only. You may not extract the image for any other use.,北京大学第三医院海淀院区,非感染、导管相关性菌血症、脓毒症、重症脓毒
16、症和脓毒症休克 PCT CRP,各组PCT水平有显著差别（P0.05），且与疾病严重程度成正相关。PCT是可靠的诊断指标。Kim KE, . Korean J Lab Med. 2010 Apr;30(2):153-9,Company Logo,PCT对真菌和病毒的区分,Image information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to
17、customers: This image has been licensed to be used within this PowerPoint template only. You may not extract the image for any other use.,北京大学第三医院海淀院区,区别细菌及病毒感染的原理,1、病毒感染时，释放INF-和IL-1，前者阻断了降钙素原释放；2、而细菌感染时只有IL-1，造成了其大量释放。Adapted from Linscheid et al. 2003,Company Logo,外科术后应用,外科术后、大面积创伤、烧伤等、患者血清PCT浓度变
18、化1、72小时以内，PCT血清浓度会明显上升2、72小时以后、无细菌性感染，PCT急剧下 降3、如果患者在以后仍出现持续性发热等感染 症状，建议每隔12天可进行PCT监测。,Image information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be use
19、d within this PowerPoint template only. You may not extract the image for any other use.,北京大学第三医院海淀院区,Company Logo,PCT用于外科术后评估,Image information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers
20、: This image has been licensed to be used within this PowerPoint template only. You may not extract the image for any other use.,北京大学第三医院海淀院区,术后脓毒症的检测和预后的评估,术后立即检测（D0-D1):PCT水平显著升高（2ng/ml）是脓毒症开始的早期指标。,Company Logo,PCT对术后有无并发症的判断,Image information in product Title Master-www.iclickart.co.kr - Image l
21、icensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used within this PowerPoint template only. You may not extract the image for any other use.,北京大学第三医院海淀院区,外科术后：术后低水平的PCT提示无并发症,明显优于其他指标,Company Logo,术后感染的判断,Image
22、 information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used within this PowerPoint template only. You may not extract the image for any other use.,北京大
23、学第三医院海淀院区,细菌感染后PCT特异性增高（ROC曲线）,细菌感染与非细菌感染的鉴别诊断PCT:88%敏感性/81%特异性CRP:75%敏感性67%特异性术后2天内PCT2，可判定为感染的准确率为9798%,Company Logo,术后感染的判断,Image information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers
24、: This image has been licensed to be used within this PowerPoint template only. You may not extract the image for any other use.,北京大学第三医院海淀院区,无论是对脓毒症的诊断、预后评估及治疗监测PCT都体现出最优异的性能,Report of the 5th Toronto Sepsis Roundtable, Toronto, Ontario, Canada, October 25, 26, 2000.,诊断 预后 监测,Company Logo,对细菌类型的区分,
25、Image information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used within this PowerPoint template only. You may not extract the image for any other use
26、.,海医人民精诚团结，共渡难关,1、革兰氏阴性菌感染是PCT值升高是最高的，平均25；2、其次是革兰氏阳性菌，平均15.9；3、然后是厌氧菌，平均10。原因：可能是因为革兰氏阴性菌无论是存活阶段、还是菌体死亡都会释放内毒素，可能存在一个二次刺激导致PCT浓度较高。,目前国外普遍认为：PCT升高的幅度没有太大的区分不同类型细菌的能力，但是可供临床参考！比如PCT30或40，或者更高，临床在经验性选用抗生素时应偏重考虑阴性菌感染。,G-杆菌 G+杆菌 厌氧菌,Company Logo,细菌感染VS真菌感染,Image information in product Title Master-www.
27、iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used within this PowerPoint template only. You may not extract the image for any other use.,海医人民精诚团结，共渡难关,念珠菌引起的脓毒症PCT水平显著低于菌血症逆向思维：对免疫功
28、能低下的患者，如果PCT长期在灰色浓度间起伏、血培养阴性、但又存在炎性症状，可考虑真菌感染可能性较大,Company Logo,PCT与真菌感染,Image information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used within this
29、PowerPoint template only. You may not extract the image for any other use.,北京大学第三医院海淀院区,诊断念珠菌时PCT和CRP反映 敏感性和特异性的ROC曲线PCT的ROC曲线面积（0.97）显著大于CRP（0.80）PCT临界值2ng/ml区别念珠菌性脓毒症和菌血症的敏感性92%，特异性93%CRP最佳临界值为100mg/L,敏感性82%，特异性53%,Martini A,etc. 2010 Jun;60(6):425-30. Epub 2010 Mar 10,Company Logo,PCT对外科病人预后的判断,I
30、mage information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used within this PowerPoint template only. You may not extract the image for any other use.
31、,海医人民精诚团结，共渡难关,持续升高的PCT水平，提示比较差的预后（程度加重、死亡）,腹膜炎患者，差的预后效果,Company Logo,PCT对外科病人预后的判断,Image information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used w
32、ithin this PowerPoint template only. You may not extract the image for any other use.,海医人民精诚团结，共渡难关,严重外伤导致脓毒血症患者，生存,PCT呈快速下降趋势，预示着成功的治疗效果（感染控制、存活）连续的动态监测PCT血中浓度可以更好的评估患者的预后,Company Logo,PCT对外科病人预后的判断,PCT是是机体受感染时内毒素刺激各器官的巨噬细胞、单核细胞而产生的一种炎症介质，正常人体中PCT是甲状腺C细胞分泌的无激素活性的降钙素的前体物质。PCT是由四种主要肽链组成：氨基端的氨基端降钙素原(N
33、-PCT) ；中心部位经加工生成成熟的CT；以及羧基端的降钙素羧基端肽-I(CCP-I) 和未成熟CT与CCP-I 结合形成的结合肽CT-CCP-I。,Image information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used within th
34、is PowerPoint template only. You may not extract the image for any other use.,海医人民精诚团结，共渡难关,Company Logo,PCT指导抗生素使用,1、早期确定或排除细菌感染 细菌感染或脓毒症的病人早期即开始治疗 不是细菌感染的病人停止抗生素的治疗2、抗生素治疗的监测 抗生素治疗无效的确定 改变治疗方案 缩短有效治疗的疗程,Image information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates Sl
35、ide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used within this PowerPoint template only. You may not extract the image for any other use.,北京大学第三医院海淀院区,抗生素使用越来越严格的外环境 提供依据,Company Logo,PCT对抗生素使用量影响,Image information in product Title
36、 Master-www.iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used within this PowerPoint template only. You may not extract the image for any other use.,北京大学第三医院海淀院区,抗生素的使用及成本减少50（83-44
37、）Lancet 2004; 363, 600-607,Company Logo,PCT对抗感染治疗效果及预后监测,Image information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used within this PowerPoint templ
38、ate only. You may not extract the image for any other use.,北京大学第三医院海淀院区,通过PCT不断在体内衰减，反映出抗生素治疗策略的成功,N=109随着患者对抗生素治疗的响应，引起了PCT血中浓度水平的典型变化过程,F. Stber, University Bonn, Lecture at ISICEM, Brussels 2001,Company Logo,PCT的影响因素,受以下因素影响 1、甲状腺功能 是功能性甲状腺髓样癌的肿瘤标志物2、肾功能？（有点矛盾）不受以下因素影响1、 类固醇药物2、 自身免疫性疾病3、年龄、性別4、免
39、疫功能低下状态:肝硬化、HIV感染,Image information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used within this PowerPoint template only. You may not extract the image
40、 for any other use.,海医人民精诚团结，共渡难关,Company Logo,对感染的判断+抗生素的指导,Image information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used within this PowerPoint t
41、emplate only. You may not extract the image for any other use.,北京大学第三医院海淀院区,随病情发展，PCT浓度在严重的疾病中（eg脓毒症、脓毒性休克）逐渐升高。0.25 指导用抗生素0.5 双联抗生素2 正常量的3倍5 严重的脓毒症,浓度随感染扩散和病情加重而升高,Company Logo,PCT在免疫抑制中的监测,PCT可用于监测免疫抑制病人，监测化疗中WBC减少的病人，在肿瘤病人中可鉴别由肿瘤分解或化疗引起的发热还是由感染引起的发热，是病毒还是细菌引起的发热。中性粒细胞减少症患者和存在确定原因的系统感染的病人PCT值显著性升高
42、，而在局部感染或不明原因的发热（吸收热、药物反应）中PCT值无明显升高。联想：化疗病人等 （应用价值）,Image information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used within this PowerPoint template o
43、nly. You may not extract the image for any other use.,北京大学第三医院海淀院区,Company Logo,细菌？病毒？真菌？,Image information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be
44、used within this PowerPoint template only. You may not extract the image for any other use.,北京大学第三医院海淀院区,Company Logo,PCT的影响因素,受以下因素影响 1、甲状腺功能 是功能性甲状腺髓样癌的肿瘤标志物2、肾功能？（有点矛盾）不受以下因素影响1、 类固醇药物2、 自身免疫性疾病3、年龄、性別4、免疫功能低下状态:肝硬化、HIV感染,Image information in product Title Master-www.iclickart.co.kr - Image licen
45、sed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used within this PowerPoint template only. You may not extract the image for any other use.,北京大学第三医院海淀院区,Company Logo,总 结,一个哲人曾经说过：提到感染时，PCT总是很有用！ 当我们外科医生遇到感染，或者不明原因
46、发热时一定不要忘记还有这样一个高端、大气、上档次的指标。 谢谢各位同行聆听！,Image information in product Title Master-www.iclickart.co.kr - Image licensed by affiliates Slide Master www.iclickart.co.kr- Image licensed by affiliates Note to customers: This image has been licensed to be used within this PowerPoint template only. You may not extract the image for any other use.,北京大学第三医院海淀院区,海淀医院普通外科,谢谢聆听！,
