降钙素原在外科中的应用课件.ppt

1、LOGO降钙素原（降钙素原（Procalcitonin）在外科临床中的应用）在外科临床中的应用 普通外科 张晓圣Company LogoContentsPCT概述1在外科围手术期应用和对预后的判断2在抗生素治疗中的指导和判断3在免疫抑制期间对感染的判断Company Logo 概 述 l 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。l 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

2、。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 北京大学第三

3、医院海淀院区北京大学第三医院海淀院区Company Logo 概 述 l 1993年，法国学者（M Asscot）第一个发现PCT在严重细菌感染时显著升高，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。l 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)。l 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。l 特点：不受机体免疫抑制状态的影响。特点：不受机体免疫抑制状态的影响。Imag

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5、区北京大学第三医院海淀院区Company Logo 概 述 l PCT产生部位：正常情况下由甲状腺的髓质细胞分泌，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。有激素样活性的降钙素。l 健康人血清健康人血清PCT的浓度为的浓度为0.1ug/L，病理情况下，可升，病理情况下，可升高至高至100ug/L，大部分由甲状腺以外的组织产生。研究，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

6、高，其确切产生部位还不清楚（神经内水平仍然很高，其确切产生部位还不清楚（神经内分泌细胞、肺脏、肝脏中的巨噬单核分泌细胞、肺脏、肝脏中的巨噬单核cell）。）。l PCT的代谢：至今为止未发现的代谢：至今为止未发现PCT排出的特定途径，它排出的特定途径，它经肾脏排出很少。数据表明严重肾衰病人不大量升高。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-

7、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 北京大学第三医院海淀院区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

8、 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 北京大学第三医院海淀院区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

9、司提供。￥：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 may

10、not extract the image for any other 北京大学第三医院海淀院区北京大学第三医院海淀院区PCT血中浓度与病程发展呈正相关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.co.kr-Image licensed by aff

11、iliates 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 北京大学第三医院海淀院区北京大学第三医院海淀院区降钙素在正常降钙素在正常人体的产生部位人体的产生部位细菌感染诱导降钙素原的产生部位（不细菌感染诱导降钙素原的产生部位（不确定）确定）Company Logo PCT产生机理图 Image information in product Title Master

12、-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 北京大学第三医院海淀院区北京大学第三医院海淀院区 细菌与病毒感染时细菌与病毒感染时PCTPCT的

13、合成的合成全身性细菌感染与病毒感染的鉴别：后者0.5ng/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 within this PowerPoint t

14、emplate only.You may not extract the image for any other 北京大学第三医院海淀院区北京大学第三医院海淀院区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 licensed by affiliates Note to customers:This image has been lic

15、ensed to be used within this PowerPoint template only.You may not extract the image for any other 北京大学第三医院海淀院区北京大学第三医院海淀院区Company Logo 区别感染及其他原因引起的发热 Image information in product Title Master-www.iclickart.co.kr -Image licensed by affiliates Slide Master www.iclickart.co.kr-Image licensed by affilia

16、tes 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 北京大学第三医院海淀院区北京大学第三医院海淀院区 PCT CRPCompany 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 M

17、aster 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 北京大学第三医院海淀院区北京大学第三医院海淀院区 区别细菌及病毒感染的原理区别细菌及病毒感染的原理1、Company Logo 外科术后应用 Image information in product Title

18、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 北京大学第三医院海淀院区北京大学第三医院海淀院区Company Logo PCT用于

19、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:This image has been licensed to be used within this PowerPoint template only.You may not extract the image for any other

20、北京大学第三医院海淀院区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脓毒症的检测和预后的评估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 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 t

21、his PowerPoint template only.You may not extract the image for any other 北京大学第三医院海淀院区北京大学第三医院海淀院区外科术后：术后低水平的外科术后：术后低水平的PCT提示无并发症提示无并发症明显优于其他指标明显优于其他指标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

22、 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 北京大学第三医院海淀院区北京大学第三医院海淀院区细菌感染后细菌感染后PCT特异性增高特异性增高（ROC曲线）曲线）Company Logo 术后感染的判断Image information in product Title Master-www.iclickart.co.k

23、r -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 北京大学第三医院海淀院区北京大学第三医院海淀院区Report of the 5th Toronto Sepsis Roundtable

24、,Toronto,Ontario,Canada,October 25,26,2000.诊断诊断 预后预后 监测监测Company Logo对细菌类型的区分 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 customers:This image has been licensed to be used within thi

25、s PowerPoint template only.You may not extract the image for any other 海医人民精诚团结，共渡难关海医人民精诚团结，共渡难关1 1、革兰氏阴性菌、革兰氏阴性菌感染是感染是PCTPCT值值升高是最高的，平均升高是最高的，平均2525；2 2、其次是、其次是革兰氏阳性菌革兰氏阳性菌，平均，平均15.915.9；3 3、然后是、然后是厌氧菌厌氧菌，平均，平均1010。原因：可能是因为革兰氏阴性原因：可能是因为革兰氏阴性菌无论是存活阶段、还是菌体菌无论是存活阶段、还是菌体死亡都会释放内毒素，可能存死亡都会释放内毒素，可能存在一个二次

26、刺激导致在一个二次刺激导致PCTPCT浓度较浓度较高。高。目前国外普遍认为：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！比如力，但是可供临床参考！比如PCT30或或40，或者更高，临床在经验性，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。选用抗生素时应偏重考虑阴性菌感染。G-杆菌杆菌 G+杆菌杆菌 厌氧菌厌氧菌Company Logo 细菌感染VS真菌感染Image information in product Title Master-www.iclickart.co.kr -Image licen

27、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 海医人民精诚团结，共渡难关海医人民精诚团结，共渡难关Company Logo PCT与真菌感染 Image information in product Titl

28、e 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 北京大学第三医院海淀院区北京大学第三医院海淀院区诊断念珠菌时诊断念珠菌时PCT和

29、和CRP反映反映 敏感性和特异性的敏感性和特异性的ROC曲线曲线PCT的的ROC曲线面积（曲线面积（0.97）显著大）显著大于于CRP（0.80）PCT临界值临界值2ng/ml区别念珠菌性脓毒区别念珠菌性脓毒症和菌血症的症和菌血症的敏感性敏感性92%，特异性，特异性93%CRP最佳临界值为最佳临界值为100mg/L,敏感性敏感性82%，特异性，特异性53%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 Sl

30、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 海医人民精诚团结，共渡难关海医人民精诚团结，共渡难关持续升高的持续升高的PCT水平，提示比较水平，提示比较差的预后差的预后（程度加重、死（程度加重、死亡）亡）腹膜炎患者，差的预后效果腹膜炎患者，差的预后

31、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 within this PowerPoint template only.You may not extract the

32、 image for any other 海医人民精诚团结，共渡难关海医人民精诚团结，共渡难关严重外伤导致脓毒血症患者严重外伤导致脓毒血症患者，生存，生存PCT呈快速下降趋势，呈快速下降趋势，预示着成功的治疗效果预示着成功的治疗效果（感染控制、存活）（感染控制、存活）Company LogoPCT对外科病人预后的判断l 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-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(CC

33、P-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 this PowerPoint template only.You may not extra

34、ct the image for any other 海医人民精诚团结，共渡难关海医人民精诚团结，共渡难关Company Logo PCT指导抗生素使用 1 1、早期确定或排除细菌感染、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不是细菌感染的病人停止抗生素的治疗2 2、抗生素治疗的监测、抗生素治疗的监测 抗生素治疗无效的确定抗生素治疗无效的确定 改变治疗方案改变治疗方案 缩短有效治疗的疗程缩短有效治疗的疗程Image information in product Title Master-www.icli

35、ckart.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 北京大学第三医院海淀院区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抗生素使用越来越严格的外环境 提供依据

36、提供依据Company Logo PCT对抗生素使用量影响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 th

37、e image for any other 北京大学第三医院海淀院区北京大学第三医院海淀院区Lancet 2004;363,600-Company Logo PCT对抗感染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 wi

38、thin this PowerPoint template only.You may not extract the image for any other 北京大学第三医院海淀院区北京大学第三医院海淀院区N=109随着患者对抗随着患者对抗生素治疗的响生素治疗的响应，引起了应，引起了PCT血中浓度血中浓度水平的典型变水平的典型变化过程化过程F.Stber,University Bonn,Lecture at ISICEM,Brussels Company Logo PCT的影响因素 受以下因素受以下因素影响影响 1 1、甲状腺、甲状腺功能功能 是功能性是功能性甲状腺甲状腺髓髓样样癌的癌的肿瘤标

39、志物肿瘤标志物2 2、肾、肾功能功能？（有点矛盾）？（有点矛盾）不受以下因素不受以下因素影响影响1 1、类固醇药物类固醇药物2 2、自身免疫性疾病自身免疫性疾病3 3、年龄、年龄、性別、性別4 4、免疫免疫功能低下状态功能低下状态:肝硬化、肝硬化、HIVHIV感染感染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 cust

40、omers:This image has been licensed to be used within this PowerPoint template only.You may not extract the image for any other 海医人民精诚团结，共渡难关海医人民精诚团结，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.c

41、o.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 北京大学第三医院海淀院区北京大学第三医院海淀院区v 随病情发展，随病情发展，PCT浓度在严重的疾病中（浓度在严重的疾病中（eg脓毒症、脓毒性脓毒症、脓毒性休克）逐渐升高。休克）逐渐升高。v 0.25 指导用抗生素指导用抗生素v 0.5 双联抗生素双联抗生

42、素v 2 正常量的正常量的3倍倍v 5 严重的脓毒症严重的脓毒症Company Logo PCT在免疫抑制中的监测 l 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。l 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，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。l 联想：化疗病人等（应用价值）Image information in product Title Master-www.iclickart.co.kr -Image licensed

43、 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 北京大学第三医院海淀院区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 Mast

44、er-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 北京大学第三医院海淀院区北京大学第三医院海淀院区Company Logo PCT的影响因素

45、受以下因素受以下因素影响影响 1 1、甲状腺、甲状腺功能功能 是功能性是功能性甲状腺甲状腺髓髓样样癌的癌的肿瘤标志物肿瘤标志物2 2、肾、肾功能功能？（有点矛盾）？（有点矛盾）不受以下因素不受以下因素影响影响1 1、类固醇药物类固醇药物2 2、自身免疫性疾病自身免疫性疾病3 3、年龄、年龄、性別、性別4 4、免疫免疫功能低下状态功能低下状态:肝硬化、肝硬化、HIVHIV感染感染Image information in product Title Master-www.iclickart.co.kr -Image licensed by affiliates Slide Master www.i

46、clickart.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 北京大学第三医院海淀院区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，一个哲人曾经说过：提到感染时，PCTPCT总是很有用！总是很有用！当我们外科医生遇到感染，或者不明原当我们外科医生遇到感染

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