摘要
目的:探讨清胰汤加减联合连续性血液净化辅助治疗腑实热结型重症急性胰腺炎(SAP)合并多器官功能障碍(MODS)的疗效。方法:选择2015年5月至2019年5月在湖南中医药大学第一附属医院重症医学科(ICU)住院,西医符合SAP合并MODS诊断标准,中医诊断符合腑实热结证的患者共100例,随机分为对照组和观察组,各50例。对照组患者予以禁食禁饮、胃肠减压、胰蛋白酶抑制剂、胃黏膜保护、早期空肠营养、减轻炎症反应、连续性床旁血液净化(CBP)、机械通气、循环支持等综合治疗,观察组患者在常规综合治疗的基础上,辨证论治经鼻空肠管注入清胰汤加减,疗程为7 d。记录患者腹痛腹胀缓解时间、首次排气排便时间、住ICU时间、样本脱落数、死亡原因和例数;治疗开始前、治疗第3,7天分别测定相关指标,包括胰腺炎评价指标血淀粉酶(AMS)、血脂肪酶(LPS)、改良的CT严重指数评分(MCTSI);炎症反应指标采用白细胞介素-6(IL-6)和超敏C反应蛋白(hs-CRP);器官功能和组织灌注评价指标包括急性生理与慢性健康评分(APACHE-Ⅱ)、血清乳酸(Lac)、中心静脉压(CVP)、动脉血氧分压(PaO2)、氧合指数(PaO2/FiO2)、谷氨酸-丙酮酸氨基转移酶(ALT)、天门冬氨酸氨基转移酶(AST)、碱性磷酸酶(ALP)、谷氨酰转肽酶(γ-GGT)、尿量、肌酐(CREA)、尿素氮(UREA)、肾小球滤过率(GFR)、肌酸激酶(CK)、肌酸激酶同工酶(CKMB)、乳酸脱氢酶(LDH)、肌红蛋白(Mb);中医治疗评分采用急性胰腺炎腑实热结证证候评分。结果:观察组中医证候疗效总有效率为86.67%(39/45),高于对照组的73.91%(34/46)(χ^2=13.524,P<0.01);治疗第7天,两组患者的症状和指标均得到改善;与本组治疗前比较,观察组和对照组治疗后第3,7天,AMS,LPS,IL-6,hs-CRP,MCTSI评分,APACHE-Ⅱ评分,Lac,CVP,PaO2,PaO2/FiO2,ALT,AST,ALP,γ-GGT,尿量,CREA,UREA,GFR,CK,CKMB,LDH,Mb的水平均显著改善(P<0.05);与对照组第3,7天比较,观察组相应时间点的AMS,LPS,IL-6,hs-CRP,MCTSI评分,APACHE-Ⅱ评分,Lac,CVP,PaO2,PaO2/FiO2,ALT,AST,ALP,γ-GGT,尿量,CREA,UREA,GFR,CK,CKMB,LDH,Mb明显改善(P<0.05)。与对照组比较,观察组患者腹痛、腹胀缓解时间、首次排气/排便时间、住ICU时间明显缩短(P<0.05),观察组患者的死亡率明显降低(P<0.05)。结论:SAP患者并发MODS时,使用血液净化联合清胰汤加减,可以促进胰腺修复,抑制炎症反应,改善脏器功能,对于改善症状,缓解中医证候,延缓病程进展,减少住院时间,降低病死率起到了重要作用。
Objective:To explore the effect of modified Qingyitang combined with continuous blood purification in the adjuvant treatment of severe acute pancreatitis(SAP)complicated with multiple organ dysfunction(MODS)caused by heat accumulation of viscera.Method:Totally 100 cases of patients of SAP complicated with MODS,who were diagnosed as heat accumulation of viscera by traditional Chinese medicine(TCM)and treated in ICU of the First Affiliated Hospital of Hunan University of Chinese Medicine during May2015 and May 2019,were randomly divided into two groups,namely control group and observation group,with 50 cases in each group.The patients in control group were treated with fasting and abstinence,gastrointestinal decompression,inhibition of trypsin secretion,gastric mucosal protection,early jejunal nutrition,reduction of inflammatory reaction,continuous blood purification(CBP),mechanical ventilation and circulatory support.The patients in observation group were treated by nasojejunal tube according to syndrome differentiation in addition to routine comprehensive therapy.Modified Qingyitang was injected for 7 days.The remission time of abdominal pain and distention,the time of first exhaust and defecation,the time of ICU residence,the number of samples falling off,the cause of death and the number of cases were recorded.Relevant indexes were measured before treatment,on the 3rd and 7th day of treatment,including the evaluation indexes of pancreatitis:blood amylase(AMS),blood lipase(LPS),and modified computed tomography severity index(MCTSI),inflammatory response indexes were interleukin-6(IL-6)and hypersensitive C-reactive protein(hs-CRP).Organ function indexes included APACHE-Ⅱ,arterial partial pressure of oxygen(PaO2),oxygenation index(PaO2/FiO2),alanine aminotransferase(ALT),aspartate aminotransferase(AST),alkaline phosphatase(ALP),glutamyltransferase(γ-GGT),urine volume,creatinine(CREA),urea nitrogen(UREA),glomerular filtration rate(GFR),creatine kinase(CK),creatine kinase isoenzymes(CKMB),lactate dehydrogenase(LDH),myoglobin(Mb).Tissue perfusion evaluation indexes included acute physiology and chronic health score,serum lactic acid(Lac)and central venous pressure(CVP).TCM treatment score was based on the syndrome score of acute pancreatitis with heat accumulation of viscera syndrome.Result:The total effective rate of TCM syndromes was 86.67%(39/45)in observation group and 73.91%(34/46)in control group(χ^2=13.524,P<0.01).On the 7th day of treatment,the symptoms and indicators of the two groups were improved.Compared with before treatment,AMS,LPS,IL-6,hs-CRP,MCTSI,APACHE-Ⅱ,Lac,CVP,PaO2,PaO2/FiO2,ALT and AST were improved on the 3rd and 7th day after treatment in observation group and control group.The levels of AMS,LPS,IL-6,hs-CRP,MCTSI,APACHE-Ⅱ,Lac,CVP,PaO2,PaO2/FiO2,ALT,AST,ALP,γ-GGT,urine volume were significantly improved(P<0.05).Compared with control group on the 3rd and 7th day,the levels of AMS,LPS,IL-6,hs-CRP,MCTSI,APACHE-Ⅱ,Lac,CVP,PaO2,PaO2/FiO2,ALT,AST,ALP,γ-GGT,urine volume were significantly improved(P<0.05).CREA,UREA,GFR,CK,CKMB,LDH and Mb were significantly improved(P<0.05).Compared with control group,the abdominal pain,abdominal distension relief time,first exhaust/defecation time,ICU stay time in observation group were significantly shortened(P<0.05),and the mortality rate in observation group was significantly reduced(P<0.05).Conclusion:Patients of SAP accompanied with MODS can be treated with blood purification combined with modified Qingyitang by promoting pancreas repair,inhibiting inflammation and improving organ function.It plays an important role in improving symptoms,alleviating TCM syndromes,delaying progression of disease,reducing hospital stay and reducing mortality.
作者
易琼
戴飞跃
郭志华
王建湘
刘东亮
林泉成
丁灿
YI Qiong;DAI Fei-yue;GUO Zhi-hua;WANG Jian-xiang;LIU Dong-liang;LIN Quan-cheng;DING Can(The First Affiliated Hospital of Hunan University of Chinese Medicine,Changsha 410007,China;Hunan University of Chinese Medicine,Changsha 410208,China)
出处
《中国实验方剂学杂志》
CAS
CSCD
北大核心
2020年第8期95-104,共10页
Chinese Journal of Experimental Traditional Medical Formulae
基金
国家自然科学基金面上项目(81673955)。
关键词
重症急性胰腺炎
多器官功能障碍(MODS)
血液净化
腑实热结
清胰汤加减
severe acute pancreatitis
multiple organ dysfunction(MODS)
blood purification
heat accumulation of viscera
modified Qingyitang
