乌司他丁对严重脓毒症大鼠外周血各细胞因子水平及中性粒细胞凋亡的影响

目的探讨乌司他丁(Ulinastatin,UTI)对细菌性严重脓毒症大鼠外周血各细胞因子的表达的水平以及中性粒细胞(polymorphonuclear neutrophil,PMN)凋亡情况的影响。方法将SD大鼠随机分为5组:正常对照组、病理对照组、生理盐水治疗对照组、氧氟沙星抗感染组、乌司他丁-氧氟沙星抗炎抗感染组,每组10只。经腹腔内注射创伤弧菌建立脓毒症模型,15 h后取单侧颈总动、静脉血标本测定IL-10、TNF-αI、L-1β,锌金属蛋白酶,溶细胞素的水平以及在不同时间测定PMN的凋亡情况。结果在严重脓毒症大鼠的确存在PMN凋亡滞后的现象,合用乌司他丁的抗炎抗感染组较单纯氧氟沙星抗感染组及生理盐水对照组IL-10水平显著增高(P<0.01),而TNF-αI、L-1β,锌金属蛋白酶,溶细胞素水平则显著降低(P<0.01)。中性粒细胞凋亡时间明显提前。结论乌司他丁能改善严重脓毒症大鼠的预后,其机制可能通过调节各细胞因子的分泌水平并改变PMN凋亡滞后的现象。从而减轻组织器官炎症反应的病现损害而起保护作用,避免全身炎症反应综合征进一步向MODS发展。     

血必净注射液对脓毒症患者外周血TLR4表达的影响

目的 观察中药血必净时脓毒症患者外用血单核细胞(PBMC)TOLL样受体4(TLR4)及其下游炎症介质表达的影响.方法 40例脓毒症患者随机分为两组,对照组20例予常规综合治疗,治疗组20例加用血必净注射液治疗,检测两组患者治疗前和治疗后第3、7天PBMC表面TLR4表达的变化及血清中TNF-α、IL-6水平的变化.结果 两组患者经过7d治疗后,TLR4的表达及血清中TNF-α、IL-6水平均较治疗前下降.但血必净治疗组下降更为显著.结论 中药血必净注射液有较好的控制炎症介质的作用,对改善脓毒症患者的预后有重要的意义.     

肝硬化伴自发性细菌性腹膜炎患者血浆降钙素原与预后的关系

目的　探讨血浆降钙素原 (procalcitonin ,PCT)与肝硬化伴自发性细菌性腹膜炎 (spontaneousbacterialperitonitis,SBP)患者预后的关系。方法　采用免疫发光法检测 10 2例肝硬化腹水 (54例SBP、18例腹部脓毒症和 3 0例单纯腹水 )血浆PCT水平。结果　肝硬化伴SBP组血浆PCT水平显著高于单纯腹水组 ,腹部脓毒症组显著高于SBP组 (均P <0 0 0 1)。死亡组 (SBP和腹部脓毒症病人 )入院时血浆PCT水平与同期存活组相比 ,差异有显著性意义 (P <0 0 5)。最初 3天血浆PCT水平变化与SBP临床不同结局密切相关 ,但对腹部脓毒症预后判断价值有限。结论　血浆PCT检测对肝硬化伴SBP患者预后判断和腹部脓毒症的早期诊断具有重要价值     

动态监测重症监护室患者HLA—DR＋／CDl4＋变化的临床意义

目的在重症监护室（ICU）患者中动态监测外周血中人类白细胞抗原（HLA）-DR＋／CDl4＋、CDl4＋的表达,并评价HLA—DR＋／CDl4＋的临床意义。方法应用流式细胞术,测定入院后第l、3、7、14天ICU患者外周血中HLA—DR＋／CDl4＋、CDl4＋的表达,并进行脓毒症相关性器官衰竭（SOFA）评分。结果入院后动态监测第1天。两组HLA—DR＋／CDl4＋表达差异无统计学意义（t=0．86,P〉0．05）;第3天、第7天和第14天时存活组HLA—DR＋／CDl4＋表达高于死亡组,差异均有统计学意义（t分别=3．34、6．61、7．60,P均〈0．05）;第7天和第14天时存活组CDl4＋表达高于死亡组,差异均有统计学意义（t分别：3．46、2．56,P均〈0．05）;SOFA评分第7天和第14天时低于死亡组,差异均有统计学意义（t分别=2．08、2．53,P均〈0．05）。结论单核细胞活化功能表达持续低下可提示机体处于免疫抑制状态．动态监测HLA—DR＋／CDl4＋是监测患者免疫功能的早期、连续的方法。     

凉山地区小儿脓毒血症病原菌分布及药物敏感性分析

目的分析凉山地区小儿脓毒血症病原菌分布及药敏情况,指导临床合理使用抗生素。方法回顾性分析经血培养分离出的385株阳性菌株的构成比及药敏状况。结果 385株中G＋菌84.9%;G-菌15.1%。前6位病原菌为凝固酶阴性葡萄球菌（CNS）（66.5%）、沙门菌（6.2%）、肠球菌属（5.2%）、非发酵菌属（4.2%）、大肠埃希菌（3.1%）、金黄色葡萄球菌（3.1%）。大多数G＋菌对万古霉素、利福平、哌拉西林/他唑巴坦、喹诺酮类敏感。G-杆菌中沙门菌对亚胺培南、氨曲南、三代头孢菌素、酶抑制剂复方制剂、喹诺酮类、复方新诺明敏感;大肠埃希菌多重耐药。结论 CNS是本地区小儿脓毒血症的主要病原菌,不同病原菌的药敏状况差异大。万古霉素、利福平、亚胺培南、氨曲南、3代头孢菌素、阿米卡星及喹诺酮类目前仍为主要敏感抗生素。     

脓毒症诊断标准变迁及热点问题探讨

近年来,脓毒症概念和诊断标准不断更新,是优化脓毒症临床诊治的必然要求,但同时给临床实践带来了新的挑战。本文回顾性分析脓毒症1.0、2.0、3.0三个版本中诊断标准的变迁情况,发现已发布的脓毒症指南中相关定义,无论国内外均存在不同程度不足。过去三十年,相关定义不断改变,不同的文献资料可能采用不同版本的定义,易引起对脓毒症认识及其数据上的混淆,可能导致临床脓毒症延误治疗或盲目扩大治疗。脓毒症诊断标准及流行病学数据仍需进一步探索和完善,中国也需要考虑设定容易测量,且有利于明确患者诊断及管理的推荐意见。     

Some new aspects of the pathology,pathogenesis, and aetiology of disseminated lung lesions in slaughter pigs

From 40 pigs rejected for human consumption at slaughter due to an apparent presence of pyemic lung lesions (defined as disseminated processes containing pus and/or necrotic material), the lungs, spleen, liver, and kidneys were subjected to an extended macroscopic examination. Several lung lesions were sampled from each animal for histological and bacteriological examination. Samples from the kidneys and spleens were also subjected to bacteriological examination. At gross level, four groups of lung lesions were identified: 1) disseminated foci with contents of pus and/or necrotic material (n=26); 2) disseminated or multifocally located ecchymoses with a central area of fibroplasia (n=9); 3) non-pneumonic lesions, i.e., disseminated areas of atelectasis (n=1) or haemorrhagic areas developing due to the process of slaughter (n=1); and 4) suppurative lesions without a disseminated distribution pattern (n=3). Histologically, the disseminated suppurative/necrotic foci were identified as: A) abscesses (n=10); B) necrotic lesions (n=6); and C) ectatic or ectatic-like bronchioles with contents of pus and necrotic material (n=10). The macroscopic observation of disseminated centres of fibroplasia with peripheral ecchymoses (n=9) was confirmed histopathologically. The livers of five pigs contained multiple areas of chronic interstitial fibrosis related to migration of Ascaris suum larvae ("milk spotted liver"). Such hepatic lesions were significantly (p<0.01) related to the simultaneous occurrence of disseminated pulmonary ecchymoses with a central area of fibroplasia. Generally, all lung lesions of each individual animal contained identical monocultures of bacteria following this pattern: Staphylococcus aureus (abscesses); Actinomyces hyovaginalis (necroses); S. aureus, A. hyovaginalis, and Arcanobacterium pyogenes (ectatic and ectatic-like bronchioles). Areas with fibrosis were sterile or contained bacteria considered to be a result of contamination. Apart from one kidney, from which S. aureus was cultured, all other organs were sterile. It is concluded that difficulties exist in differentiating pulmonary pyemic lesions from non-pyemic lesions at the gross level. Thus, it was not possible to distinguish between abscesses/necroses and ectatic bronchioles, the pathogenesis of the latter being uncertain. However, the chronic non-pyemic lesions related to the migration of A. suum larvae should be identified by the absence of pus/necrosis. S. aureus was predominantly isolated from abscesses, whereas, and most surprisingly, A. hyovaginalis was the dominant bacterium isolated from the pulmonary necroses.     

Falciform ligament abscess with portal pyemia in a newborn

An 18-day-old female neonate presented with abdominal distention and bilious vomiting for 5 days. Abdominal examination showed hepatomegaly and a mass in the right hypochondrium. Ultrasound showed an extrahepatic cyst with internal echoes and dilated intrahepatic radicals. A contrast computer tomography showed a large cyst arising from the falciform ligament, extending into the liver parenchyma and a dilated portal venous system. Diagnosis of falciform ligament abscess with portal pyemia was made. Excision of the falciform ligament was done. After a follow up of 1 year, the child remains asymptomatic. To our knowledge, a falciform ligament abscess causing intrahepatic portal pyemia in a newborn has not been previously been described.     

胃肠穿孔伴脓毒性休克患者ARDS危险因素分析

目的 探讨胃肠穿孔后脓毒性休克患者急性呼吸窘迫综合征（ARDS）的危险因素.方法 收集2005年7月~2012年10月在我科手术后进入中心ICU的99例胃肠穿孔伴脓毒性休克患者临床资料,回顾性分析发生ARDS的相关危险因素.结果发生ARDS 47例（69.16%）,死亡19例（19.19%）.单因素分析显示,年龄≥65岁、APACHE Ⅱ≥15、BMI≥30 kg/m^2、吸烟指数≥400支/年、穿孔时间≥8 h、休克且持续时间≥4 h、术中复苏液量≥3000 ml、入ICU时乳酸水平≥2.5 μmol/L、结肠穿孔、合并糖尿病和/或COPD以及首次血/痰细菌培养阳性等,是胃肠穿孔后ARDS的独立高危因素.结论 胃肠穿孔后早期监测和控制这些高危因素,可以降低ARDS发生率.     

《严重脓毒症与感染性休克中西医结合治疗指南》解读——（江苏省中医药学会急诊分会、江苏省中西医结合学会急诊分会2008版拯救严重脓毒症与感染性休克治疗指南）

脓毒症（Sepsis）是创伤、烧伤、休克、感染等临床急危重患者的严重并发症,近年来已成为十分活跃的前沿领域。现对脓毒症发病机制研究进展、中医药、中西医结合研究成果和主要文献的综合,加以扼要阐述,以作为《严重脓毒症与感染性休克中西医结合治疗指南》的解读。