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脓毒症常合并不同程度的凝血功能障碍。组织因子介导的促凝机制增强,生理抗凝机制下调以及纤溶系统功能抑制是脓毒症凝血功能障碍发生的主要机制。针对凝血系统功能障碍的不同机制给予针对性的药物治疗,对改善脓毒症病人的预后可能有益。     

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1病历简介病人女性,28岁。以黑便、呕血19h为主诉于2012-05-20入院。5月19日10时如厕时排黑便,量约100mL。5月20日3时再次排黑便量约800mL并出现晕厥,家属唤醒后入中国医科大学附属第一医院急诊室。在急诊室呕血4次,呈鲜红色并混有血块,每次量约500mL,收缩压最低20～30mmHg(1mmHg=0.133kPa),伴有意识不     

脓毒症与免疫营养治疗

脓毒症病人常因能量需求增加及某些特殊营养素缺乏,从而导致器官功能障碍。营养支持对脓毒症病人非常重要。某些特殊营养素包括谷氨酰胺、精氨酸、ω-3脂肪酸、核苷酸、维生素及微量元素除了能够发挥营养支持的作用之外,还能够发挥免疫调节作用以改善机体防御能力并促进恢复。谷氨酰胺能够抑制促炎因子反应并维持肠道黏膜屏障及细胞防御功能。精氨酸通过一氧化氮依赖性及非依赖性途径发挥代谢性、免疫调节性及血流动力学作用。ω-3脂肪酸能够减轻炎性反应。维生素和微量元素能够发挥抗氧化作用。但是,脓毒症病人免疫营养治疗仍存在理论与实践上的差异,目前并不能常规应用于脓毒症病人的治疗。临床医生应根据脓毒症病人的具体情况及相关影响因素仔细选择营养制剂的成分,合理应用免疫营养治疗。     

早期肝素治疗对重症急性胰腺炎大鼠胰腺组织微血栓形成的影响

目的 观察和评价早期肝素治疗对重症急性胰腺炎(SAP)大鼠胰腺组织微血栓形成的影响和疗效.方法 SD大鼠随机分为SAP组、肝素组和假手术组.12 h检测血清淀粉酶、血浆D-二聚体(D-dimer)、肿瘤坏死因子α(TNF-α)和白细胞介素6(IL-6);采集胰腺行普通病理检查并计数微血栓.结果 SAP诱发后12 h,SAP组大鼠的存活率显著低于肝素组和假手术组(P<0.05);胰腺组织病理学观察显示,肝素组微血栓数、病理评分显著少于SAP组(P<0.05);血清淀粉酶、D-dimer、TNF-α以及IL-6检测结果也显示肝素组较SAP组显著改善(P<0.05).结论 早期肝素治疗能减轻胰腺病理损害,减少胰腺组织微血栓数量,降低全身炎性反应,提高SAP大鼠的生存率.     

小剂量肝素治疗脓毒症的临床分析

Objective To investigate the therapeutic effects of low-dose heparin on sepsis. Methods Seventy-nine sepsis patients were randomly divided into tow groups: beparin treatment group (n=37) and routine treatment group(n =42). The 7-day and 28-day mortality, the days in ICU and the length of stay, the changes of oxygenation index, the days of mechanical ventilation and the rates of disseminated intravascular coagulation (DIC), acute renal failure (ARF), acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome(MODS) were observed. The levels of APTT, PT and platelet (PLT) count were determined before and after treatment in two groups. Results The rates of DIC, ARF and MODS in beparin group decreased significantly after therapy: rate of BIC, 15.4% vs 38. 7% (P=0.03) ; rate of ARF, 25.0% vs51.9% (P=0.04); rate of MODS, 26.3% vs50.0% (P=0.04). In heparin group, the 28-day mortality was statistically reduced (15.4% vs 32.4%, P = 0. 03). The differences between beparin group and routine group were not statistically significant in the 7-day mortality (7. 7% vs 12. 9% ,P =0. 08) ,the days in ICU(Z =0. 281 ,P =0. 779,rank sum test) ,the length of stay (Z = 0. 562, P = 0. 574, rank sum test), the oxygenation index (P = 0. 82), the days of mechanical ventilation [(126.07±166.21)h vs (179.27±221.7)h,P=0.28] and the rate of ARDS (44.0% vs 46.2% ,P= 0. 88). The differences in APTT, PT and PLT were not significant between the two groups. Conclusion Low-dose beparin can decrease the mortality rate of sepsis and improve the prognosis of patients. It is a safe promising therapy in sepsis patients without severe side effects.     

多黏菌素吸附在脓毒症中的应用

严重感染和感染性休克是威胁危重病人生命的严重问题之一,临床有较高的发病率和病死率.有研究报道,美国每年发生严重感染和感染性休克的病人高达75万例.     

低分子肝素和阿司匹林对急性肺损伤的治疗作用

目的 探讨核转录因子-κB（NF-κB）活化对急性肺损伤（AL1）大鼠P-选择素、细胞间黏附分子-1（ICAM-1）表达的影响，并观察低分子肝素（LMWH）和阿司匹林（ASA）对AL1的保护作用，并探讨其机制。方法尾静脉注射内毒素制备AL1大鼠模型。60只大鼠按随机数字表法分为正常对照组、AL1组、LMWH组和ASA组，每组15只。观察NF-κB、ICAM-1和P-选择素在肺组织中的表达情况。结果 ALI组肺组织NF-κB活性显著增强；ICAM-1、P一-选择素明显表达于血管内皮细胞和支气管上皮细胞膜（P均〈0．05）；LMWH组和AsA组NF-κB、ICAM-1、P-选择素活性降低，炎症反应和病理损伤明显减轻，ASA组治疗效果优于LMWH组（P均〈0．05）。结论NF-κB活化在AL1发病机制中起作用，NF-κB参与活化中性粒细胞、血管内皮细胞等多种炎症细胞，并且调控ICAM-1、P-选择素基因的表达进而造成肺组织损伤。LMWH通过改善微循环，间接抑制NF-κB活化，减少中性粒细胞及血小板的黏附进而减轻肺损伤。ASA通过抗氧化特性直接抑制NF-κB活化而减轻肺损伤。     

小剂量肝素治疗脓毒症的临床分析

Objective To investigate the therapeutic effects of low-dose heparin on sepsis. Methods Seventy-nine sepsis patients were randomly divided into tow groups: beparin treatment group (n=37) and routine treatment group(n =42). The 7-day and 28-day mortality, the days in ICU and the length of stay, the changes of oxygenation index, the days of mechanical ventilation and the rates of disseminated intravascular coagulation (DIC), acute renal failure (ARF), acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome(MODS) were observed. The levels of APTT, PT and platelet (PLT) count were determined before and after treatment in two groups. Results The rates of DIC, ARF and MODS in beparin group decreased significantly after therapy: rate of BIC, 15.4% vs 38. 7% (P=0.03) ; rate of ARF, 25.0% vs51.9% (P=0.04); rate of MODS, 26.3% vs50.0% (P=0.04). In heparin group, the 28-day mortality was statistically reduced (15.4% vs 32.4%, P = 0. 03). The differences between beparin group and routine group were not statistically significant in the 7-day mortality (7. 7% vs 12. 9% ,P =0. 08) ,the days in ICU(Z =0. 281 ,P =0. 779,rank sum test) ,the length of stay (Z = 0. 562, P = 0. 574, rank sum test), the oxygenation index (P = 0. 82), the days of mechanical ventilation [(126.07±166.21)h vs (179.27±221.7)h,P=0.28] and the rate of ARDS (44.0% vs 46.2% ,P= 0. 88). The differences in APTT, PT and PLT were not significant between the two groups. Conclusion Low-dose beparin can decrease the mortality rate of sepsis and improve the prognosis of patients. It is a safe promising therapy in sepsis patients without severe side effects.     

50例重症院内获得性肺炎的诊治分析

目的:观察重症院内获得性肺炎患者的细菌耐药情况和预后.方法:对50例重症HAP患者进行前瞻性观察研究,分析患者一般情况、初始痰培养和药物敏感性、机械通气时间以及病死率.结果:初始细菌培养阳性菌株53株,其中革兰阴性菌39株(73.6％),以铜绿假单胞菌(28.3％)、鲍曼不动杆菌(18.9％)、肺炎克雷伯杆菌(11.3％)为多见;革兰阳性菌14株(26.4％),均为耐甲氧西林金黄色葡萄球菌(MRSA).细菌耐药情况严重.所有患者30 d粗病死率为16％(8/50).在43例初始细菌培养阳性患者中,恰当初始抗生素应用率为63.8％ (27/43);治疗组恰当与不恰当组的机械通气时间分别为8.9±5.2d和15.4±10.1d,有显著性差异(P＜0.05);2组30d粗病死率分别为11.1％和25.0％,无显著性差异(P＞0.05).结论:重症院内获得性肺炎的致病菌耐药率高,恰当初始抗生素治疗可以降低机械通气时间.应加强细菌耐药监测及合理应用抗生素.     

普通肝素通过降低肺组织Rho激酶活性缓解脓毒症小鼠的肺损伤

目的探讨普通肝素对腹腔注射脂多糖(LPS)所致脓毒症小鼠肺组织Rho激酶活性以及肺损伤的影响。方法腹腔注射LPS制作小鼠脓毒症模型,将小鼠随机分为对照组、LPS组和LPS+肝素治疗组。分别于造模后3h和6h收集血液标本和肺组织。ELISA法分别测定血清TNF-α、IL-1β浓度;取肺组织进行HE染色,测定肺水含量;用Westernblot法观察肺组织中p-MYPT1蛋白表达变化。结果 LPS组和肝素治疗组3h和6h的血浆TNF-α和IL-1β含量均显著高于正常对照组(P<0.05);与LPS组比较,肝素组3h和6h的血浆TNF-α和IL-1β含量均有显著降低(P<0.05);肝素可以缓解脓毒症小鼠肺损伤程度(6h),降低肺水含量(6h),下调肺组织p-MYPT1蛋白表达(3h,6h)。结论普通肝素缓解脓毒症小鼠的肺损伤可能与降低肺组织Rho激酶活性相关。