高渗盐水对创伤性休克患者单核细胞表面分子14/16表达及血浆抗炎因子的影响

目的 探讨高渗盐水对创伤性休克患者单核细胞CD14/CD16表达及血浆抗炎性因子的影响.方法 采用前瞻性随机对照的方法,观察2007年3至10月在武汉大学人民医院急诊室内收治的30例创伤失血性休克患者,复苏前至少有一次测量收缩压≤90 mmHg,存在明显的胸腹或四肢出血;若确认创伤达6 h以上、孕妇或伴有慢性疾病患者排除此研究之列.患者入急诊室后立即静脉输注250 ml HSD(7.5%氯化钠+6%右旋糖酐-70,HSD治疗组)或0.9%氯化钠(对照组).分别在输液前、输液后1、3.6、24 h采上肢静脉血,用流式细胞术动态观察单核细胞表面CD14和CD16的表达水平,用酶联免疫吸附测定血浆IL-1ra,IL-10和TNF-α水平,记录液体输入量及预后情况.结果 与基础值比较HSD组CD14++CD16-单核细胞亚群明显增加,而CD14+CD16+亚群显著减少(P＜0.05);对照组结果却相反,两组差异具有统计学意义(P＜0.05).同时,HSD显著降低促炎性因子TNF-α的产生(P＜0.05),而显著加强抗炎性因子IL-1ra和IL-10的释放(P＜0.05),与对照组比较差异具有统计学意义(P＜0.05).两组患者的临床一般资料差异无统计学意义,HSD组患者血浆渗透压仅呈暂时性轻度升高.结论 HSD对创伤失血性休克患者有较好的免疫调节和抗炎性反应效应,对预防创伤后多器官功能障碍综合征(MODS)的发生有重大意义.

Effects of hypertonic saline on CD14/CD16 expression by monocytes and the levels of anti-inflammatory cytokines in patients sustaining traumatic hemorrhagic shock

Objective To investigate the expression of CD14/CD16 by monocytes and the anti-inflammatory effects of hypertonic saline plus dextran (HSD) in adult blunt trauma patients in hemonhagic shock. Method A total of 30 adult patients were eligible for inclusion in the study if they sustained blunt trauma from March to October 2007 and had at least one recorded episode of hypotension (systolic blood pressure ≤ 90 mm Hg) with clear evidence of blood loss (external or internal including the thorax, abdomen or retroperitoneum). Patients were excluded if they refused to participate, were admitted ≥ 6 hours after injury, were pregnant, or had chronic disease. The enrolled patients were randomly divided in a double-blinded manner into an HSD group which was administered 7.5% Nad plus 6% dextran - 70, and a control group which was administered 0.9% NaCl. A single 250 ml dose of either HSD or NaO was immediately administered to the patients in each of the two groups while they were in the emergency room. The primary outcomes were to measure the changes in CD4/CD16 expression by monocytes and the levels of anti-inflammatory cytokines, including tumor necrosis factor-alpha (TNF-α), interleukin (IL)-lra and IL-10. Patient demographics, fluid requirements, organ dysfunction, infection and death were recorded. Results A total of 28 patients were enrolled with no significant differences in their clinical measurements. Hyperosmolarity was modest and transient. HSD altered the shock-induced monocyte redistribution pattern by reducing the drop in the "classic" CD14 ++ subset and remarkably affecting the expansion of the "pro-inflammatory" CD14+CD16+ subsets. In parallel, HSD significamly reduced pro-inflammatory TNF-α production while increasing anti-inflammatory IL-lra and IL-10 production. Conclusions This human trial demonstrates that HSD has anti-inflammatory and immunologic properties for trauma patients in hemorrhagic shock. HSD exerts profound immunomodulatory effects, promoting more balanced pro-/anti-inflammatory responses and reducing post-traumatic complications. Therefore, it could be useful in attenuating post-trauma multiorgan dysfunction (MOD).