The impact of trauma on neutrophil function

A well described consequence of traumatic injury is immune dysregulation, where an initial increase in immune activity is followed by a period of immune depression, the latter leaving hospitalised trauma patients at an increased risk of nosocomial infections. Here, we discuss the emerging role of the neutrophil, the most abundant leucocyte in human circulation and the first line of defence against microbial challenge, in the initiation and propagation of the inflammatory response to trauma. We review the findings of the most recent studies to have investigated the impact of trauma on neutrophil function and discuss how alterations in neutrophil biology are being investigated as potential biomarkers by which to predict the outcome of hospitalised trauma patients. Furthermore, with trauma-induced changes in neutrophil biology linked to the development of such post-traumatic complications as multiple organ failure and acute respiratory distress syndrome, we highlight an area of research within the field of trauma immunology that is gaining considerable interest: the manipulation of neutrophil function as a means by which to potentially improve patient outcome.     

Treatment of impaired perfusion in septic shock

Severe sepsis and septic shock are relatively common problems in intensive care. The mortality in septic shock is still high, and the main causes of death are multiple organ failure and refractory hypotension. Impaired tissue perfusion due to hypovolemia, disturbed vasoregulation and myocardial dysfunction contribute to the multiple organ dysfunction. Treatment of hemodynamics in septic shock consists of appropriate fluid therapy guided by invasive monitoring combined with vasoactive drugs aiming to correct hypotension and inappropriately low cardiac output. The drug of choice for low vascular resistance is norepinephrine, while insufficient myocardial contractility is commonly treated with dobutamine. The use of norepinephrine seems to be associated with better prognosis as compared to results from the use of dopamine or epinephrine. In septic shock, vasopressin levels are low, and therefore, vasopressin has been advocated as a vasopressor. Its effectiveness and safety have not yet been documented, and so far it is regarded as an experimental treatment. Recent data support the use of corticosteroid, at least in some of the patients with septic shock. Also, activated protein C, a drug with anti-inflammatory and antithrombotic properties, decreases mortality in patients with septic shock.     

Die extrakorporale Therapie septischer Patienten

Zusammenfassung Trotz zahlreicher Fortschritte in der Intensivmedizin stellt die Behandlung von Patienten mit schwerer Sepsis und septischem Schock eine medizinische Herausforderung dar. In der Pathogenese der systemischen Inflammation (SIRS) kommt es zur exzessiven Freisetzung von multiplen endogenen und exogenen inflammatorischen Mediatoren [z. B. Lipopolysaccharid (LPS), Tumor-Nekrose-Faktor (TNF)-α, Interleukin (IL)-1, IL-6] und zur Entwicklung eines Multi- Organ-Versagen (MOV). Dies führt bekannterma?en zu schlechten überlebenszahlen septischer Patienten. Ein komplexes dynamisches Kontrollsystem führt in der Abfolge meist zur zeitnahen gegen-regulatorischen antiinflammatorischen Antwort mittels Induktion anti-inflammatorischer Mediatoren (IL-10, transforming growth factor-beta [TGF-β]). In einer gro?en Anzahl septischer Patienten kommt es durch eine Persistenz des inflammatorischen Reizes zu einer Deaktivierung von antigenpr?sentierenden Zellen bzw. zu einem Versagen des zellvermittelten Immunsystems („Immunparalyse“). Unselektive und selektive intermittierende und kontinuierliche extrakorporale Therapieverfahren wurden evaluiert, ob diese in der Lage sind, in inflammatorische durch den klinischen Verlauf günstig zu beeinflussen. Technologische Fortschritte im Hinblick auf die Entwicklung von extrakorporalen Plasmapherese- bzw. Adsorptionsverfahren bieten heute neue, effektive M?glichkeiten, Mediatoren aus der Blutbahn septischer Patienten zu entfernen. In der vorliegenden übersichtsarbeit werden aktuell verfügbare und zukünftige adjunktive extrakorporale Therapiestrategien vorgestellt und vor dem Hintergrund aktueller Studien diskutiert.      

严重感染患者下丘脑-垂体-肾上腺轴功能的再评价

应用化学免疫发光法分组测定10例严重全身性感染（危重组）和12例感染性休克（休克组）患者在病程早期（确诊后1，3，5d）血清皮质醇和血浆ACTH水平，与12例对照组患者进行对照分析；并进行1μg ACTH刺激试验评价严重感染患者下丘脑-垂体-肾上腺（HPA）轴功能。结果显示，与对照组相比，危重组的ACTH明显升高（P〈0．05），休克组的ACTH明显降低（P〈0．05），ACTH与严重感染患者的病情危重程度密切相关（P〈0．05），在存活组和死亡组间存在显著差异（P〈0．05）。提示HPA轴在严重感染发生早期已经出现功能改变，ACTH水平与严重感染患者的病情危重程度及住院病死率密切相关。     

Streptococcus pneumoniae Peritonitis Postpartum

Summary A peritonitis cause by an ascending infection is a rare complication postpartum. A 37-year-old women presented with a secondary peritonitis due to Streptococcus pneumoniae. The patient had given birth to a healthy boy 4 weeks before and showed no symptoms of a bronchitis on admission. A operation was performed after the patient developed an acute abdomen, showing a diffuse peritonitis. High vaginal swabs and blood cultures taken on admission were positive for S. pneumoniae as well as the specimen taken during the operation. Thus we concluded that this was a case of an ascending infection. After antibiotic therapy with penicillin the patient could be discharged 8 days after the operation. Received: July 6, 1999 · Accepted: January 5, 2000     

乌司他丁对脓毒症患者肾损伤的保护作用及对免疫功能的影响

目的探讨乌司他丁对于脓毒症肾损伤的保护作用,并分析其对预后及免疫功能的影响,并探讨其可能的作用机制,为临床治疗提供依据。方法选择2010年3月~2014年2月浙江省丽水市人民医院收治的脓毒症患者46例,随机将所有患者分为对照组(22例)和观察组(24例),对照组患者给予常规治疗和护理;观察组患者在常规治疗基础上应用乌司他丁治疗。主要评估患者治疗前后血尿素氮(BUN)、血肌酐(SCr)和胱抑素C(Cystatin C)含量、T细胞亚群结果 ,检测血清中肿瘤坏死因子-α(TNF-α)和白细胞介素-6(IL-6)水平,并进行急性生理与慢性健康(APACHEⅡ)评分。结果两组患者治疗后Cystatin C、BUN和SCr均低于治疗前,差异均有统计学意义(P<0.05);观察组患者治疗后Cystatin C、BUN和SCr分别为(1.21±0.24)mg/L、(14.92±1.23)mmol/L和(210.74±18.36)μmol/L,均低于对照组患者治疗后[(1.57±0.16)mg/L、(16.12±1.04)mmol/L和(254.33±23.82)μmol/L](P<0.05);两组患者治疗后CD4+、CD8+和CD4+/CD8+与治疗前比较,差异均有统计学意义(P<0.05)。观察组患者治疗后CD4+和CD4+/CD8+分别为(43.87±5.04)%和(1.82±0.29),均高于对照组治疗后[(38.04±4.51)%、(1.30±0.37)](P<0.05)。观察组患者治疗后CD8+为(31.92±3.26)%,低于对照组治疗后[(35.42±3.11)%],差异有统计学意义(P<0.05)。两组患者治疗后TNF-α和IL-6与治疗前比较,差异均有统计学意义(P<0.05)。观察组患者治疗后TNF-α和IL-6分别为(201.66±17.44)、(173.54±15.8)ng/L,均低于对照组治疗后[(236.85±19.51)、(217.96±20.32)ng/L],差异有统计学意义(P<0.05)。观察组患者治疗后APACHEⅡ评分为(15.60±1.23)分,低于对照组治疗后[(19.24±1.65)分],且两组患者治疗后均低于治疗前(P<0.05)。结论乌司他丁对于脓毒症肾损伤患者具有保护作用,且能够显著改善患者的免疫功能,降低炎性因子,值得临床推广应用。     

联合检测降钙素原和超敏C反应蛋白对新生儿败血症早期诊断的临床价值

目的：探讨在新生儿败血症诊断中,联合检测降钙素原和超敏C反应蛋白的临床价值。方法收集2013年10月—2014年6月来该院治疗的新生儿105例,其中败血症组为47例败血症新生儿、对照组为58例健康新生儿,测定两组新生儿血清中降钙素原和超敏C反应蛋白的水平含量。结果在败血症组新生儿中,超敏C反应蛋白和降钙素原血清水平含量分别为(26．9±17．8)mg／L和(13．5±10．1)ng／mL,检测结果明显高于对照组水平含量,差异有统计学意义(P<0．05)。PCT、CRP对诊断新生儿早期败血症试验中,阴性预测值无显著差异(P＞0．05);PCT敏感性、阳性预测值、特异性及准确度均高于hs—CRP (P<0．05)。结论在临床中新生儿败血症早期诊断中,检测新生儿降钙素原和超敏C反应蛋白的水平含量,参考联合两者能够更有效的对出评估。     

Hyperglycemia,Insulin, and Insulin Resistance in Sepsis

Critically ill patients frequently have hyperglycemia. This event may reflect severe stress with an imbalance between anabolic hormones and catabolic hormones. Alternatively, it may reflect alterations in either insulin levels or insulin function. Insulin is a pleiotropic hormone with multiple important metabolic effects. In patients with sepsis, insulin levels are increased but insulin sensitivity is decreased. However, there is variability in insulin sensitivity, and this creates variability in glucose levels and insulin requirements and increases the frequency of hypo- and hyperglycemia. The factors that influence insulin sensitivity are complex and include inhibition of tyrosine kinase activity of the beta subunit, increased proteolytic activity resulting in loss of receptors from the plasma membrane, and possibly the transfer of insulin receptors into the nucleus where they bind to gene promoters. Better understanding of the role of insulin in critically ill patients requires prospective studies measuring insulin levels in various patient groups and the development of a simple measure of insulin sensitivity.     

连续性血液净化治疗重症脓毒症合并应激性心肌病疗效分析

目的探讨连续血液净化(CBP)对重症脓毒症合并应激性心肌病患者的疗效。方法回顾性收集2012年1月至2014年1月60例重症脓毒症合并应激性心肌病患者,分为常规治疗组30例和血液净化组30例,分析2组治疗前、治疗后24、48、72 h相关血流动力学及72 h炎症感染指标变化。结果CBP治疗后患者平均动脉压、心率、每搏输出量、左心室射血分数和氧合指数(Pa O2/Fi O2)均较治疗前有所改善(P<0.05);与常规治疗组相比,CBP治疗组在C-反应蛋白、降钙素原、白细胞介素-6、脑利钠肽及血乳酸等指标均降低(P<0.05),氧合指数上升(P<0.05),急性生理学及慢性健康状况评分Ⅱ(APACHEⅡ)亦降低(P<0.05)。结论对于重症脓毒症合并应激性心肌病患者采用连续性血液净化治疗,在早期能有效清除炎症因子,维持血流动力学稳定,改善氧合功能。