【作者】 李菁雅；

【导师】 张敏州；

【作者基本信息】 广州中医药大学 ， 中西医结合临床， 2008， 硕士

【摘要】 背景:多器官功能障碍综合征(multiple organ dysfunction syndrome,MODS)是创伤、休克、感染、心肺复苏后的严重并发症,是当今国际医学界所瞩目的研究热点,也是当今世界危重病学、创伤医学、急诊医学所面临的最大挑战,烬管目前对其发病机理和治疗的研究很多,且近年来采用了各种新的治疗方案及手段,但仍是死亡率最高的临床危重症之一。全身炎症反应综合征(systemic inflammatory response syndrome,SIRS)是指机体对各种刺激或打击,包括感染、缺氧、创伤、坏死等引起的全身失控性炎症免疫反应。各种感染因素和非感染因素均可引起SIRS。SIRS是发生MODS的根本原因和重要过程,MODS是SIRS的严重并发症,是SIRS持续发展的结果。祖国医学中无MODS名称,亦无相关类似症情描述,近年有称之为“脏竭证”,认为本病起因是,素体已虚,又感受外邪,致气机不畅,疏泄失职,气血逆乱,阴阳离决。虽然中医对其研究很多,但大都集中在治疗方面,其中医发病机理及证候方面的研究却很少,对于MODS发生发展过程中脏腑的传变及证候的演变规律缺乏系统研究。所以运用中医辨证思维对SIRS/MODS进行辨证,运用脏腑功能相关等中医基础理论综合探讨SIRS/MODS中的证型规律,对我们从中医方面认识SIRS/MODS及其病因病机,运用中医理论对其辨证论治,有着十分重要的意义。目的:运用中医基础理论对SIRS/MODS进行辨证分型,找出其中的脏腑传变及八纲演变的规律,提出“启动脏腑”与“枢纽脏腑”的概念,建立SIRS/MODS的中医辨证理论体系,为中医治疗SIRS/MODS及防止传变提供理论依据,以更好的把握SIRS/MODS的发生发展过程,按中医“治未病”、“已病防变”的理论防止疾病传变,保护未传变之脏。方法:根据SIRS/MODS诊断标准,对广州中医药大学第二附属医院(广东省中医院)2006年1月～2008年4月符合纳入标准的的ICU住院患者91人(存活时间＞72h),在入住ICU Oh、24h、72h,结合主症及相关辅助证据、舌脉等判定累及脏腑,进行脏腑、八纲辨证。根据所得证型演变规律,结合古代现代文献、临床经验及中医基础理论,确定其中五脏的传变规律,提出“启动脏腑”(在发生MODS后累及的第一个脏)与“枢纽脏腑”(当传变至该脏时病情迅速恶化,导致患者死亡)的概念。建立数据库,采用SPSS13.0软件进行数据处理。结果:(1)MODS死亡率显著高于SIRS(P＜0.01)。通过Logistic回归分析,对死亡有显著影响为SIRS/MODS、72h累及脏腑个数。(2)累及脏腑个数在转归方面:SIRS/MODS患者在入住ICU Oh的差异无统计学意义(P＞0.05),24h、72h死亡率随着累及脏腑个数而显著上升(P＜0.01)。(3)SIRS组和MODS组比较:累及脏腑个数在入住ICU Oh的差异无统计学意义(P＞0.05),24h与72h MODS组累及脏腑个数显著多于SIRS组(P＜0.01)。(4)死亡组和好转组比较:累及脏腑个数在入住ICU Oh的差异无统计学意义(P＞0.05),24h与72h死亡组累及脏腑个数显著多于好转组(P＜0.01)。(5)累及脏腑个数与转归的相关性分析:24h、72h与转归呈显著正相关关系(P＜0.01)。(6)寒热程度比较:入住ICU 0h、24h、72h的差异无统计学意义(P＞0.05);SIRS组和MODS组、死亡组和好转组比较,差异均无统计学意义(P＞0.05);SIRS组、MODS组、死亡组、好转组的差异均无统计学意义(P＞0.05)。三个时点寒热证与转归的差异均无统计学意义(P＞0.05)。(7)由虚到实:24h＞72h＞入住ICU 0h(P＜0.05);SIRS组和MODS组、死亡组和好转组比较,差异均无统计学意义(P＞0.05)。SIRS组中:24h＞入住ICU Oh＞72h(P＜0.05)。死亡组中:72h＞24h＞入住ICU Oh(P＜0.05)。MODS组、好转组的差异无统计学意义(P＞0.05)。入住ICU Oh虚实证在转归的差异无统计学意义(P＞0.05),24h实证死亡率高,72h虚证死亡率高(P＜0.05)。(8)SIRS组和MODS组比较、死亡组和好转组比较,辨证组合在三个时点的差异均无统计学意义(P＞0.05)。(9)各原发疾病组比较:寒热证在入住ICU 0h、24h、72h的差异均无统计学意义(P＞0.05);入住ICU Oh虚实程度受原发疾病影响(P＜0.05),24h、72h的差异均无统计学意义(P＞0.05)。(10)虚实证与累及脏腑的相关性分析:入住ICU Oh累及脾与虚实证呈正相关关系(P＜0.05),累及肠与虚实证呈显著负相关关系(P＜0.01);72h累及肾与虚实证呈正相关关系(P＜0.05)。(11)MODS患者中,在三个时点,共计累及脏腑由多到少排列为:肺＞肠＞心＞肾＞脾＞脑＞肝;24h累及脏腑的增减变化由多到少排列为:肠＞脾＞肝=肾＞心＞脑＞肺;72h累及脏腑的增减变化由多到少排列为:脑＞肝＞肾＞脾=肠＞肺＞心。各累及脏腑的总死亡人数在总累及人数所占比例由多到少排列为肾＞心＞脾＞肠＞肺＞脑＞肝。结论:(1)SIRS/MODS患者死亡率随着累及脏腑个数增多而上升。随时间进展,实证向虚证发展,死亡率逐渐上升,辨证的虚实也逐渐与原发疾病无关。(2)SIRS/MODS患者入住ICU Oh累及脾容易出现虚证,累及肠容易出现实证,72h累及肾容易出现虚证。(3)SIRS/MODS可能的八纲演变规律为:实热证/单纯实证→(虚实夹杂证)→气阴两虚证/虚热证→亡阴亡阳证。(4)MODS启动脏腑为肺,枢纽脏腑为肾,传变规律可能为肺→心→脾→肝→肾。更多还原

【Abstract】 Background: Multiple organ dysfunction syndrome(MODS) is serious complication of wound, shock, infection and post-CPR. Nowadays it becomes the research focus of the international medical group and the biggest challenge of critical medicine, wound medical science, emergency in the world. Nowadays there are so much study about pathogenesis and treatment of MODS and sorts of new therapeutic regimen and tool, however, MODS is still one of the highest mortality of clinic critical disease. Systemic inflammatory response syndrome(SIRS) means human body responsed for various stimulation or attachment, such as infection, hypoxia, wound, necrosis which originated systemic inflammatory immunoreaction out of control. Both of sorts of infective and un-infective element can cause SIRS. SIRS is the basic reason and important process of MODS. MODS is serious complication and persistent developed consequence of SIRS.There is no name of MODS and delineation of correlated and similar symptom in TCM. Recently MODS is called "ZANG-organ exhaust syndrome" .The cause of MODS to be considered is the deficient body invaded by exogenous pathogen induced to functional activity of QI being not smooth, aberration of catharsis, backrun of QI and blood and segregation of yin-yang. Although a deal of aspect about treatment of MODS in TCM is investigated, there is seldom research about etiopathogenesis and syndrome of TCM, which is lack of systematic research about transmission and syndrome principles in entrails’ process of occurrence and development in MODS. Utilizing the thought of syndrome differentiation in TCM and probing into pattern law of TCM with entrails’ function correlated with Chinese medicine basic theory synthetically in SIRS/MODS, it is important for us to know the etiopathogenisis and pathogenesis of SIRS/MODS in Chinese medicine theory and determination of treatment based in pathogenesis obtained through differentiation of symptoms and signs.Objcetive: Making use of Chinese medicine basic theory to carry on differentiation of symptoms and signs for classification of syndrome to SIRS/MODS, we could find out transmission and syndrome principles about entrails of TCM, put forward the concepts of "priming entrail" and "pivot entrail" and set up the theoretical system of differentiation of symptoms and signs of SIRS/MODS in TCM. By means of offerring the theoretical foundation for treating and preventing transmission of TCM in SIRS/MODS, we could grasp occurrence and development better in SIRS/MODS. According to the theory of "following the prognosis of a disease" and "preapring for progress of disease" in TCM, we could prevent transmission of a disease and protect ZANG-organ which transmit not yet.Method: On the basis of the diagnostic criteria in SIRS/MODS, we internalized 91 patients(the time of surviving>72 hours) accorded with standard in ICU of the second affiliated hospital of Guangzhou university of Chinese medicine (Guangdong Province hospital of TCM), which were from January 2006 to April 2008). Combined the main sign, the evidence assisted and tongue/nervure to judge entrails involved, the patients were analysed and differentiated pathological conditions in accordance with entrails and the eight principal syndromes in ICU 0h, 24h and 72h. According to pattern of syndrome and regularity of evol in the patients, combined ancient modern literature, clinical experience and basic theory of Chinese medicine, we could confirm transmission principles of TCM in five viscera and put forward the concepts of "priming entrail" (the first ZANG-organ involved when MODS took place)and "pivot entrail" (the ZANG-organ involved when pathogenetic condition aggravated and patients died rapidly).We set up the database and deal with the data with the software of SPSS13.0.Result:(1)The death rate in MODS was significantly higher than that in SIRS(P<0.01).Through logistic regression analysis, SIRS/MODS and number of entrail damaged in 72h influenced death prominently.(2)The relation between number of entrail damaged and outcome: the difference of SIRS/MODS in ICU 0h was no statistical significance(P>0.05), and the fatality rised with the number of entrail damaged in 24h and 72h significantly (P<0.01).(3) Compared with SIRS group and MODS group: the difference of number of entrail damaged in ICU 0h was no statistical significance (P>0.05), the number of entrail damaged in MODS group was significantly higher than that in SIRS group in 24h and 72h(P<0.01).(4)Compared with death group and improvement group: the difference of number of entrail damaged in ICU 0h was no statistical significance(P>0.05), the number of entrail damaged in death group was significantly higher than that in improvement group in 24h and 72h(P<0.01).(5)Correlation analysis of entrail damaged and outcome was prominent positive correlation in 24h and 72h(P<0.01).(6)Compared with the degree of cold and pyretic: the difference was no statistical significance in ICU 0h, 24h and 72h(P>0.05); compared with SIRS group and MODS group, death group and improvement group, the difference was no statistical significance (P>0.05); the difference in SIRS group, MODS group, death group and improvement group was no statistical significance (P>0.05). The difference of "cold and pyretic syndrome" and outcome was no statistical significance in three time point(P>0.05).(7) From asthenia to sthenia: 24h>72h>in ICU 0h (P<0.05); compared with SIRS group and MODS group, death group and improvement group, the difference was no statistical significance(P>0.05). SIRS group: 24h>in ICU 0h>72h (P<0.05); death group: 72h>24h>in ICU 0h(P<0.05). The difference in MODS group and improvement group was no statistical significance(P>0.05).The difference of"asthenia and sthenia syndrome" and outcome was no statistical significance in ICU 0h(P>0.05), sthenia syndrome in 24h and asthenia syndrome in 72h were high mortality(P<0.05).(8) Compared with SIRS group and MODS group, death group and improvement group, the difference of differentiation of symptoms and signs group was no statistical significance in three time point(P>0.05).(9)Compared with primarily sickness group: the difference of cold and pyretic syndrome was no statistical significance in ICU 0h, 24h and 72h(P>0.05); primarily sickness influenced the degree of asthenia and sthenia in ICU 0h(P<0.05).There was no statistical significance in 24h and 72h (P>0.05).(10)Correlation analysis of "asthenia and sthenia syndrome" and spleendamaged was positive correlation in ICU 0h(P<0.05). Correlation analysis of"asthenia and sthenia syndrome" and bowel was prominent negative correlationin ICU 0h(P<0.01); Correlation analysis of "asthenia and sthenia syndrome"and nephros was negative correlation in 72h(P<0.05).(11) Patients of MODS in three time point, total number of entrail damaged in arranged from more to less:pulmo>bowel>cardia>nephros>spleen>encephalon>hepar. The increase and decrease number of entrail damaged in 24h arranged from more to less: bowel>spleen>hepar=nephros>cardia>encephalon>pulmo. The increase and decrease number of entrail damaged in 72h arranged from more to less: encephalon>hepar>nephros>spleen=bowel>pulmo>cardia. The total death toll of each entrail damaged in proportion of total patients damaged arranged from more to less: nephros>cardia>spleen>bowel>pulmo>encephalon>hepar.Conclusions:(1)The fatality of SIRS/MODS rised with the number of entrail damaged. With the time passed, sthenia syndrome turned into asthenia syndrome and the fatality of SIRS/MODS rised. Furthermore, what the differentiation of symptoms and signs was sthenia or asthenia had nothing to do with primarily sickness gradually.(2) If spleen was damaged in patients of SIRS/MODS in ICU 0h, the patients would appear asthenia syndrome. If intestine was damaged in ICU 0h, the patients would appear sthenia syndrome. If nephros was damaged in ICU 72h, the patients would appear asthenia syndrome.(3)The progress of disease in eight principal syndromes of TCM might be: excess-heat syndrome/simple sthenia syndrome→(asthenia mixed with sthenia syndrome)→deficiency of both vital energy and yin syndrome/asthenia-heat syndrome→yin and yang exhaustion syndrome.(4)The priming entrails might be pulmo and the pivot entrails may be nephros in patients of MODS. The five viscera progress of disease in patients of MODS might be pulmo→cardia→spleen→hepar→nephros.更多还原