中华危重病急救医学
中華危重病急救醫學
중화위중병급구의학
Chinese Critical Care Medicine
2014年
3期
184-187
,共4页
黄若兰%张忠%徐慕娟%常晓%乔秋杰%王玲%孟新科
黃若蘭%張忠%徐慕娟%常曉%喬鞦傑%王玲%孟新科
황약란%장충%서모연%상효%교추걸%왕령%맹신과
四逆汤%脓毒症%下丘脑-垂体-肾上腺轴%肾上腺皮质激素%皮质醇
四逆湯%膿毒癥%下丘腦-垂體-腎上腺軸%腎上腺皮質激素%皮質醇
사역탕%농독증%하구뇌-수체-신상선축%신상선피질격소%피질순
Sini decoction%Sepsis%Hypothalamic-pituitary-adrenal axis%Adrenocorticotropic hormone%Cortisol
目的 观察四逆汤对脓毒症患者下丘脑-垂体-肾上腺轴功能的影响.方法 采用前瞻性单盲随机对照研究,将60例脓毒症患者按随机数字编码法随机分为对照组(20例)、中药组(20例)、激素组(20例).所有患者均给予常规治疗；中药组加用四逆汤[熟附子(先煎)15 g,干姜15 g,炙甘草10g],制成100 mL的煎剂,每日分2次温服或鼻饲；激素组加用氢化可的松200 mg/d静脉滴注,3组均治疗7d.分别于治疗前、治疗3d及治疗14 d时取血,测定促肾上腺皮质激素(ACTH)和皮质醇水平,并观察3组患者对ACTH刺激试验的反应；同时计算急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分,统计3d休克复苏率及28 d病死率.结果 3组患者对ACTH刺激试验差异无统计学意义(x2=1.101,P=0.605).3组患者治疗后ACTH水平逐渐下降；与治疗前比较,中药组和激素组治疗3d时ACTH水平即明显下降(ng/L:29.90±3.31比33.10±3.31,28.20±2.45比33.30±3.84,均P＜0.01),而对照组治疗14d时ACTH水平才明显下降(ng/L:29.40±5.63比33.50±4.89,P＜0.05)；但中药组与激素组治疗后ACTH水平比较差异无统计学意义(均P＞0.05).对照组治疗前后皮质醇水平变化不明显；中药组和激素组皮质醇水平呈先上升后下降趋势,治疗3d时皮质醇水平均明显高于治疗前(μg/L:343.04±31.20比294.70±42.10,331.25±42.80比280.36±38.10,均P＜0.01)和对照组(μg/L:291.61±41.50,均P＜0.01)；但中药组与激素组治疗后皮质醇水平比较差异无统计学意义(均P＞0.05).对照组、中药组和激素组治疗14 d APACHEⅡ评分均较治疗前明显下降(分:16.8±5.1比20.1±4.3,13.4±3.2比18.3±3.8,15.1±2.5比19.5±4.0,均P＜0.01),且中药组较对照组下降显著(P＜0.05).对照组、中药组和激素组在降低患者28 d病死率[35.0％(7/20)、25.0％(5/20)、20.0％(4/20)]、提高3d休克复苏率[40.0％(8/20)、70.0％(14/20)、60.0％(12/20)]方面差异均无统计学意义(均P＞0.05).结论 四逆汤能提高脓毒患者早期皮质醇水平,降低ACTH,有效改善病情严重程度,提高应激状态下机体下丘脑-垂体-肾上腺轴的功能,但对病死率无影响.
目的 觀察四逆湯對膿毒癥患者下丘腦-垂體-腎上腺軸功能的影響.方法 採用前瞻性單盲隨機對照研究,將60例膿毒癥患者按隨機數字編碼法隨機分為對照組(20例)、中藥組(20例)、激素組(20例).所有患者均給予常規治療；中藥組加用四逆湯[熟附子(先煎)15 g,榦薑15 g,炙甘草10g],製成100 mL的煎劑,每日分2次溫服或鼻飼；激素組加用氫化可的鬆200 mg/d靜脈滴註,3組均治療7d.分彆于治療前、治療3d及治療14 d時取血,測定促腎上腺皮質激素(ACTH)和皮質醇水平,併觀察3組患者對ACTH刺激試驗的反應；同時計算急性生理學與慢性健康狀況評分繫統Ⅱ(APACHEⅡ)評分,統計3d休剋複囌率及28 d病死率.結果 3組患者對ACTH刺激試驗差異無統計學意義(x2=1.101,P=0.605).3組患者治療後ACTH水平逐漸下降；與治療前比較,中藥組和激素組治療3d時ACTH水平即明顯下降(ng/L:29.90±3.31比33.10±3.31,28.20±2.45比33.30±3.84,均P＜0.01),而對照組治療14d時ACTH水平纔明顯下降(ng/L:29.40±5.63比33.50±4.89,P＜0.05)；但中藥組與激素組治療後ACTH水平比較差異無統計學意義(均P＞0.05).對照組治療前後皮質醇水平變化不明顯；中藥組和激素組皮質醇水平呈先上升後下降趨勢,治療3d時皮質醇水平均明顯高于治療前(μg/L:343.04±31.20比294.70±42.10,331.25±42.80比280.36±38.10,均P＜0.01)和對照組(μg/L:291.61±41.50,均P＜0.01)；但中藥組與激素組治療後皮質醇水平比較差異無統計學意義(均P＞0.05).對照組、中藥組和激素組治療14 d APACHEⅡ評分均較治療前明顯下降(分:16.8±5.1比20.1±4.3,13.4±3.2比18.3±3.8,15.1±2.5比19.5±4.0,均P＜0.01),且中藥組較對照組下降顯著(P＜0.05).對照組、中藥組和激素組在降低患者28 d病死率[35.0％(7/20)、25.0％(5/20)、20.0％(4/20)]、提高3d休剋複囌率[40.0％(8/20)、70.0％(14/20)、60.0％(12/20)]方麵差異均無統計學意義(均P＞0.05).結論 四逆湯能提高膿毒患者早期皮質醇水平,降低ACTH,有效改善病情嚴重程度,提高應激狀態下機體下丘腦-垂體-腎上腺軸的功能,但對病死率無影響.
목적 관찰사역탕대농독증환자하구뇌-수체-신상선축공능적영향.방법 채용전첨성단맹수궤대조연구,장60례농독증환자안수궤수자편마법수궤분위대조조(20례)、중약조(20례)、격소조(20례).소유환자균급여상규치료；중약조가용사역탕[숙부자(선전)15 g,간강15 g,자감초10g],제성100 mL적전제,매일분2차온복혹비사；격소조가용경화가적송200 mg/d정맥적주,3조균치료7d.분별우치료전、치료3d급치료14 d시취혈,측정촉신상선피질격소(ACTH)화피질순수평,병관찰3조환자대ACTH자격시험적반응；동시계산급성생이학여만성건강상황평분계통Ⅱ(APACHEⅡ)평분,통계3d휴극복소솔급28 d병사솔.결과 3조환자대ACTH자격시험차이무통계학의의(x2=1.101,P=0.605).3조환자치료후ACTH수평축점하강；여치료전비교,중약조화격소조치료3d시ACTH수평즉명현하강(ng/L:29.90±3.31비33.10±3.31,28.20±2.45비33.30±3.84,균P＜0.01),이대조조치료14d시ACTH수평재명현하강(ng/L:29.40±5.63비33.50±4.89,P＜0.05)；단중약조여격소조치료후ACTH수평비교차이무통계학의의(균P＞0.05).대조조치료전후피질순수평변화불명현；중약조화격소조피질순수평정선상승후하강추세,치료3d시피질순수평균명현고우치료전(μg/L:343.04±31.20비294.70±42.10,331.25±42.80비280.36±38.10,균P＜0.01)화대조조(μg/L:291.61±41.50,균P＜0.01)；단중약조여격소조치료후피질순수평비교차이무통계학의의(균P＞0.05).대조조、중약조화격소조치료14 d APACHEⅡ평분균교치료전명현하강(분:16.8±5.1비20.1±4.3,13.4±3.2비18.3±3.8,15.1±2.5비19.5±4.0,균P＜0.01),차중약조교대조조하강현저(P＜0.05).대조조、중약조화격소조재강저환자28 d병사솔[35.0％(7/20)、25.0％(5/20)、20.0％(4/20)]、제고3d휴극복소솔[40.0％(8/20)、70.0％(14/20)、60.0％(12/20)]방면차이균무통계학의의(균P＞0.05).결론 사역탕능제고농독환자조기피질순수평,강저ACTH,유효개선병정엄중정도,제고응격상태하궤체하구뇌-수체-신상선축적공능,단대병사솔무영향.
Objective To investigate the effects of Sini decoction on function of hypothalamic-pituitary-adrenal axis in patients with sepsis.Methods A prospective single-blind randomized controlled trial was conducted.60 septic patients were divided into three groups with the method of random number table,20 cases in the control group,20 in the Chinese herb group,and 20 in corticoid group.All of them received routine treatment.Patients in Chinese herb group were given Sini decoction in addition (decoction of monkshood 15 g,dried ginger 15 g,honey-fried licorice 10 g) 100 mL/d orally or by nasal feeding,while patients in corticoid group were given hydrocortisone 200 mg/d intravenously instead,both for 7 days.Before the treatment,3 days and 14 days after treatment,blood was collected to determine the levels of adrenocorticotropic hormone (ACTH) and cortisol,and the result of ACTH stimulating test was observed.At the same time,acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score was recorded,and 3-day shock recovery rate and 28-day death rate were also compared among these groups.Results None of the three groups showed different result in ACTH stimulating test (x2=1.101,P=0.605).ACTH in three groups was gradually decreased.Compared with that before treatment,ACTH in Chinese herb group and corticoid groups began to decrease obviously on day 3 (ng/L:29.90 ± 3.31 vs.33.10 ±.3.31,28.20 ±.2.45 vs.33.30 ± 3.84,both P＜0.01),while in control group declined ACTH appeared later (on day 14) compared with before treatment (ng/L:29.40 ±5.63 vs.33.50 ±4.89,P＜0.05).No obvious difference in ACTH level was showed between the Chinese herb group and the cortical group (both P＞0.05).Cortisol level in both Chinese herb and cortical groups showed a raise-fall biphase trend while there was no change in the control.The cortical levels on day 3 in Chinese herb and cortical groups were much higher than that before treatment (μg/L:343.04 ± 31.20 vs.294.70 ±42.10,331.25 ±42.80 vs.280.36 ± 38.10,both P＜0.01) and that of control group (μg/L:291.61 ± 41.50,both P＜0.01),though no significant statistical difference was observed between two groups (both P＞0.05).APACHE Ⅱ score on day 14 in control,Chinese herb and cortical groups was significantly lower than that before treatment (16.8 ± 5.1 vs.20.1 ± 4.3,13.4 ± 3.2 vs.18.3 ± 3.8,15.1 ± 2.5 vs.19.5 ± 4.0,all P＜0.01),and the score was much lower in Chinese herb group comparing with that of control group (P＜0.05).No statistical difference was observed among control,Chinese herb and cortical groups in lowering 28-day death rate [35.0％ (7/20),25.0％ (5/20),20.0％ (4/20)] and improving 3-day shock recovery rate [40.0％ (8/20),70.0％ (14/20),60.0％ (12/20),all P＞0.05].Conclusions Sini decoction could elevate cortisol while lower ACTH at the early stage of sepsis.Sini decoction could also effectively improve symptoms and hypothalamic-pituitary-adrenal axis function in septic patients without affecting death rate.
