脓毒症患者中医证型分布及其与免疫功能及预后的关系

Distribution of Traditional Chinese Medicine Syndromes in Patients with Sepsis and Its Relationship with Immune Function and Prognosis

目的:探究脓毒症患者中医证型分布及其与免疫功能及预后的关系。方法:对我院2019年4月~2021年4月期间220例脓毒症患者回顾性分析,收集患者一般资料、中医症素、西医理化指标及预后情况;分析患者中医证候分布、组合特点及常见证型,比较不同证型患者病情程度(APACHE II)评分、淋巴细胞亚群百分比及活化淋巴细胞(CD3^(+)CD4^(+)、CD3^(+)CD8^(+)、CD3^(+)CD4^(+)/CD3^(+)CD8^(+)、CD3^(+)HLA-DR+、CD4^(+)HLA-DR+、CD8^(+)HLA-DR+)、预后相关指标(ICU住院天数、病死率)。结果:脓毒症最常见实证证素分别为热证(143/220)、毒证(127/220)、痰证(119/220),最常见虚证证素分别为阴虚证(74/220)、阳虚证(51/220)、气虚证(40/220),证素组合常见以痰证+热证(76/220)、热证+毒证(54/220)、阳虚证+痰证(35/220);常见证型分别为毒热内盛证(64/220)、痰热壅盛证(47/220)、瘀毒内阻证(40/220)、瘀毒损络证(37/220)、气阴耗竭证(32/220);不同证型患者APACHE II评分比较,气阴耗竭证最高,瘀毒损络证次之,两种证型差异无统计学意义(P>0.05),其他证型与上述两种证型差异均有统计学意义(P<0.05);毒热内盛证、痰热壅盛证、瘀毒损络证、气阴耗竭证、瘀毒内阻证CD3^(+)CD4^(+)、CD3^(+)CD4^(+)/CD3^(+)CD8^(+)依次降低,CD3^(+)CD8^(+)、CD3^(+)HLA-DR+、CD4^(+)HLA-DR+、CD8^(+)HLA-DR+依次升高(P<0.05);ICU住院天数比较,气阴耗竭证最长,其次为瘀毒损络证(P<0.05),其他三种证型之间差异无统计学意义(P>0.05),病死率以气阴耗竭证最高(P<0.05),其他四种证型之间差异无统计学意义(P>0.05)。结论:脓毒症常见中医证型毒热内盛证、痰热壅盛证、瘀毒内阻证、瘀毒损络证、气阴耗竭证,以气阴耗竭证病情最为严重,预后最差,患者免疫功能随中医证型变化有所不同,动态观察这些指标,可为中医辨证分型提供依据。

Objective:To explore the distribution of TCM syndromes in patients with sepsis and its relationship with immune function and prognosis.Methods:220 patients with sepsis in the hospital between April 2019 and April 2021 were retrospectively analyzed,and the general data,TCM symptoms elements,western medicine physicochemical indicators and prognosis were collected among all patients.The distribution of TCM syndromes,combination characteristics and common syndrome types were analyzed,and the disease severity(APACHE II score),lymphocyte subset percentage and activated lymphocytes(CD3^(+)CD4^(+),CD3^(+)CD8^(+),CD3^(+)CD4^(+)/CD3^(+)CD8^(+),CD3^(+)HLA-DR+,CD4^(+)HLA-DR+,CD8^(+)HLA-DR+)and prognosis-related indicators(ICU stay,case fatality rate)were compared among patients with different syndromes.Results:The most common sthenia-syndrome elements of sepsis were heat syndrome(143/220),toxin syndrome(127/220)and phlegm syndrome(119/220),and the most common asthenia-syndrome elements were Yin deficiency syndrome(74/220),Yang deficiency syndrome(51/220)and Qi deficiency syndrome(40/220),and the common combinations of syndrome elements included phlegm syndrome+heat syndrome(76/220),heat syndrome+toxin syndrome(54/220)and Yang deficiency syndrome+phlegm syndrome(35/220).The common syndrome types were the syndrome of exuberance of internal heat toxin(64/220),syndrome of abundant phlegm-heat(47/220),syndrome of stasis toxin internal resistance(40/220),syndrome of stasis toxin impairing collaterals(37/220),and syndrome of Qi-Yin exhaustion(32/220).Comparison of APACHE II score of patients with different syndrome types showed that Qi-Yin exhaustion syndrome had the highest score,followed by syndrome of stasis toxin impairing collaterals,and there was no statistically significant difference between the two syndrome types(P>0.05),and there was a significant difference between the other types of syndromes and the above two syndrome types(P<0.05).The CD3^(+)CD4^(+)and CD3^(+)CD4^(+)/CD3^(+)CD8^(+)of syndrome of exuberance of internal heat toxin,syndrome of abundant phlegm-heat,syndrome of stasis toxin impairing collaterals,syndrome of Qi-Yin exhaustion and syndrome of stasis toxin internal resistance were decreased in sequence while the CD3^(+)CD8^(+),CD3^(+)HLA-DR+,CD4^(+)HLA-DR+and CD8^(+)HLA-DR+were increased in sequence(P<0.05).ICU stay was the longest by syndrome of Qi-Yin exhaustion,followed by syndrome of stasis toxin impairing collaterals(P<0.05),and there was no statistical difference among the other three types of syndromes(P>0.05).The case fatality rate was the highest by syndrome of Qi-Yin exhaustion(P<0.05),and the difference was no statistically significant among the other four syndrome types(P>0.05).Conclusion:The common TCM syndrome types of sepsis are syndrome of exuberance of internal heat toxin,syndrome of abundant phlegm-heat,syndrome of stasis toxin internal resistance,syndrome of stasis toxin impairing collaterals,and syndrome of Qi-Yin exhaustion.Syndrome of Qi-Yin exhaustion is the most serious and has the worst prognosis.The immune function of patients varies with the changes of TCM syndrome types.The immune function of patients varies with the TCM syndrome types,and dynamic observation of these indicators can provide a basis for TCM syndrome differentiation.