重度创伤病人胃粘膜酸碱度与细胞因子的关系

Monitoring the gastric intramucosal pH and inflammatory cytokines in severely injured patients

目的 观察重度创伤病人创伤后胃粘膜酸碱度 (pHi)与白介素 6 (IL 6 )和肿瘤坏死因子 (TNF)的关系。方法 选择 18例重度创伤病人 (ISS >2 5 ) ,进入ICU 12小时后 ,即经鼻置入胃张力计 ,测定胃粘膜二氧化碳张力 (PCO2 ) ,并通过Henderson Hasselbalch方程 ,计算pHi(pHi≤ 7.32为异常 )。同时行动脉血气分析、乳酸值以及静脉血IL 6和TNF α测定。伤后 72小时重复上述测定。结果 伤后 12小时 ,pHi与TNF α呈负相关 ,P <0 .0 5 ;ISS与TNF α明显正相关 ,P <0 .0 5 ;伤后 72小时 ,pHi与TNF α和IL 6均呈明显负相关 ,P<0 .0 1;同时 ,ISS与IL 6呈明显正相关 ,P <0 .0 1。结论 重度创伤可导致内脏器官缺血 ,通过细菌与内毒素移位以及其他更为复杂的途径 ,诱发TNF α和IL 6等细胞因子的释放 ,导致严重并发症。

Objective To determine the relationship between the gastric intramucosal pH(pHi),TNF-α,IL-6,ISS and lactatte in 18 patients.Methods The study was carried out in ICU.The pHi was measured in 18 patients (ISS>25).Exclusion criteria included a history of upper gastrointestinal bleeding or any contraindications.Normal saline( 2.5ml) was used to fill the tonometry balloon and was allowed to equilibrate for 90 minutes before removal.A simultaneous arterial blood sample was sent for measurement of blood gas tensions and blood lactate.The PCO 2 value from the tonometry balloon and the bicarbonate value from the arterial blood gases were then used in the Henderson-Hasselbach equation to calculate the pHi(pHi≤7.32) which was used to differentiate between normal and low pHi.At same time,TNF-α and IL-6 were measured.Results Of a total of 18 patients,three patients developed MODS and died after 48 hours.Their pHi were low,7.12,7.20 and 7.18 respectively at 12 hours after injury,no correlation was found between pHi values and IL-6,but there was a significant negative correlation between pHi and TNF-α(P<0.05,r=-0.719,P=0.01).At 72 hours,there was a negative correlation between pHi and IL-6 and TNF-α(r=-0.601,P=0.008;r= -0.762 ,P=0.001,P<0.01,respectively).There was also a significant negative correlation between pHi and lactate(P<0.001).In addition,at 12 hours,there was a significant negative correlation between ISS and TNF-α(P<0.05,r=0.513,P=0.029),and at 72 hours,positive correlation was found between ISS and IL-6(P<0.01,r=0.736,P= 0.001 ).Conclusion In severely injured patients,pHi decreased in various degrees,and could result in gut ischemia,also developed the septic state because translocation of intestinal of endotoxin,which might be related to release of inflammatory cytokines after trauma.