急诊脓毒症中医证型分布特点的研究

A study on distribution characteristics of traditional Chinese medical syndromes of emergency sepsis

目的通过分析本院急诊科脓毒症患者临床资料和中医四诊信息,探讨急诊脓毒症患者的中医证型分布特点及规律,为脓毒症的中医规范化诊治提供依据。方法选择2016年7月至2017年10月浙江中医药大学附属第一医院急诊科和急诊重症加强治疗病房(EICU)收治脓毒症患者135例,其中脓毒症组110例,脓毒性休克组25例。制定统一的调查表,收集患者入院确诊当天的一般资料、感染部位、采集患者中医临床四诊信息(中医证候、舌苔、脉象等)进行辨证分型,于确诊24h内完成相关实验室检查,并计算快速序贯器官衰竭评分(qSOFA)及序贯器官衰竭评分(SOFA)。结果135例脓毒症患者以肺部感染为主(占51.9%),其次为腹腔感染(占25.9%)。中医证型分布:脓毒症组以毒热证为主(占61.8%);脓毒性休克组以急性虚证为主(占68.0%),两组比较差异有统计学意义(P<0.001)。脓毒症组与脓毒性休克组间以及脓毒症不同中医证型之间感染相关指标,如白细胞计数(WBC)、中性粒细胞比例及绝对值、C-反应蛋白(CRP)、降钙素原(PCT)的比较差异均无统计学意义(均P>0.05);而急性虚证患者乳酸(Lac)较毒热证、腑气不通证、血瘀证明显升高〔mmol/L:2.8(1.5,4.2)比1.3(1.0,1.8)、1.6(1.3,3.8)、1.6(1.2,2.9),P<0.001〕,脓毒性休克组较脓毒症组显著升高〔mmol/L:4.0(2.7,5.7)比1.4(1.1,1.9),P=0.000〕。qSOFA≥2分患者在脓毒症组为25.5%(28/110),在脓毒性休克组为80.0%(20/25),差异有统计学意义(P<0.001);而急性虚证qSOFA≥2分患者为69.4%(25/36),气不通证为42.1%(8/19),毒热证为19.1%(13/68),血瘀证为16.7%(2/12),差异亦有统计学意义(P<0.001)。脓毒性休克组〔7.0(5.0,10.0)分〕和急性虚证患者〔6.0(4.0,9.0)分〕SOFA评分显著升高,与脓毒症组〔3.0(2.0,4.0)分〕和其他证型患者〔毒热证为3.0(2.0,4.0)分,腑气不通证为4.0(2.0,6.0)分,血瘀证为4.5(3.0,5.0)分〕比较差异均有统计学意义(均P<0.001)。结论脓毒症中医证型分布与病情的严重程度相关,脓毒症中医辨证分型,从毒热证到腑气不通证、血瘀证到急性虚证,SOFA评分和Lac逐渐升高,病情不断加重,SOFA评分和Lac可以作为判断脓毒症病情严重程度的参考指标;不同中医证型脓毒症患者qSOFA≥2分的占比不同,脓毒症患者qSOFA≥2分的符合率与中医证型相关,结合qSOFA评分和患者中医证型可提高脓毒症的早期诊断。

Objective To explore the distribution characteristics and regularity of traditional Chinese medical (TCM) syndromes in patients with sepsis in Department of Emergency of our hospital by enalyzed their clinical data and TCM four clinical diagnostic information so as to provide the basis for TCM standardized diagnosis and treatment of sepsis. Methods From July 2016 to October 2017, 135 patients with sepsis were admitted to the Department of Emergency and Department of Emergency Intensive Care Unit (EICU) of the First Affiliated Hospital of Zhejiang Chinese Medical University, 110 cases in sepsis group, 25 cases in sepsis shock group. An unified questionnaire was developed to collect the patients' general data, infection site and TCM four clinical diagnostic information (TCM syndromes, tongue coating, pulse signs, etc.) for dialectical typing on the day of admission with definite diagnosis, the relevant laboratory examinations were completed within 24 hours after the confirmative diagnosis was made, and the quick sequential organ failure assessment (qSOFA) and SOFA scores were calculated. Results In 135 cases of sepsis, pulmonary infection (51.9%) was the main one, followed by abdominal infection (25.9%). The distribution of TCM syndromes: the toxic heat syndrome was the main syndrome in sepsis group (61.8%) and acute deficiency syndrome was the main syndrome in sepsis shock group (68.0%), the difference between the two groups being statistically significant (P < 0.001). There were no statistical significant differences in comparisons of infection related indicators between sepsis and septic shock groups, different TCM syndromes of sepsis (all P > 0.05), such as white blood cell count (WBC), percentage and absolute value of neutraphils, C-rative poucin (CRP)_ proraleitonin (PCr). the lactic acid in patients oK the arute deficiencysyndone was xignifieantly higher than those in patients of the toxic hrat syndrome, the stoppage of the qi of the bxowelssyndrome and blond stanis syndrome [mmo/Lz 28(15, 4.2)vm.13(10, 1.8), L6(L3, 3.8). 16(12, 29), P< 0001],and in septier shonk gnoup was sigirantly higher than that in the чepsis gmupi [mo/L.40 (2.7. 57)ve.14(1.I. l.9)P= 000. The nale of qSOFA 2 2 wote wals 2559 (28/10 in sepsin. groups. aund 8008 120725) in sepsis shuckgroup. the diference being staistially significant (P < 0001). while the rate ofqSOFA s 2 score was 69.4% 2536)in patienta of acute defciency syndrome, 42.1% (8191 in patients of the stoppage of the qi of the lkowela syndrme,19.1% (13168) in puatients of tnxic heat syndrome and 16.79 1212) in gatienta of blood slasis syndnome, the diffreeealso bring stuistially significant (all P < 0.001). 'The scons of SOFA in septie shuw:k group [7.0 (5.0, 100)] and arutedefirieney ayndrome gmup [6.0 (40, 9.01 were signifirantly higher eompared with thse in serpais group 130 020. 4.0)1and other syndrome typen patiento [toxie heat. syndrome 30 (20, 4.0). the stepage of the qi of the bkowels *y ndrone4,0 20, 6.0) and. blood stasis syndrvone 4.5 (3.0, 5.0)], the difereer being statistically signifceant (all P < 001)Conclusions 'The. disrinbution of TCM syndmmee of aepsis in reluted to the srverity degree of sepsis, in TCM diadecticaltyping of sepsin, from toxic heat ayndrome developing into the stoppage of the qi of the bxoweln eyndnome, and fnomblound stasis syndrome to acute deficiency syndeone, the S0FA score and lactic acid level were gradually increased asthe disease condition was ontinuously aggravating. so the. SOFA sore and lactic acid could be used as the reference.indicators for ther srverity degree of srpis; in sepic patientis with diffrnrf TCM syndromes, the ratee of qSOFA a 2were diere and the qSOFA scxure combined with patient's TCM syndrome can enlunce the early diagneis of sepsie.