肠型脂肪酸结合蛋白和D-乳酸在危重症肠黏膜屏障功能的临床研究

Clinical study on intestinal mucosal barrier function of intestinal fatty acid binding protein and D-lactate in critically ill patients

目的:通过检测危重症患者不同时间点血中肠型脂肪酸结合蛋白(IFABP)和D-乳酸浓度,结合胃肠功能障碍/衰竭(GIDF)评分系统,早期判断肠黏膜屏障功能,探讨其与危重症疾病严重程度的关系及预后,并观察早期予保护肠黏膜屏障措施后的效果评价。方法:采用前瞻性研究方法,纳入我院2014-05-2015-12期间在急诊重症监护病房收治的危重症患者,根据患者是否发生胃肠功能障碍分为胃肠功能障碍组100例和非胃肠功能障碍组100例,其中非胃肠功能障碍组根据是否入院时给予胃肠保护措施治疗,分为治疗组及常规治疗组,观察选定患者入院时、24h、72h及住院第7天IFABP、D-乳酸,GIDF评分、急性生理和慢性健康评估评分(APACHEⅡ)、多器官功能障碍综合征(MODS)评分、序贯器官功能衰竭评分(SOFA)、入住EICU天数、住院天数、机械通气时间、血管活性药物应用时间及28d后病死率、存活率。结果:胃肠功能障碍组血浆IFABP、D-乳酸水平均升高,与非胃肠功能障碍组比较,差异有统计学意义(P<0.05);两组患者不同时间点测得的血浆IFABP、D-乳酸浓度差异有统计学意义(P<0.05);不同程度胃肠功能障碍患者血浆IFABP、D-乳酸浓度差异有统计学意义(P<0.05);血浆IFABP、D-乳酸水平变化与GIDF评分呈显著正相关(P<0.05);血浆IFABP、D-乳酸水平,GIDF评分与APACHEⅡ评分、MODS评分、SOFA、入住EICU天数、机械通气时间、血管活性药物应用时间呈正相关(P<0.05),与住院天数无相关性;28d后两组患者病死率及存活率比较,差异有统计学意义(P<0.05);危重症患者病死组血浆IFABP、D-乳酸水平、GIDF评分高于存活组,差异有统计学意义(P<0.05)。非胃肠功能障碍组中治疗组血浆IFABP、D-乳酸水平,GIDF评分,与常规治疗组比较,差异有统计学意义(P<0.05),且胃肠功能障碍发生率、MODS发病率、细菌移位发生率及28d病死率明显低于常规治疗组,差异有统计学意义(P<0.05)。结论:血浆IFABP和D-乳酸水平,结合GIDF评分,对危重症肠黏膜功能损害可进行早期判断,评估病情严重程度及预后,在常规综合治疗基础上,早期给予肠黏膜保护措施,改善胃肠功能,降低MODS及细菌移位的发生率,改善患者预后。

Objective：To detect the concent of intestinal fatty-acid binding protein and D-lactate of critically ill patients at different time points in Plasma,combined with gastrointestinal dysfunction/failure scoring system,early judgement of intestinal mucosal barrier function,to explore its relationship with severity of critical disease and prognosis,and to observe the early protection of intestinal mucosal barrier measures after evaluation.Method：A prospective study was conducted,the critically ill patients admitted to Emergency ICU of the Harrison International Peace Hospital in Hebei province from May 2014 to December 2015 were enrolled.According to whether the gastrointestinal dysfunction,they were divided into gastrointestinal dysfunction Group 100 cases and the non-gastrointestinal dysfunction group 100 cases.The non-gastrointestinal dysfunction group,according to whether or not to give gastrointestinal protection measures to treat,divided into treatment groups and conventional treatment group.IFABP,D-lactate,gastrointestinal dysfunction/failure score（GIDF）,acute physiology and chronic Health Assessment Score,multiple organ dysfunction syndrome score（MODS）,sequential organ failure score（SOFA）,the length of EICU stay,the length of hospital stay,mechanical ventilation time,application time of vasoactive drugs were observed on the day of admission,24 hours,72 hours and 7 days in the critically ill patients,and 28-day mortality and survival rate.Result：The levels of plasma IFABP and D-lactate in gastrointestinal dysfunction group were increased,which were statistically significant compared with those in the non-gastrointestinal dysfunction group（P〈0.05）.The difference of plasma IFABP and D-lactate concentrations measured at different time points in the two groups was statistically significant（P〈0.05）;There were statistically significant differences in plasma IFABP and D-lactate concentrations in patients with different degrees of gastrointestinal dysfunction（P〈0.05）;The changes of plasma IFABP and D-lactate concentrations were positively correlated with GIDF score（P〈0.05）;IFABP,D-Lactate,GIDF,were positively correlated with acute Physiology and chronic Health Assessment Score,MODS score,SOFA,the length of EICU stay,mechanical ventilation time（P〈0.05）,no correlation with the length of hospital stay.Difference of mortality and survival rate after 28 days were statistically significant between the two groups（P〈0.05）.The levels of plasma IFABP,D-lactate and GIDF scores in the mortality group of critically ill patients were higher than those in the Survival Group（P〈0.05）.The levels of plasma IFABP and D-lactate、GIDF scores in the treatment group of non-gastrointestinal dysfunction group,were statistically significant compared with the conventional treatment group（P〈0.05）,and the incidence of gastrointestinal dysfunction,the morbidity of MODS,the incidence of bacterial translocation and the 28-day mortality rate were significantly lower than those in the conventional treatment group（P〈0.05）.Conclusion：The plasma IFABP and D-lactate levels were early judged on the functional impairment of intestinal mucosa in critically ill,combined with gastrointestinal dysfunction/failure score,assessment of severity and prognosis.Early intestinal mucosal protection measures,improve gastrointestinal function,reduce the incidence of MODS and bacterial translocation,improve the prognosis of patients.