脑水肿程度对劳力性热射病患者多器官功能损害的影响

Effect of cerebral edema on multiple organ dysfunction in patients with exertional heat stroke

目的观察不同脑水肿程度与劳力性热射病（EHS）患者多器官功能障碍综合征（MODS）的关系。方法选择2015年6月至2017年6月解放军第-五九医院重症医学科收治的EHS患者，均于发病2、24、72h应用BORN-BE无创脑水肿动态监护仪监测双侧大脑半球电阻抗扰动系数（EIDC）以反映脑水肿程度，并根据3个时间点的均值将患者分为9＋组、10＋组、11＋组。所有患者于发病2h和72h取空腹静脉血，检测血清白细胞介素-1β（IL-1β）、肿瘤坏死因子-α（TNF-α）、-氧化氮（NO）、一氧化氮合酶（NOS）、心肌肌钙蛋白I（cTnI）、肌酸激酶同T酶（CK-MB）、肌酐（Cr）、β2-微球蛋白（β2-MG）、丙氨酸转氨酶（ALT）和天冬氨酸转氨酶（AST）活水平；记录发病72h内MODS发生情况，线性回归分析EIDC与MODS的相关性。结果124例EHS患者均为男性；平均年龄（22．10±4．43）岁；EIDC9＋组20例，EIDC10＋组61例，EIDC11＋组43例。不同脑水肿程度组患者发病2h血清IL-1β、TNF-α、NO、NOS、cTnI、CK-MB、Cr、β2-MG、ALT、AST水平比较差异均无统计学意义，发病72h各指标均明显高于发病2h时；脑水肿程度越重，各指标升高越明显[EIDC9＋组、10＋组、11＋组72hIL-1β（ng／L）分别为12．05±3，75、18．49±7．94、23．21±10．44，TNF-α（ng／L）分别为13．10±3．18、18．92±7．23、23．40±10．17，NO（μmol／L）分别为99．50±12．10、111．41±17．75、120．81±15．58，NOS（kU／L）分别为47．95±8．33、56．70±12．12、63．37±12．60，cTnI（ng／L）分别为92．75±20．92、107．20±18．96、117．30±14．53，CK-MB（U／L）分别为73．55±9．25、83．23±13．19、93．49±12．25，Cr（μmol／L）分别为165．30±9．41、176．62±9．83、180．09±10．14，13，-MG（mg／L）分别为16．45±2．68、19．07±3．68、22．05±3．93，ALT（U／L）分别为500．10±87．05、563．90±91．28、612．16±90．61，AST（U／L）分别为414．30±53．35、470．51±73．83、512．09±81．29．两两比较均P〈0．05]，MODS发生率也越高【40．00％（8／20）、65．57％（40／61）、83．72％（36／43），x2=12．199，P=0．002]。线性回归分析显示，脑水肿程度与MODS发生率呈显著正相关（R2=0．905，P=0．002）。结论EHS患者72h内脑水肿程度越重，机体炎症反应越强烈，心、肝、肾等器官损伤越严重。

Objective To observe the relationship between different degree of cerebral edema and-multiple organ dysfunction syndrome （MODS） of exertional heat stroke （EHS） patients. Methods The patients with EHS admitted to intensive care unit （ICU） of the 159th Hospital of PLA from June 2015 to June 2017 were enrolled. The electrical impedance perturbation coefficient （EIDC） of bilateral cerebral hemispheres were monitored at 2 24 and 72 hours after the onset of the disease by BORN-BE non-invasive dynamic cerebral edema monitor, and the patients were divided into 9＋ group, 10＋ group and 11＋ group according to the resistance of the measured mean impedance coefficients. Fasting venous blood of the patients were acquired after 2 hours and 72 hours of the disease, the levels of serum interleukin-1β （IL-1β）, tumor necrosis factor-α （TNF-α）, nitric oxide （NO）, nitric oxide synthase （NOS）, cardiac troponin I （cTnI）, MB isoenzyme of creatine kinase （CK-MB）, creatinine （Cr）, β 2-microglobulin （ β 2-MG）, alanine aminotransferase （ALT） and aspartate transaminase （AST） were detected. The occurrence of MODS within 72 hours was recorded. Linear regression analysis of the correlation between EIDC and MODS was done. Results All 124 EHS patients were male; the age was （22.10±4.43） years. Among them, 20 in EIDC 9＋ group, 61 in 10＋ group, and 43 in 11＋ group. There were no significant differences in the levels of IL-1 β, TNF-α, NO, NOS, cTnI, CK-MB, Cr, β 2-MG, ALT, AST after onset of 2 hours among different EPIC groups; all the indexes of 72 hours were significantly higher than those of 2 hours in each group; and the higher the EIDC, the more obvious increase of each index[EIDC 9＋ group, 10＋ group, 11＋ group at 72 hours IL-1 β （ng/L）： 12.05±3.75, 18.49±7.94, 23.21±10.44 TNF- α （ng/L）： 13.10±3.18, 18.92±7.23, 23.40± 10.17; NO （μmol/L）： 99.50±12.10, 111.41 ± 17.75, 120.81±15.58; NOS （kU/L）： 47.95±8.33, 56.70± 12.12, 63.37± 12.60; cTnl （ng/L）： 92.75±20.92, 107.20± 18.96, 117.30± 14.53 CK-MB （U/L）： 73.55±9.25, 83.23± 13.19, 93.49± 12.25; Cr （μmol/L）： 165.30±9.41, 176.62±9.83, 180.09± 10.14; 2-MG （mg/L）： 16.45 ± 2.68, 19.07 ± 3.68, 22.05 ± 3.93; ALT （U/L）： 500.10± 87.05, 563.90 ± 91.28, 612.16± 90.61, AST （U/L）： 414.30 ± 53.35, 470.51 ±73.83, 512.09 ± 81.29, respectively, two-two comparison all P 〈 0.05], the higher of the MODS incidence [40.00 % （8/20）, 65.57% （40/61）, 83.72% （36/43）, x 2 = 12.199, P = 0.002]. Linear regression analysis showed that the degree of cerebral edema was positively correlated with the incidence of MODS （R2 = 0.905, P = 0.002）. Conclusion The higher nf the EIDC, the more severe of cerebral edema, the stronger of the inflammatoty reaction, and the more severe damage of heart, liver, kidney and other organs in EHS patients within 72 hours.