远端缺血后处理提高创伤失血性休克患者在PICCO指导下液体复苏效果及其对促炎—抗炎平衡的影响

Effect of distal ischemic postconditioning on fluid resuscitation guided by PICCO and its effect on proinflammatory and anti-inflammatory balance in patients with traumatic hemorrhagic shock

目的观察远端缺血后处理(RIPC)对创伤失血性休克(THS)患者在PICCO指导下液体复苏的效果及体内促炎—抗炎平衡的影响。方法纳入2013年5月—2017年9月南京鼓楼医院集团宿迁市人民医院ICU病房收治的THS患者114例作为研究对象,按随机数字表法分为RIPC组(n=57)和对照组(n=57)。所有患者均在PICCO监测指导下进行液体复苏。选择肿瘤坏死因子α(TNF-α)、白介素-1β(IL-1β)、IL-6等促炎因子和IL-10、转移生长因子β(TGF-β)、IL-4等抗炎因子进行分析。结果RIPC组患者晶体液、胶体液均明显低于对照组[(2 135.21±442.35)ml vs.(2 563.92±610.52)ml,t=4.293,P<0.001;(645.23±221.23)ml,vs.(783.76±98.83)ml,t=4.316,P<0.001]。T1时RIPC组患者LCR明显高于对照组(13.54%±2.88%vs.7.25%±3.14%,t=11.14.P<0.001)。2组患者MAP和GEDVI均明显升高(RIPC组:t=3.359、7.354,P<0.001;对照组:t=2.373、2.690,P<0.01),而RIPC组SVRI明显降低(t=8.601,P<0.001),对照组EVIWI明显升高(t=3.391,P<0.001);T1时RIPC组患者SVRI、GEDVI和EVLWI水平均明显低于对照组(t=6.291、2.668、1.980,P<0.05);促炎因子(TNFα、IL-1β和IL-6)明显低于对照组(t=6.227、14.856、16.506,P均<0.001),而抗炎因子(IL-10、TGF-β和IL-4)水平明显高于对照组患者(t=20.280、6.307、18.877,P均<0.001);相关性分析提示RIPC与△IL-1β和△IL-10明显相关(r=-0.633、r=0.661)。结论RIPC干预有助于提高TIS患者在PICCO指导下液体复苏的临床效果,同时进一步改善TIS患者体内促炎—抗炎平衡。

Objective To observe the effect of distal ischemic postconditioning （RIPC） on fluid resuscitation under the guidance of PICCO in patients with traumatic hemorrhagic shock （THS） and the effect of proinflammatory and anti-inflammatory balance in the body. Methods One hundred and fourteen THS patients were enrolled in this study from May 2013 to Sep 2017. All the patients were randomly and equally divided into two group,RIPC group （ n =57） and control group （ n =57）. The protocol of fluid resuscitation was based on PICCO guidance. Three proinflammation factors （TNF-α, IL-1β and IL-6） and three anti-inflammation factors （TGF-β,IL-4 and IL-10） were selected for anti-inflammation system evaluation. Results The dosage of both crystalloid [（2 135.21±442.35） ml vs. （2 563.92±610.52） ml, t =4.293, P 〈0.001] and colloidal solution [（645.23±221.23） ml vs. （783.76±98.83） ml, t =4.316, P 〈0.001] in RIPC group were lower than those in control group. The levels of LCR in RIPC group were higher than those in control group [（13.54±2.88）% vs. （ 7.25± 3.14）%, t =11.14, P 〈0.001]. On T1 stage, it could be found the increase of MAP （ t RIPC =3.359, P =0.001; t control =2.373, P =0.012） and GEDVI （ t RIPC =7.354, P 〈0.001; t Control =2.690, P =0.005） in both of two group. The levels of SVRI （ t =8.601, P 〈0.001） in RIPC group were decreased, while the EVIWI （ t =3.391, P 〈0.001） in control group were increased on T1 stage. The levels of proinflammation factors （TNF-α, IL-1β and IL-6） in RIPC group were lower than those in control group （ t =6.227, t =14.856, t =16.506, P 〈0.001）, while the levels of anti-inflammation factors （TGF-β, IL-4 and IL-10） in RIPC group were higher than those in control group （ t =20.280, t =6.307, t =18.877, P 〈0.001）. Correlation analysis suggested that △IL-1β（ r =0.633） and △IL-10（ r =0.661） were related factors to RIPC. Conclusion RIPC intervention can help improve the clinical effect of fluid resuscitation guided by PICCO in THS patients, and further improve the proinflammatory and anti-inflammatory balance in THS patients.