电针刺联合清胰陷胸汤治疗重症急性胰腺炎所致急性呼吸窘迫综合征的临床观察

Clinical observation of electroacupuncture combined with Qingyi Xianxiong Decoction in the treatment of acute respiratory distress syndrome due to severe acute pancreatitis

目的观察电针刺联合清胰陷胸汤治疗重症急性胰腺炎(SAP)所致急性呼吸窘迫综合征(ARDS)的临床效果。方法选择2021年2月至2022年4月天津市南开医院重症医学科收治的120例SAP所致ARDS且辨证属于结胸里实证的患者,随机分为中药组和针药组,每组60例。中药组在常规西医治疗基础上给予清胰陷胸汤,针药组在中药组的基础上给予电针刺治疗,两组持续治疗7 d。主要结局指标为入住重症监护病房(ICU)后28 d内无呼吸机天数;次要结局指标为机械通气时间、ICU监护时间、总住院时间、腹内压恢复时间、器官功能评分、氧合指数(PaO2/FiO2)、血清炎症因子、血淀粉酶、尿淀粉酶等。结果与中药组比较,针药组患者入ICU后28 d内无呼吸机天数明显长于中药组〔d:22.10±2.29比20.97±2.31,P<0.05,优势比(OR)=1.24,95%CI可信区间(95%CI)为1.053~1.460,P<0.05〕,机械通气时间、ICU监护时间、总住院时间、腹内压恢复时间均明显缩短〔机械通气时间(d):5.90±2.29比7.03±2.31,ICU监护时间(d):8.07±1.89比12.08±2.23,总住院时间(d):19.55±6.82比22.28±5.19,腹内压恢复时间(d):6.05±1.81比8.45±1.76,均P<0.05〕。两组治疗7 d Murray评分和急性胰腺炎严重程度床旁指数(BISAP)评分均较治疗前明显降低,而PaO2/FiO2较治疗前明显升高,且治疗7 d时针药组Murray肺损伤评分显著低于中药组〔分:0.50(0.33,0.75)比1.00(1.00,1.33),P<0.05〕,PaO2/FiO2显著高于中药组〔mmHg(1 mmHg≈0.133 kPa):390.75±27.73比330.02±42.34,P<0.05〕。随治疗时间延长,两组治疗后肿瘤坏死因子-α(TNF-α)、白细胞介素-6(IL-6)、C-反应蛋白(CRP)等炎症因子及血清血淀粉酶和尿淀粉酶水平均持续降低,且治疗7 d时针药组炎症因子水平均明显低于中药组〔TNF-α(ng/L):38.20±10.00比45.35±5.09,IL-6(ng/L):0.95±0.44比7.42±1.39,CRP(mg/L):8.55±2.79比36.20±13.97,均P<0.05〕。亚组分析显示,胆道系统疾病是针药联合治疗ARDS的机械通气时间≥7 d的危险因素(OR=2.728,95%CI为1.293~5.754)。结论与单纯应用中药相比,针药结合治疗能够更好地减轻SAP所致ARDS患者临床症状,促进患者康复,减轻全身炎症反应,值得临床推广。

Objective To observe the clinical effect of electroacupuncture combined with Qingyi Xianxiong Decoction on the treatment of acute respiratory distress syndrome(ARDS)caused by severe acute pancreatitis(SAP).Methods From February 2021 to April 2022,120 patients with ARDS caused by SAP who were admitted to the department of critical care medicine of Tianjin Nankai Hospital and whose syndrome differentiation belonged to the syndrome of knot chest were selected.They were randomly divided into pure traditional Chinese medicine group and acupuncture medicine group,with 60 cases in each group.The pure traditional Chinese medicine group was received Qingyi Xianxiong Decoction on the basis of conventional western medicine treatment,and the acupuncture medicine group was received electric acupuncture treatment on the basis of the pure traditional Chinese medicine group.The two groups continued to be treated for 7 days.The primary outcome was the ventilator-free days within 28 days after admission to the intensive care unit(ICU),and the secondary outcome measures were mechanical ventilation time,the length of ICU stay,total lenth of hospital stay,time of intra-abdominal pressure recovery,scores of organ function,oxygenation index(PaO2/FiO2),serum inflammatory factors,blood amylase,urine amylase,etc.Results Compared with the pure traditional Chinese medicine group,the ventilator-free days in the acupuncture medicine group within 28 days after admission to the ICU were significantly longer[day:22.10±2.29 vs.20.97±2.31,P<0.05,odds ratio(OR)=1.24,95%confidence interval(95%CI)was 1.053-1.460,P<0.05].The time of mechanical ventilation,the length of ICU stay,total length of hospital stay,and recovery time of intra-abdominal pressure were significantly shortened[mechanical ventilation time(days):5.90±2.29 vs.7.03±2.31,the length of ICU stay(days):8.07±1.89 vs.12.08±2.23,total length of hospital stay(days):19.55±6.82 vs.22.28±5.19,recovery time of intra-abdominal pressure(days):6.05±1.81 vs.8.45±1.76,all P<0.05].The Murray score and bedside index for severity in acute pancreatitis(BISAP)score of the two groups after 7 days of treatment were significantly lower than those before treatment,while PaO2/FiO2 was significantly higher than those before treatment,and the Murray score of the acupuncture medicine group after 7 days of treatment was significantly lower than that of the pure traditional Chinese medicine group[score:0.50(0.33,0.75)vs.1.00(1.00,1.33),P<0.05],PaO2/FiO2 was significantly higher than that in the pure traditional Chinese medicine group[mmHg(1 mmHg≈0.133 kPa):390.75±27.73 vs.330.02±42.34,P<0.05].With the prolongation of treatment time,the levels of inflammatory factors such as tumor necrosis factor-α(TNF-α),interleukin-6(IL-6),C-reactive protein(CRP),serum amylase and urine amylase in both groups after treatment continued to decrease,and the levels of the inflammatory factors in the acupuncture medicine group after 7 days of treatment were significantly lower than those in the pure traditional Chinese medicine group[TNF-α(ng/L):38.20±10.00 vs.45.35±5.09,IL-6(ng/L):0.95±0.44 vs.7.42±1.39,CRP(mg/L):8.55±2.79 vs.36.20±13.97,all P<0.05].Subgroup analysis showed that biliary system disease was a risk factor for the duration of mechanical ventilation≥7 days in the treatment of ARDS with acupuncture and medicine(OR=2.728,95%CI was 1.293-5.754).Conclusion Compared with the pure traditional Chinese medicine,acupuncture combined can better reduce the clinical symptoms of patients with ARDS caused by SAP,promote the recovery of patients,and reduce systemic inflammatory reaction,which is worthy of clinical promotion.