加味破格救心汤联合针刺治疗脓毒性心肌病的临床研究

Clinical study of modified Poge Jiuxin decoction combined with acupuncture in the treatment of septic cardiomyopathy

目的观察加味破格救心汤联合针刺治疗对脓毒性心肌病(SIC)的影响,并探讨其可能的作用机制。方法选择成都市第一人民医院2022年1月至2023年6月收治的76例SIC患者作为研究对象,按随机数字表法分为对照组和治疗组,每组36例。对照组给予脓毒症西医常规治疗,治疗组在对照组基础上加用加味破格救心汤〔组成:制附子30 g(先煎),红参30 g(另炖),山萸肉60 g,干姜30 g,生龙骨30 g(先煎),生牡蛎30 g(先煎),磁石30 g(先煎),茯苓90 g,车前子30 g(包煎),炙甘草60 g,麝香0.5 g(人工)〕,每日1剂,早中晚各100 mL分服;同时针刺双侧足三里、关元、内关、三阴交及气海穴,每日针刺2次。两组均连续治疗7 d。观察治疗前后两组C-反应蛋白(CRP)、降钙素原(PCT)、心肌肌钙蛋白I(cTnI)、N末端脑钠肽前体(NT-proBNP)、血乳酸(Lac)等指标的变化;记录急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、序贯器官衰竭评分(SOFA);采用超声心动图观察左室射血分数(LVEF)、左室短轴缩短率(LVFS)及二尖瓣口舒张早期/晚期血流速度峰值比值(E/A比值),同时观察心率(HR)、平均动脉压(MAP)、机械通气时间、使用血管活性药物时间、重症监护病房(ICU)住院时间、多器官功能障碍综合征(MODS)发生率及28 d病死率的变化。结果两组治疗后炎症指标(CRP、PCT)、心肌标志物指标(cTnI、NT-proBNP)、血流动力学及灌注指标(HR、Lac)、病情严重程度评分(APACHEⅡ、SOFA)和28 d病死率均较治疗前明显降低,LVEF、MAP均较治疗前明显升高,且治疗组治疗后上述各项指标的改善程度均明显优于对照组〔CRP(mg/L):22.18±9.46比68.45±13.46,PCT(μg/L):1.16±0.59比4.35±1.28,LVEF:0.48±0.06比0.41±0.05,cTnI(μg/L):0.60±0.14比0.98±0.30,NT-proBNP(ng/L):204.35±26.54比240.12±56.12,HR(次/min):88.75±10.05比98.57±10.56,MAP(mmHg,1 mmHg≈0.133 kPa):82.10±5.08比73.46±3.55,Lac(mmol/L):0.75±0.28比1.60±0.36,APACHEⅡ评分(分):10.46±1.80比15.50±2.16,SOFA评分(分):2.60±1.24比6.76±1.60,均P<0.05〕。两组治疗后LVFS、E/A比值均较治疗前明显升高,但治疗组和对照组治疗后比较差异均无统计学意义〔LVFS:(25.12±3.46)%比(22.61±3.88)%,E/A比值:1.16±0.46比0.96±0.32,均P>0.05〕;治疗组使用血管活性药物时间、ICU住院时间均较对照组明显缩短〔使用血管活性药物时间(d):9.62±3.05比10.48±3.40,ICU住院时间(d):12.51±2.04比13.72±1.14,均P<0.05〕,MODS发生率和28 d病死率虽较对照组有所降低〔38.89%(14/36)比52.77%(9/36),44.44%(16/36)比47.22%(17/36)〕,但差异均无统计学意义(均P>0.05)。结论加味破格救心汤联合针刺可改善SIC患者预后,其机制可能与控制炎症反应,改善心功能有关。

Objective To observe the effects of modified Poge Jiuxin decoction combined with acupuncture in the treatment of septic cardiomyopathy(SIC),and explore its possible mechanism.Methods Totally 72 patients with SIC admitted to Chengdu First People's Hospital from January 2022 to June 2023 were enrolled.The patients were divided into control group and treatment group according to random number table method,with 36 cases in each group.Patients in control group received basic treatment for SIC.On this basis,the treatment group was administrated with modified Poge Jiuxin decoction[includes Prepared Aconite 30 g(earlier decocted),Red Ginseng 30 g(another stew),Cornel Meat 60 g,Dried Ginger 30 g,Raw Keel 30 g(earlier decocted),Raw Oyster 30 g(earlier decocted),Magnet 30 g(earlier decocted),Poria Cocos 90 g,Plantain Seeds 30 g(in bag),Roasted Licorice 60 g,Musk 0.5 g(artificial)],one dose a day,100 mL in 3 meals a day.Acupuncture at bilateral Zusanli,Guangyuan,Neiguan,Sanyinjiao and Qihai points,twice a day.Both groups were treated for 7 days.The changes of C-reactive protein(CRP),procalcitonin(PCT),cardiac tropomin I(cTnI),N-terminal pro-B type natriuretic peptide(NT-proBNP)and lactic acid(Lac)were observed before and after treatment,acute physiology and chronic health evaluationⅡ(APACHEⅡ)and sequential organ failure assessment(SOFA)were calculated,left ventricular ejection fraction(LVEF),left ventricle fractional shortening(LVFS),and mitral orifice early/late diastolic blood flow velocity ratio(E/A ratio)were measured with echocardiography,the heart rate(HR),mean arterial pressure(MAP),mechanical ventilation time,vasoactive drug use time,in the intensive care unit(ICU)stay time,the incidence of multiple organ dysfunction syndrome(MODS)and 28-day mortality were recorded.Results After treatment,the indexes of inflammation(CRP,PCT),myocardial markers(cTnI,NT-proBNP),hemodynamics and perfusion(HR,Lac),illness severity score(APACHEⅡ,SOFA)and the 28-day mortality in the two groups were significantly reduced,while LVEF and MAP were significantly increased compared to before treatment.The improvement of various indexes in the treatment group were better than those in the control group[CRP(mg/L):22.18±9.46 vs.68.45±13.46,PCT(μg/L):1.16±0.59 vs.4.35±1.28,LVEF:0.48±0.06 vs.0.41±0.05,cTnI(μg/L):0.60±0.14 vs.0.98±0.30,NT-proBNP(ng/L):204.35±26.54 vs.240.12±56.12,HR(bmp):88.75±10.05 vs.98.57±10.56,MAP(mmHg,1 mmHg≈0.133 kPa):82.10±5.08 vs.73.46±3.55,Lac(mmol/L):0.75±0.28 vs.1.60±0.36,APACHEⅡscore:10.46±1.80 vs.15.50±2.16,SOFA score:2.60±1.24 vs.6.76±1.60,all P<0.05].After treatment,LVFS and E/A ratio in the two groups increased significantly compared to those before treatment,however,there was no significant difference between the treatment group and the control group after treatment[LVFS:(25.12±3.46)%vs.(22.61±3.88)%,E/A ratio:1.16±0.46 vs.0.96±0.32,both P>0.05].The vasoactive drug use time and ICU stay time were shortened in the treatment group than those in the control group[vasoactive drug use time(days):9.62±3.05 vs.10.48±3.40,ICU stay time(days):12.51±2.04 vs.13.72±1.14,both P<0.05],the incidence of MODS and the 28-day mortality were lower than those of the control group[38.89%(14/36)vs.52.77%(9/36),44.44%(16/36)vs.47.22%(17/36)],but there were no statistical differences(both P>0.05).Conclusion Modified Poge Jiuxin decoction combined with acupuncture can effectively improve the prognosis of patients with SIC,and its mechanism may be related to inhibition of inflammatory reaction and improvement of cardiac function.