本文選題：創(chuàng)傷　切入點(diǎn)：急性胃腸損傷　出處：《蘭州大學(xué)》2017年碩士論文

【摘要】：目的:本實驗通過測定嚴(yán)重創(chuàng)傷后患者不同時間點(diǎn)瓜氨酸、I-FABP、內(nèi)毒素及PCT水平,觀察嚴(yán)重創(chuàng)傷后患者腸粘膜損傷與內(nèi)毒素移位程度,分析生物學(xué)標(biāo)志物相互之間及與創(chuàng)傷后AGI之間的相關(guān)性,并納入SOFA評分、APACHEⅡ評分,探討腸粘膜損傷在MODS病理變化過程中作用。方法:采用前瞻性研究方法,納入2015年8月至2016年12月入住蘭州大學(xué)第二醫(yī)院內(nèi)科ICU創(chuàng)傷后24h內(nèi)首診我院的患者(18歲年齡80歲)。排除閉合及開放性腹部創(chuàng)傷、急慢性腸道疾病及胃腸道手術(shù)史患者,存在急慢性腎臟、肝臟疾病患者,可疑感染患者,妊娠期婦女。根據(jù)創(chuàng)傷嚴(yán)重程度評分ISS分為輕度創(chuàng)傷組(ISS16),重度創(chuàng)傷組(ISS≥16)。根據(jù)入院72h內(nèi)是否發(fā)生急性胃腸損傷分為AGI組,AGI0組,根據(jù)2012年歐洲危重病醫(yī)學(xué)會對AGI分級指南,對AGI組分為3個亞組,A GI1組,AGI2組,AGI3組。選擇同期蘭州大學(xué)第二醫(yī)院健康體檢者作為正常對照組。收集患者基本臨床資料及AGI分級,采集入院第1天及第3天靜脈血標(biāo)本,用于測量瓜氨酸、I-FABP、內(nèi)毒素及PCT水平。結(jié)果:1.第1天重傷組、輕傷組瓜氨酸水平較對照組均顯著降低(P0.01或P0.05),且重傷組顯著低于輕傷組(P0.01),第3天各組瓜氨酸水平進(jìn)一步下降(P均0.01),重傷組仍顯著低于輕傷組(P0.01)。第1天AGI3組中瓜氨酸水平較AGI0組、AGI1組、AGI2組顯著降低(P0.01或P0.05),AGI2、AGI1組也較AGI0組顯著下降(P0.01或P0.05)。第3天各組瓜氨酸水平均進(jìn)一步下降(P均0.01),各亞組間分級越高,瓜氨酸水平下降越顯著(P0.01或P0.05)。瓜氨酸水平與AGI嚴(yán)重程度呈負(fù)相關(guān)。瓜氨酸對嚴(yán)重創(chuàng)傷后AGI預(yù)測的ROC曲線下面積為0.88,最佳界值為19.07umol/L,此時敏感性為87.10%,特異性為76.47%.2.第1天重傷組、輕傷組I-FABP水平較對照組顯著升高(P均0.01),且重傷組顯著高于輕傷組(P0.01)第3天各組I-FABP水平進(jìn)一步下降(P均0.01),重傷組仍高于輕傷組(P0.05)。第1天AGI3組中I-FABP水平較AGI0組、AGI1組、AGI2組顯著升高(P0.01或P0.05),AGI2組也較AGI0組顯著升高(P0.01)。第3天AGI0組、AGI2組、AGI3組I-FABP水平均進(jìn)一步下降(P均0.01),AGI3組、AG2組I-FABP水平仍顯著高于AGI0組(P0.01或P0.05)。I-FABP與AGI嚴(yán)重程度呈正相關(guān)。I-FABP對嚴(yán)重創(chuàng)傷后AGI預(yù)測的ROC曲線下面積為0.84,最佳界值為1657pg/ml,此時敏感性為90.32%,特異性為64.71%。3.第1天重傷組、輕傷組內(nèi)毒素水平較對照組顯著升高(P均0.01),且重傷組顯著高于輕傷組(P0.01)第3天各組內(nèi)毒素水平較第1天變化不明顯,差異不具有統(tǒng)計學(xué)意義(P0.05),但重傷組仍顯著高于輕傷組(P0.01)。第1天AGI3組中內(nèi)毒素水平較AGI0組、AGI1組、AGI2組顯著升高(P0.01或P0.05),AGI2組也較AGI0、AGI1組顯著升高(P0.01或P0.05),AGI1組較AGI0組升高(P0.05)。第3天僅AGI0組內(nèi)毒素水平進(jìn)一步下降(P0.05),AGI3組內(nèi)毒素水平仍顯著高于AGI0、AGI1組(P0.01),AGI2組仍顯著高于AGI0組、AGI1組(P0.01或P0.05),AGI1組水平仍顯著高于AGI0組(P0.05)。內(nèi)毒素水平與AGI嚴(yán)重程度呈正相關(guān)。內(nèi)毒素對嚴(yán)重創(chuàng)傷后AGI預(yù)測的ROC曲線下面積為0.90,最佳界值為0.234EU/ml,此時敏感性為90.32%,特異性為82.35%。4.第1天重傷組PCT水平較對照組、輕傷組顯著升高(P0.01或P0.05),第3天各組PCT水平較第1天差異不具有統(tǒng)計學(xué)意義(P0.05),但重傷組仍高于正常組(P0.05)。第1天僅AGI3組中PCT水平較AGI0組、AGI1組、AGI2組顯著升高(P均0.01),第3天其水平與第1天相比差異無統(tǒng)計學(xué)意義(P0.05),但AGI3組PCT水平仍高于AGI1、AGI0組(P0.01或P0.05),AGI2組高于AGI0組(P0.01)。5.創(chuàng)傷后瓜氨酸水平與I-FABP、內(nèi)毒素、PCT、APACHEⅡ評分、SOFA評分呈明顯負(fù)相關(guān),與I-FABP、內(nèi)毒素、PCT、APACHEⅡ評分、SOFA評分之間存在明顯正相關(guān)。入院后72h內(nèi)手術(shù)組第3天的I-FABP水平較非手術(shù)組顯著升高,存在正相關(guān)。結(jié)論:創(chuàng)傷后早期血清I-FABP、內(nèi)毒素、PCT水平顯著升高,其水平變化均與創(chuàng)傷嚴(yán)重程度和AGI嚴(yán)重程度程度有明顯的正相關(guān),血清瓜氨酸水平顯著降低,其水平變化與創(chuàng)傷嚴(yán)重程度和AGI嚴(yán)重程度程度有明顯的負(fù)相關(guān);APACHEⅡ評分、SOFA評分與瓜氨酸水平呈明顯負(fù)相關(guān),與I-FABP、內(nèi)毒素、PCT之間存在明顯正相關(guān),瓜氨酸、I-FABP、內(nèi)毒素、PCT相關(guān)之間存在明顯相關(guān)性;瓜氨酸、I-FABP、內(nèi)毒素水平可以作為是預(yù)測創(chuàng)傷后早期腸粘膜損傷的潛在生物學(xué)標(biāo)志物。
[Abstract]:Objective: through the determination of severe trauma patients at different time points of I-FABP, citrulline, endotoxin and PCT levels were observed after severe trauma patients with intestinal mucosal injury and endotoxin translocation, biological analysis of correlations of biomarkers between and after trauma and AGI, and included in the SOFA score, APACHE score, to explore the role of intestinal mucosa in MODS during the pathological process of injury. Methods: the prospective study included in August 2015 to December 2016 in Second Hospital Affiliated to Lanzhou University, medical ICU 24h after trauma in our hospital diagnosed patients (aged 18 years old 80 years old). Exclusion of closed and open abdominal trauma, acute and chronic bowel disease and gastrointestinal surgery patients had acute and chronic patients with kidney, liver disease, patients with suspected infection in pregnant women. According to the injury severity score ISS were divided into mild trauma group (ISS16), severe trauma group (ISS = 16). According to the admission 72h is the occurrence of acute gastrointestinal injury were divided into AGI group, AGI0 group, according to the 2012 European Society of critical care medicine on AGI classification guide, the AGI were divided into 3 groups, A GI1 group, AGI2 group, AGI3 group. The Second Hospital Affiliated to Lanzhou University selected healthy subjects as normal control group were collected. The basic clinical the data acquisition and AGI classification, the first day of admission and 3 days blood samples for the measurement of citrulline, I-FABP, endotoxin and PCT level. Results: 1. of first days of severe injury group, the level of citrulline group were significantly decreased slightly compared with the control group (P0.01 or P0.05), and the severe injury group was significantly lower than that in slight group (P0.01), third days the citrulline levels were further decreased (P 0.01), severe injury group was significantly lower than that in slight group (P0.01). First days in group AGI3 citrulline levels compared with AGI0 group, AGI1 group, AGI2 group significantly decreased (P0.01 or P0.05), AGI2, AGI1 group was significantly lower than that in AGI0 group (P0.01 or P0. 05). Third days each were further reduced citrulline levels (P 0.01), among the sub groups with the higher grade of citrulline levels decreased more remarkably (P0.01 or P0.05). The level of citrulline was negatively correlated with the severity of AGI. The area of ROC AGI citrulline curve prediction after severe trauma was 0.88, the best cut-off value for 19.07umol/L, the sensitivity was 87.10%, specificity was first days 76.47%.2. injured group, the level of I-FABP minor injury group were significantly higher than the control group (P 0.01), and the severe injury group was significantly higher than that in slight group (P0.01) third days the level of I-FABP was further decreased (P 0.01), severe injury group was still higher than the minor injury group (P0.05) first days in the AGI3 group. The level of I-FABP compared with AGI0 group, AGI1 group, AGI2 group increased significantly (P0.01 or P0.05), AGI2 group was significantly higher than that of AGI0 group (P0.01). Third days in AGI0 group, AGI2 group, the level of I-FABP in AGI3 group were further decreased (P 0.01), AGI3 group, the level of I-FABP AG2 group is significantly higher In the AGI0 group (P0.01 or P0.05).I-FABP and AGI were positively correlated with the severity of.I-FABP ROC curve area prediction of AGI after severe trauma was 0.84, the optimum value of 1657pg/ml, the sensitivity was 90.32%, specificity was first days 64.71%.3. injury group, the levels of endotoxin in minor injury group than the control group increased significantly (P < 0.01), and the severe injury group was significantly higher than that in slight group (P0.01) were compared with third days of endotoxin first days did not change significantly, the difference was not statistically significant (P0.05), but the injured group was still higher than that of minor injury group (P0.01). First days in group AGI3 endotoxin levels compared with AGI0 group, AGI1 group, AGI2 group significantly increased (P0.01 or P0.05), AGI2 group was AGI0, AGI1 group increased significantly (P0.01 or P0.05), the AGI1 group was higher than that in AGI0 group (P0.05). The third day only AGI0 group further decreased levels of endotoxin (P0.05), the levels of endotoxin in AGI3 group was still significantly higher than that in AGI0 group, AGI1 (P0.01), AGI2 group was still higher high In AGI0 group, AGI1 group (P0.01 or P0.05), AGI1 group was still higher than that of AGI0 group (P0.05). The level of endotoxin was positively correlated with the degree of AGI. LPS on ROC curve area prediction of AGI after severe trauma was 0.90, the optimum value of 0.234EU/ml, the sensitivity was 90.32%, specificity was first 82.35%.4. days of severe injury group PCT levels than the control group, injury group increased significantly (P0.01 or P0.05), the level of PCT was third days compared to first days the difference was not statistically significant (P0.05), but the injured group still higher than the normal group (P0.05). Only first days in the AGI3 group PCT levels compared with AGI0 group, AGI1 group, AGI2 group increased significantly (P 0.01) third days, first days compared with the level of the difference was not statistically significant (P0.05), but the PCT level of AGI3 group was higher than AGI1, AGI0 group (P0.01 or P0.05), AGI2 group than in AGI0 group (P0.01) and citrulline levels I-FABP,.5. after trauma of endotoxin, PCT, APACHE score the SOFA score was. Significant negative correlation with I-FABP, endotoxin, PCT, APACHE score, there was a positive correlation between SOFA scores. 72h after admission surgery group third days I-FABP levels than the non operation group increased significantly, there is a positive correlation. Conclusion: early after trauma and endotoxin, serum I-FABP, PCT levels significantly increased significantly the level changes were positively correlated with the extent of injury and severity of AGI, serum citrulline levels were significantly reduced, there was a negative correlation between the severity and the AGI level and the severity of injury degree; APACHE score, SOFA score was negatively correlated with I-FABP, endotoxin and citrulline levels, there was a positive correlation. PCT I-FABP, citrulline, endotoxin, there is obvious correlation between PCT; citrulline, I-FABP, endotoxin levels can be used as potential biomarkers for early prediction of intestinal mucosal injury after trauma.

【學(xué)位授予單位】：蘭州大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R641

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