本文总结目前多器官功能障碍综合征(MODS)中西医结合分型的现状及中医的理论认识,从中医理论出发,论述"痰"、"因地制宜"对MODS治则及转归的影响,深入探讨MODS的中西医结合证型诊断;从治未病对MODS治疗指导的重要性及个体化治疗是MODS治疗的方向等方面进行阐述,为MODS的防治寻求新的理论支持和治疗思路。

目的观察醒脑静注射液对心肺复苏术(CPR)后患者血清肿瘤坏死因子α(TNF-α)以及白细胞介素10(IL-10)、IL-6的影响。方法将CPR后存活≥48h的32例患者随机分为两组,均予西医常规处理,治疗组加用醒脑静注射液静滴;于CPR后当日及72h抽取外周静脉血,检测两组血清TNF-α、IL-10、IL-6水平,统计全身炎症反应综合征(SIRS)发生率。结果治疗组与对照组比较,血清细胞因子水平均明显升高,治疗组治疗72h后血清细胞因子水平均出现下降,而对照组出现上升趋势;CPR后72h治疗组SIRS发生率31.25%,对照组为68.75%,两组差异显著。结论早期应用醒脑静注射液可以降低呼吸心跳骤停患者血清细胞因子水平,减轻CPR后机体的全身炎症反应。

Objective To study the influence of fluoride on the expression of osteoprotegerin(OPG) mRNA and protein in suckling rat osteoblasts. Methods Osteoblasts obtained from calvarial of suckling Wistar rats were cultured in vitro in the media supplemented with NaF at a series of doses[O(control), 1,2 and 4 mg/L groups], and OPG mRNA expression and protein were evaluated by RT-PCR and ELISA methods, respectively. Results OPG mRNA expression in suckling rat osteoblasts cultured in vitro significantly increased after exposure to NaF for 48 h and 72 h(F=333.48,808.34,P<0.05). OPG mRNA expression in suckling rat osteoblasts cultured in vitro after exposure to NaF for 48 h at different doses(0.810±0.003, 0.819±0.031 and 0.870±0.044 for 1,2 and 4 mg/L groups, respectively) compared with that of control (0.800±0.040, all P<0.05). OPG mRNA expression further increased for 72 h exposure to NaF(0.933±0.047,1.031±0.051,1.240±0.062 for 1,2 and 4 mg/L, respectively), significantly higher than that of the control (0.805±0.020,all P<0.05) and corresponding groups at 48 h. NaF doses and time exposure exhibited a significant synergistic effect on OPG mRNA expression(F=2004.16, P<0.05). NaF also enhanced OPG protein expression in suckling rat osteoblasts cultured in vitro. Significant differences were observed only in 4 mg/L group(0.228±0.014,0.277±0.048) and control(0.205±0.012,0.229±0.010) at 48 h and 72 h (P<0.05). In addition, OPG protein expression at 72 h post-exposure was higher than that at 48 h,but there was no synergistic effect between concentration and time(F=1.21,P>0.05). Conclusions The results suggested that NaF could increase OPG mRNA and protein expression in suckling rat osteoblasts with a synergistic effect between the doses and exposure time.

本文从中医学理论的合理性与局限性、医疗政策的领航作用、复合型中医人才的培养、走中西医结合之路四个方面探讨中医学的发展。

Objective To investigate the dynamic variations and relationship of tumor necrosis factor-α (TNF-α), interleukin-6(IL-6),interleukin-10(IL-10) and matrix metalloproteinase-9 (MMP-9) in serum of patients of acute organ- ophosphorus pesticide poisoning (AOPP)with multiple organs dysfunction syndrome(MODS) and discussed the mechanism of MODS.Methods 42 patients with AOPP and MODS were enrolled in this study.TNF-α,IL-6,IL-10 and MMP-9 in their serum were detected with double antibody Sandwich-Enzyme linked with immunosorbent assay(DAS-ELISA) and com- pared with control group.The relations of TNF-α,IL-6,IL-10 and MMP-9 were analyzed with person correlation analysis. Results The contents of TNF-α,IL-6,IL-10 and MMP-9 elevated obviously in the serum of patients with AOPP,there was significant difference between patients with AOPP and normal control(P0.01).The level of MMP-9 had positive correla- tion with TNF-α、IL-6、IL-10.Conclusion AOPP may induce the disturbance of the inflammatory factor,and MMP-9 plays an important role in the development from SIRS to MODS in AOPP patients by regulating the inflammatory factors.

Objective To observe the effects of intensive insulin treatment on the prognosis of multiple organ dysfunction syndrome(MODS) patients.Method From July 2005 to July 2007,65 patients with MODS from Department of Intensive Care Unit,the Second Hospital of Jilin University were randomly divided into two groups:intensive insulin therapy group(n=31)and control group(n=34).Intensive insulin treatment group received insulin by intravenous injection in order to maintain blood glucose levels at 4.0~6.1 mmol/L,while the control group received routine insulin treatment in order to maintain blood glucose levels at 10.0~11.0 mmol/L.The mortality in hospital,incidence of nosocomial infection and time of mechanical ventilation were observed in two groups.Results After the intensive insulin therapy,the mortality in hospital,incidence of nosocomial infection and time of mechanical ventilation were significantly lower than in control group(P<0.05).The prognosis of MODS patients was significantly improved.Conclusions Intensive insulin therapy might reduce the complications and mortality,improve the prognosis in the patients of MODS.

Objective: To observe the influence of Sanhuangzhongfengkang Capusle(SH-C) on hemorrheology of hypercoagulabale state rats model.Methods:Through platelet agglutination test,out-of-body thrombotes,stagnation of blood model made hypercoagulabale state rats model.Results:Compared with normal group and model group,SH-C could improve hypercoagulabale state and index of hemorrheology of rats model.Conclusion:Hemorheological hypercoagulabale state is high risk factor on ischemic apoplexy generated and developed,improving hematological hypercoagulabale state that has great prevention and cure significance about ischemic apoloexy.

Objective To explore the application of BiPAP mode to critically ill elderly patients with mechanical ventilation after the operation under general anesthesia.Methods 45 critically ill elderly patients with mechanical ventilation after the operation under general anesthesia were randomly divided into BiPAP group(n=23)and VC-SIMV group(n=22),and parameters including clinical curative effects,respiratory mechanics,hemodynamics,arterial blood gas,time of mechanical ventilation and sedative dosage were evaluated dynamically under the condition of lung protective ventilation.Results The mortality in ICU was significantly lower in BiPAP group than in VC-SIMV group(26.09% vs 50.00%,P0.05).Both BiPAP and VC-SIMV modes could effectively improve arterial blood gas without significant difference(P0.05).However,BiPAP mode showed better effects in improving respiratory mechanics and hemodynamics compared to VC-SIMV mode(P0.05).The mechanical ventilation time in BiPAP group was significantly lower than that in VC-SIMV group(163.79±22.85)h vs(356.23±32.65)h,P0.05.The dosage of sedative(1% propofol injection)used during mechanical ventilation was significantly lower in BiPAP group than in VC-SIMV group(95.26±17.28) mL vs(306.13±61.75) mL,P0.05.Conclusion BiPAP mode is superior to VC-SIMV mode and should be the first choice of mechanical ventilation for critically ill elderly patients after the operation under general anesthesia.

Objective:To study the protective effect of Sanhuangzhongfengkang Capusle(SH-C) on the Deficiency of Qi and Blood Stasis in ischemic apoplexy model of rats.Methods:The Deficiency of Qi and Blood Stasis in ischemic apoplexy mode of rats model was made by the thread-occluding method and theory about traditional Chinese medicine aetiology and the protective effects of SH-C on the score of neurological deficits,the rate of cerebral infarct and histomorphology of cerebral ischemia in rats was observed.Results:SH-C was perfused to the stomach of rats by 1.36g/kg,0.68g/kg,0.34g/kg,which could distinctly improve the score of neurological deficits of ischemic apoplexy model of rats and reduce the rats of cerebral infarction of rats and the level of cerebral ischemia injury.It was also able to improve the cerebral tissue of pathological change.Conclusion:SH-C can distinctly improve the neurological behavior of ischemic apoplexy model and reduce the rats of infarct size and profit functional restoration of nerves,which had provided proof for clinical application on ZC.

Objective To investigate the influence of ulinastatin intervention on the dynamic variation of interleukin- 6,interleukin-10 and Tumor necrotic factor-or in patients with multiple organ dysfunction syndrome caused by severe acute organophosphorus pesticide poisoning(AOPP).Methods 46 patients with MODS casued by severe AOPP were randomly and clinically divided into conventional group(24 patients) and ulinastatin intervention group (22 patients).The dynamic variations of these cytokines were detected synchronizingly and compared with healthy control group(20 patients).Results The levels of IL-6、IL-10 and TNF-α in serum of both of conventional therapy group and ulinastatin intervention group were higher than heahy control group(P0.01) and decreased obviously after therapy(P0.01).The contents of IL-6 and TNF-α of ulinastatin intervention group after therapy had a greater decrease than conventional therapy group (P 0.01),but there was no significant difference when compared with IL-10 (P0.05).The case fatality of ulinastatin inter- vention group was lower obviously than conventional therapy group,and the length of stay in hospital was also shor- ter.Conclusion TNF-α,IL-6 and IL-10 have effects on the pathological process of MODS caused by severe AOPP.Ulinastatin can obviously decrease the levels of TNF-α and IL-6,which conduce to the decrease of case fatality of se- vere AOPP patients with MODS.

Objective To investigate the protective effects of ulinastatin on multiple organs in the patients with myocardial infarction(MI) after cardiopulmonary resuscitation(CPR).Methods Fifty patients with MI after CPR,29 males and 21 females,aged(58.02±15.25)(39～78),were randomly divided into 2 equal sex,age,and APACHE-Ⅱ score-matched groups: intervention group treated with ulinastatin and control group receiving routine management.Then compare the relative clinical and laboratory components between the two groups.Results The rate of discharge or transfer from ICU of the intervention group was 76%,significantly higher than that of the control group(40%,P 0.05).The total mortality was 42%,and the patients who died all had the APACHE-II scores 25.No ventilar induced lung injury occurred in the 2 groups.The ventilar-associated pneumonia rate,severe arrhythmia rate,mortality due to MODS of the intervention group were 12%,16%,and 24% respectively,all significantly lower than those of the control group(36%,44%,and 60% respectively,all P 0.05).The level of creatine kinase isoenzyme at the first day of the control group was(183.12±12.57) U/L,not significantly different from that of the intervention group [(185.13±13.36)U/L,P =0.5863];and the levels of creatine kinase isoenzyme at the third and fifth days of the intervention group were(110.56±12.14) and(39.73±10.37)U/L respectively,both significantly lower than those of the control group were[(167.35±11.49) and(73.52±10.18)U/L respectively,both P =0.0000].The mean blood pressure and heart rate 5 days after treatment of the intervention group was(99.59±13.75) mmHg,significantly higher than that of the control group [(57.24±11.13)mmHg,P =0.0000],and the heart rate of the intervention group 5 days after treatment was(107.39±12.03)bpm,significantly lower than that of the control group [(118.59±21.85)bpm,P 0.05].The MODS score 5 days after mechanical ventilation of the intervention group was(1.59±1.36),significantly lower than that of the control group(2.96±0.23,P 0.05).Conclusion Decreasing the CK-MB level and incidence of arrhythmia,ulinastatin has protective effects in MI patients after CPR.

Objective To explore the influence of mild hypothermia on patients with acute severe cerebral stroke complicated by systemic inflammatory reaction(SIR)/MOF.Methods Sixty-one cases were randomly divided into hypothermic group(n=31) and control group(n=30).Their clinical data were analyzed.Results There were 10 cases complicated by SIR and 51 organs in failure in hypothermic group,while there were 16 cases complicated by SIR and 98 organs in failure in control group,with significant statistical difference between the 2 groups (P0.01,P0.05).Two cases died of brainstem failure and 2 cases died of MOF in hypothermic group;while in control group,2 cases died of brainstem failure,4 cases died of MOF and 2 cases died of brain hernia.The fatality rates in mild hypothermic group and control group were 12.9%(4/31) and 26.7%(8/30) respectively(P(0.01).)After followed up for 1 month,the score of CSS was significantly higher in hypothermic group than in control group.Conclusions Mild hyperthermia has the protective effect against the acute severe cerebral stroke complicated by SIR/MOF.It can reduce the number of failed organs and fatality rate,and improve the prognosis.

Objective To evaluate the effects of ulinastatin on the prevention and treatment of multiple organ dysfunction syn- drome(MODS)and the decrease of the mortality.Methods 45 patients of severe acute organophosphorus pesticide poisoning(AOPP) were randomly divided into ulinastatin intervention group and non-ulinastatin intervention group.We compared the changes of whole blood acetytcholine esterase,ereatine kinase isoenzyme,arterial blood gas(ABG)and hemodynamics of the two groups before and after the treatment.The functional improvement rate of lung and extra-pulmonary organs,complication incidence of mechanical ventilation,mor- tality in ICU and the causes of death were also compared.Results There were no significant differences in the age,whole blood acetyl- choline esterase and acute physiology and chronic health evaluationⅡ(APACHEⅡ)scores of the two groups(P＞0.05);The effects of uli- nastatin intervention on whole blood acetylcholine esterase,creatine kinase isoenzyme,ABG and hemodynamics in severe AOPP patients were superior to control group;The functional improvement rates of lung and extra-pulmonary organs in ulinastatin intervention group ob- viously outstripped those in control group ,and the incidence of ventilator-associated pneumonia(VAP),myocardial ischemia and ar- rhythmia were also obviously decreased;The mortality of multiple organ failure of ulinastatin intervention group in ICU was 4.35%, which was obviously ]ower than that(27.27%)of eontrol group(P＜0.05),and the recovery rate of severe AOPP in ICU increased from 72.73% to 95.65%(P＜0.05).Conclusion Ulinastatin intervention can improve the whole blood acetylcholine esterase,creatine ki- nase isoenzyme,ABG and hemodynamics of severe AOPP patients,and decrease the incidence of VAP,myocardial ischemia and arrhyth- mia,and has great clinical effects on the prevention and treatment of MODS induced by AOPP and the decrease of the mortality.

Objective To evaluate the effects of ulinastatin intervention in lung protective ventilation on the control of acute lung injury(ALI), prevention and cure of multiple organ dysfunction syndrome(MODS) and decreasing disease mortality.Methods Fifty seven ALI patients were randomly divided into lung protective ventilation group and ulinastatin intervention in lung protective ventilation group.We compared the changes of pneumodynamics,arterial blood gas and hemodynamics of the two groups,to observed the function improvement rate of lung and extrapulmonary organs,complication morbidity of mechanical ventilation,and disease mortality in ICU and causes of death.Results There were no significant differences in the age and acute physiology and chronic health evaluationⅡ(APACHE-Ⅱ) scores of the two groups(P0.05).Ulinastatin intervention in lung protective ventilation had further improved influence on pneumodynamics,arterial blood gas and hemodynamics than lung protective ventilation.The function improvement rate of lung and extrapulmonary organs of the ulinastatin intervention in lung protective ventilation group also outstripped the rate of the lung protective ventilation group,and the disease mortality in ICU for multiple organ failure of ulinastatin intervention in lung protective ventilation group was 20.69%,which was obviously superior to the rate(46.43%) of lung protective ventilation group(P0.05).Conclusions Ulinastatin intervention in lung protective ventilation can improve the pneumodynamics,arterial blood gas and hemodynamics of ALI patients;It could decrease the incidence of ventilator induced lung injury,mechanical ventilation associated myocardial ischemia and arrhythmic,it also has great clinical effects on the prevention and cure of MODS and decreasing the disease mortality of ALI patients.

Objective To explore the meaning of lung protective ventilatory strategies in the aged acute cerebral stroke with respiratory failure.Methods We retrospectively study the clinical data about 55 cases of ventilatory strategies in the aged acute cerebral stroke with respiratory failure and compare the effect of routine(n=27) or protective(n=28) mechanical ventilation on their arterial blood gas,respiratory mechanics,haematic dynamics,ventilatory complication,encephalic pressure and mortality.Results The protective and routine mechanical ventilation have significant effect on improving the marker of arterial blood gas analysis(P0.05).The former is more efficient in improving the respiratory mechanics and haematic dynamics and decreasing ventilatory complication and mortality than the latter(P0.05).Lung protective strategies has no bad effect on encephalic pressure.Conclusions The lung protective ventilatory strategies should be applied to the aged acute cerebral stroke with respiratory failure,which include setting low tide volume,restricting via-pulmanory pressure and adding positive end-expiratory pressure.Synchronously,it is very important for positively strengthening faculty treats and correcting circulation and metabolism malfunction.

Objective To evaluate the effects of ulinastatin intervention in lung protective ventilation on the control of acute lung injury(ALI), prevention and cure of multiple organ dysfunction syndrome(MODS) and decreasing disease mortality.Methods Fifty seven ALI patients were randomly divided into lung protective ventilation group and ulinastatin intervention in lung protective ventilation group.We compared the changes of pneumodynamics,arterial blood gas and hemodynamics of the two groups,to observed the function improvement rate of lung and extrapulmonary organs,complication morbidity of mechanical ventilation,and disease mortality in ICU and causes of death.Results There were no significant differences in the age and acute physiology and chronic health evaluationⅡ(APACHE-Ⅱ) scores of the two groups(P>0.05).Ulinastatin intervention in lung protective ventilation had further improved influence on pneumodynamics,arterial blood gas and hemodynamics than lung protective ventilation.The function improvement rate of lung and extrapulmonary organs of the ulinastatin intervention in lung protective ventilation group also outstripped the rate of the lung protective ventilation group,and the disease mortality in ICU for multiple organ failure of ulinastatin intervention in lung protective ventilation group was 20.69%,which was obviously superior to the rate(46.43%) of lung protective ventilation group(P<0.05).Conclusions Ulinastatin intervention in lung protective ventilation can improve the pneumodynamics,arterial blood gas and hemodynamics of ALI patients;It could decrease the incidence of ventilator induced lung injury,mechanical ventilation associated myocardial ischemia and arrhythmic,it also has great clinical effects on the prevention and cure of MODS and decreasing the disease mortality of ALI patients.

Objective To investigate the dynamic changes of IL -6,IL - 10 and TNF -αin serum of the patients with AOPP and MODS and to discuss the mechanism of MODS induced by AOPP.Methods 42 patients with AOPP and MODS were enrolled in this study.The contents of these cytokines in the serum were detected with double antibody sandwich - enzyme linked immunosorbent assay(DAS-ELISA) and compared with control group.Results The contents of IL -6,IL - 10 and TNF -αincreased obviously in the serum of patients with AOPP,and there was significant difference between patients with AOPP and normal control (P＜0.01). Conclusion AOPP may conduce to the maladjustment of the cytokines,and the eytokines play an important role in the development - from systemic inflammatory response syndrome (SIRS)to MODS in AOPP patients.

目的探讨老年急性呼吸衰竭病人机械通气治疗中的肺保护性策略。方法对50例次老年急性呼吸衰竭病人机械通气治疗的临床资料进行回顾性分析、评定,建立此类病人进行机械通气时具有肺保护作用的模式组合、参数设置及其调节方法。结果SIMV-PSV-PEEP/CPAP的模式组合在改善动脉血气指标和减少机械通气相关并发症等方面均有明显效果。各通气参数的设置和调节范围是Vt(6·85±1·30)ml/kg、PSV(10·5±1·6)cmH2O、PEEP/CPAP(5·45±1·23)cmH2O、f(21±1·5)bpm。结论老年急性呼吸衰竭病人机械通气治疗中SIMV-PSV-PEEP/CPAP的模式组合具有肺保护作用。通气参数的设置和调节宜在动脉血气指标的量化控制下,应用小Vt、小PSV、小PEEP/CPAP和较高f,并采用动态的线性撤机过程。围机械通气期应加强循环和营养代谢支持等综合治疗。

Objective The purpose was to explore the lung protective ventilatory strategies about pulmonary-interior and exterior respiratory failure.Methods We retrospectively studied the clinical data of 25 respiratory failure cases, including 12 interior cases and 13 exterior cases.Moreover,we also analyzed the effect of difference in respiratory mechanics on the pattern fabrication,parameters layout and regulation as well as the lung protection method.Results On the condition that there was no difference in APACHE-Ⅱ grade,mean age,and Vt between groups( P >0 05),whereas the results of Crs was significantly lower than those in exterior group (P<0 01).The mortality rates were accounted for 41 7% and 15 4%,respectively, which had markedy statistical difference in interior and exterior group(P<0 01),and they all died of MOF (APACHE-Ⅱ grade>).Conclusions We should carry out different lung protection method in mechanical ventilation of pulmonary-interior and exterior respiratory failure.The former firstly selects pre-setting pressure mechanical ventilation and the latter firstly selects pre-setting volume mechanical ventilation.In conclusion,there is a principle that setting middle or low Vt,appropriate frequency and adding PSV,CPAP/PEEP according to individual ventilation demand,which is helpful to reducing VILI,morbidity and mortality. [