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创伤失血性休克是临床常见的休克类型之一,同时也是目前全球45岁以下病人死亡的主要原因[1]。严重创伤通常导致严重的免疫功能障碍,进而导致脓毒症和多器官功能障碍综合征等多种创伤后并发症,而这些创伤后并发症是24 h内病人最常见的死亡原因[2]。免疫系统的异常改变被认为是导致创伤后并发症的关键因素,主要表现为创伤后T细胞介导的免疫功能受损,同时伴随着CD4 T细胞免疫活动的抑制或改变[3-4],其中,辅助性T细胞17(helper T cell 17, Th17)和调节性T细胞(regulatory T cell, Treg)作为免疫调节因子在创伤失血性休克后免疫调节失衡的发病机制中起核心作用[5-6],Th17/Treg平衡可能是维持创伤失血性休克病人免疫稳态的关键[7]。但目前探讨Th17、Treg比例变化及相关细胞因子在创伤失血性休克中的变化、意义以及临床常用复苏液对其影响报道较少。我们通过观察不同液体限制性复苏对创伤失血性休克病人外周血Th17、Treg比例及相关细胞因子水平的影响,评估其复苏效果,从而选择有助于维持病人免疫稳态、减少创伤后并发症发生、提高病人生存率的相对理想复苏液,为临床失血性休克早期液体复苏治疗提供理论依据。现作报道。
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复苏前对AR组和LR组受试者相应指标进行比较,结果显示,2组体质量、年龄、体温、呼吸频率、心率、收缩压、舒张压、平均动脉压、创伤严重程度评分和血红蛋白、红细胞、凝血酶原时间、活化部分凝血活酶时间差异均无统计学意义(P>0.05)(见表 1)。
分组 n 体质量/kg 年龄/岁 体温/℃ 呼吸
频率/(次/分)心率/
(次/分)收缩压/
mmHg舒张压/
mmHg平均动脉/
mmHg创伤严重
程度评分/分血红蛋白/
(g/L)红细胞/
(×1012/L)凝血酶原
时间/s活化部分
凝血活酶时间/sAR组 28 65.82±8.31 48.10±18.20 36.37±0.41 23.48±0.93 124.93±7.33 73.53±5.25 46.24±5.18 50.10±4.11 25.39±2.93 78.57±4.68 3.03±0.56 20.13±2.93 43.17±3.95 LR组 28 66.07±7.61 50.88±12.7 36.08±0.57 24.09±1.62 125.76±5.81 73.28±5.64 45.40±3.74 50.51±4.25 24.49±2.58 79.68±5.50 2.91±0.55 19.20±2.48 43.08±4.20 t — 0.12 0.67 1.97 1.78 0.45 0.16 0.67 0.52 1.10 0.95 0.75 1.45 0.07 P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 表 1 2组受试者一般情况比较(x±s)
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与对照组比较,创伤组外周血Th17、Treg比例和IL-17、IL-6、IL-23、TNF-α水平均明显升高(P < 0.01)(见表 2)。
分组 n Th17/% Treg/% IL-17/(pg/mL) IL-6/(pg/mL) IL-23/(pg/mL) TNF-α/(ng/mL) 对照组 18 0.30±0.03 2.31±0.08 7.37±1.18 5.30±1.09 2.06±0.40 1.68±0.05 创伤组 56 0.64±0.36 3.67±0.26 11.31±0.85 25.46±5.96 17.06±0.65 11.40±2.60 t — 6.99* 34.40* 15.5 24.09 117.01* 27.96* P — <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 *示t′值 表 2 对照组和创伤组外周血Th17、Treg比例及相关细胞因子水平比较(x±s)
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复苏前,创伤组2组病人外周血Th17、Treg比例及细胞因子水平差异均无统计学意义(P>0.05)。复苏后30 min,LR组Th17比例和IL-6、TNF-α水平升高幅度均大于AR组(P < 0.05~P < 0.01);2组Treg比例、IL-17、和IL-23水平变化差异无统计学意义(P>0.05)。复苏后1 h,AR组和LR组各指标变化差异均无统计学意义(P>0.05)(见表 3)。
分组 Th17/(%) Treg/(%) IL-17/(pg/mL) IL-6/(pg/mL) IL-23/(pg/mL) TNF-α/(ng/mL) 复苏前 AR组 0.69±0.38 3.74±1.08 11.18±1.04 25.59±5.15 17.43±2.36 11.29±2.19 LR组 0.59±0.32 3.78±1.14 11.22±1.07 25.23±3.54 17.49±3.08 11.23±2.90 t 1.07 0.13 0.14 0.3 0.18 0.09 P >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 复苏后30 min AR组 0.42±0.15 0.28±0.12 1.21±0.68 4.63±1.27 1.17±0.34 0.62±0.24 LR组 0.63±0.27 0.34±0.15 1.43±0.57 5.47±1.26 1.13±0.32 0.84±0.42 t 3.60* 1.65 1.31 2.48 0.45 2.41 P <0.05 >0.05 >0.05 <0.05 >0.05 < 0.05 复苏后1 h AR组 0.31±0.10 0.19±0.08 0.82±0.17 4.82±0.42 0.76±0.21 0.52±0.08 LR组 0.35±0.20 0.21±0.11 0.89±0.14 4.94±0.87 0.80±0.13 0.58±0.20 t 0.98 0.77 1.76 0.72 0.79 1.28 P >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 *示t′值 表 3 AR组和LR组外周血Th17、Treg比例及相关细胞因子水平比较(x±s)
不同液体限制性复苏对创伤失血性休克病人外周血Th17和Treg细胞比例的影响
Effects of different fluid-restricted resuscitation on the expression of Th17, Treg cells and related cytokines in peripheral blood of patients with traumatic hemorrhagic shock and its clinical significance
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摘要:
目的探讨不同液体限制性复苏对创伤失血性休克病人外周血辅助性T细胞17(Th17)和调节性T细胞(Treg)比例及相关细胞因子水平的影响,为临床选择复苏液提供参考。 方法选择创伤失血性休克病人56例作为研究对象(创伤组),随机分为醋酸钠林格氏液(AR)组和乳酸钠林格氏液(LR)组,各28例,另选择健康医师志愿者18名设为对照组。采集受试者外周血,采用流式细胞术检测各组外周血Th17和Treg比例,采用酶联免疫吸附试验检测各组外周血白细胞介素(IL)-17、IL-6、IL-23和肿瘤坏死因子α(TNF-α)水平。 结果与对照组比较,创伤组(LR组+AR组)外周血Th17、Treg比例及IL-17、IL-6、IL-23和TNF-α水平均明显升高(P < 0.01)。复苏前,LR组和AR组病人外周血Th17、Treg比例及相关细胞因子水平差异均无统计学意义(P>0.05)。复苏后30 min,LR组Th17比例和IL-6、TNF-α水平升高幅度均大于AR组(P < 0.05~P < 0.01);2组Treg比例、IL-17、和IL-23水平变化差异无统计学意义(P>0.05)。复苏后1 h,LR组和AR组各指标变化差异均无统计学意义(P>0.05)。 结论与乳酸钠林格液相比,使用醋酸钠林格液早期复苏能更进一步抑制创伤失血性休克病人外周血Th17、IL-6和TNF-α释放,进而减轻病人机体炎症反应。 Abstract:ObjectiveTo investigate the effect and clinical significance of different fluid resuscitation in patients with hemorrhagic shock on the percentage of helper T cell 17(Th17) and regulatory T cell(Treg) in peripheral blood and related cytokines, and to provide reference for clinical screening of relatively ideal resuscitation fluid. MethodsFifty-six patients with traumatic hemorrhagic shock were enrolled as the trauma group.All patients were randomly divided into sodium acetate Ringer's solution (AR) group.And the sodium lactate Ringer's solution (LR) group, 28 cases in each, 18 cases of our hospital health physician volunteers were selected as the control group.Peripheral blood was collected and the ratio of Th17 and Treg in peripheral blood was detected by flow cytometry.The levels of IL-17, IL-6 and IL-23 TNF-α level in peripheral blood of each group were detected by enzyme-linked immunosorbent assay (ELISA). ResultsCompared with the control group, the peripheral blood Th17 and Treg ratios and the levels of IL-17, IL-6, IL-23 and TNF-α in the trauma group (LR group+AR group) were significantly increased (P < 0.01).Before resuscitation, there was no significant difference in the peripheral blood Th17, Treg ratio and cytokine levels between the two groups of patients in the trauma group (P>0.05).Thirty minutes after resuscitation, the increase in Th17 ratio and IL-6 and TNF-α levels in the LR group were greater than those in the AR group (P < 0.05 to P < 0.01);there was no significant difference in the level of Treg ratio, IL-17, and IL-23 in the two groups(P>0.05).One hour after resuscitation, there was no statistically significant difference in the changes of the two groups (P>0.05). ConclusionsCompared with sodium lactate Ringer's solution, the early resuscitation with sodium acetate Ringer's solution further inhibits the release of Th17 cells and IL-6 and TNF-α in peripheral blood of patients with traumatic hemorrhagic shock, thereby reducing the patient's body inflammation. -
Key words:
- trauma /
- hemorrhagic shock /
- restrictive resuscitation /
- helper T cell 17 /
- regulatory T cell /
- inflammatory factor
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表 1 2组受试者一般情况比较(x±s)
分组 n 体质量/kg 年龄/岁 体温/℃ 呼吸
频率/(次/分)心率/
(次/分)收缩压/
mmHg舒张压/
mmHg平均动脉/
mmHg创伤严重
程度评分/分血红蛋白/
(g/L)红细胞/
(×1012/L)凝血酶原
时间/s活化部分
凝血活酶时间/sAR组 28 65.82±8.31 48.10±18.20 36.37±0.41 23.48±0.93 124.93±7.33 73.53±5.25 46.24±5.18 50.10±4.11 25.39±2.93 78.57±4.68 3.03±0.56 20.13±2.93 43.17±3.95 LR组 28 66.07±7.61 50.88±12.7 36.08±0.57 24.09±1.62 125.76±5.81 73.28±5.64 45.40±3.74 50.51±4.25 24.49±2.58 79.68±5.50 2.91±0.55 19.20±2.48 43.08±4.20 t — 0.12 0.67 1.97 1.78 0.45 0.16 0.67 0.52 1.10 0.95 0.75 1.45 0.07 P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 表 2 对照组和创伤组外周血Th17、Treg比例及相关细胞因子水平比较(x±s)
分组 n Th17/% Treg/% IL-17/(pg/mL) IL-6/(pg/mL) IL-23/(pg/mL) TNF-α/(ng/mL) 对照组 18 0.30±0.03 2.31±0.08 7.37±1.18 5.30±1.09 2.06±0.40 1.68±0.05 创伤组 56 0.64±0.36 3.67±0.26 11.31±0.85 25.46±5.96 17.06±0.65 11.40±2.60 t — 6.99* 34.40* 15.5 24.09 117.01* 27.96* P — <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 *示t′值 表 3 AR组和LR组外周血Th17、Treg比例及相关细胞因子水平比较(x±s)
分组 Th17/(%) Treg/(%) IL-17/(pg/mL) IL-6/(pg/mL) IL-23/(pg/mL) TNF-α/(ng/mL) 复苏前 AR组 0.69±0.38 3.74±1.08 11.18±1.04 25.59±5.15 17.43±2.36 11.29±2.19 LR组 0.59±0.32 3.78±1.14 11.22±1.07 25.23±3.54 17.49±3.08 11.23±2.90 t 1.07 0.13 0.14 0.3 0.18 0.09 P >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 复苏后30 min AR组 0.42±0.15 0.28±0.12 1.21±0.68 4.63±1.27 1.17±0.34 0.62±0.24 LR组 0.63±0.27 0.34±0.15 1.43±0.57 5.47±1.26 1.13±0.32 0.84±0.42 t 3.60* 1.65 1.31 2.48 0.45 2.41 P <0.05 >0.05 >0.05 <0.05 >0.05 < 0.05 复苏后1 h AR组 0.31±0.10 0.19±0.08 0.82±0.17 4.82±0.42 0.76±0.21 0.52±0.08 LR组 0.35±0.20 0.21±0.11 0.89±0.14 4.94±0.87 0.80±0.13 0.58±0.20 t 0.98 0.77 1.76 0.72 0.79 1.28 P >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 *示t′值 -
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