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急性胰腺炎是临床常见的全身性疾病之一,急性胰腺炎的诱发因素有很多种,其中最多见的病因是胆结石和过量的酒精摄入[1]。大约5%~10%的病人可能会进展为重症急性胰腺炎(severe acute pancreatitis,SAP),表现为伴有胰腺或胰腺周围组织坏死和或器官功能障碍,死亡率甚至达到20%~40%[2]。SAP可导致全身多个器官功能障碍,其中包括心肌细胞损害,临床症状主要表现为心律失常、心功能改变、心肌梗死、心包炎、中毒性心肌炎和心源性休克。现代医学研究表明,参附注射液在心脏、肾脏、肝脏以及肺等重要脏器的保护方面具有重要作用[3]。乌头类生物碱在体内经肝脏代谢转化,可扩张冠状动脉,增加冠状动脉血流量,改善缺血心肌的氧供,使心肌收缩力增强、心排出量增加[4]。研究[5-6]显示,参附注射液可减少炎性因子肿瘤坏死因子-α(TNF-α)、白细胞介素-6(IL-6)的表达,并能够显著降低脓毒症病人心肌损伤时的血浆脑钠肽水平,从而改善脓毒症病人的心功能。SAP伴发的心血管事件是导致病人生存率较低的重要因素,但是目前还未发现有循证医学依据的有效方案。结合SAP可能的发病机制及参附注射液的药物特性,本研究拟在前期研究[7-8]基础上,将乌司他丁联合参附注射液应用于SAP合并心肌损伤的病人,评价其对SAP病人心肌损害保护作用的临床价值。现作报道。
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治疗组治疗后腹痛、腹胀、排气、排便、肠鸣音恢复时间均短于对照组(P < 0.05)(见表 1)。
分组 n 腹痛 腹胀 排气 排便 肠鸣音 治疗组 45 6.18±0.76 4.37±0.35 3.42±1.19 4.58±1.85 2.76±0.59 对照组 45 8.15±1.23 6.56±0.93 5.12±1.01 5.79±1.34 3.75±0.36 t — 9.14 14.78 7.31 3.55 9.61 P — < 0.05 < 0.05 < 0.05 < 0.05 < 0.05 表 1 2组病人症状体征恢复时间比较(x±s;d)
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治疗前2组病人NT-proBNP、cTnI、CK-MB差异无统计学意义(P>0.05),治疗后10 d 2组各指标均低于治疗前(P < 0.05),且治疗组病人的血清NT-proBNP和cTnI水平均低于对照组(P < 0.05)。治疗组病人接受治疗5 d后血清cTnI和CK-MB水平均低于对照组(P < 0.01和P < 0.05)(见表 2)。
分组 治疗前 治疗5 d 治疗10 d F P MS组内 NT-proBNP/(pg/mL) 治疗组 531.89±313.51 489.96±219.30 215.44±187.35*# 21.98 < 0.01 60 493.678 对照组 556.71±332.06 499.84±214.15 307.47±178.41*# 12.25 < 0.01 62 651.398 t 0.36 0.22 2.39 — — — P >0.05 >0.05 < 0.05 — — — CTnI/(μg/mL) 治疗组 3.28±2.32 1.56±0.75* 0.30±0.19*# 50.51 < 0.01 1.994 对照组 3.68±2.21 2.17±1.22* 0.39±0.20*# 57.10 < 0.01 2.138 t 0.84 2.86 2.19 — — — P >0.05 < 0.01 < 0.05 — — — CK-MB/(U/L) 治疗组 20.17±28.92 12.06±11.17* 7.69±6.72* 5.38 < 0.01 335.431 对照组 21.63 ±26.21 18.73±17.43 8.32±7.12*# 6.35 < 0.01 347.154 t 0.25 2.16 0.43 — — — P >0.05 < 0.05 >0.05 — — — q检验:与治疗前比较*P < 0.05;与治疗5 d比较#P < 0.05 表 2 2组病人血清中NT-proBNP、cTnI、CK-MB水平比较(ni=45;x±s)
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治疗前2组病人的BISAP评分和APACHEⅡ评分差异均无统计学意义(P>0.05)。2组病人治疗前后相比,BISAP评分和APACHEⅡ评分均下降(P < 0.05);治疗组治疗后BISAP评分和APACHEⅡ评分均低于对照组(P < 0.05和P < 0.0)(见表 3)。
分组 n APACHEⅡ评分 BISAP评分 治疗前 治疗组 45 12.57±4.25 1.97±0.96 对照组 45 12.59±4.67 1.98±0.94 t — 0.02 0.05 P — >0.05 >0.05 治疗后 治疗组 45 6.42±2.74* 1.02±0.72* 对照组 45 8.49±2.86* 1.35±0.83* t — 3.51 2.01 P — < 0.01 < 0.05 组内比较*P < 0.05 表 3 2组病人治疗前后APACHEⅡ评分、BISAP评分比较(x±s; 分)
乌司他丁联合参附注射液对重症急性胰腺炎心肌损伤的保护作用
Study on the protective effects of ulinastatin combined with Shenfu injection on the myocardial injury in severe acute pancreatitis
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摘要:
目的研究乌司他丁联合参附注射液在治疗重症急性胰腺炎过程中对心肌损伤的保护作用。 方法选取重症急性胰腺炎伴心肌损伤病人90例,随机将病人分为治疗组和对照组,每组45例。对照组在常规治疗基础上加用乌司他丁,治疗组在常规治疗基础上加用乌司他丁及参附注射液,整个疗程共10 d。观察2组的临床症状恢复时间、急性生理与慢性健康评分(APACHE Ⅱ)和急性胰腺炎严重程度床边指数(BISAP)。抽取病人空腹静脉血,在治疗前、治疗5 d和治疗10 d后分别测定血清N-末端前体脑钠肽(NT-proBNP)、血清肌钙蛋白I(cTnI)、肌酸激酶同工酶(CK-MB)水平,比较2组生化指标差异。 结果治疗组治疗后腹痛、腹胀、排气、排便、肠鸣音恢复时间均短于对照组(P < 0.05)。治疗后10 d 2组NT-proBNP、cTnI、CK-MB水平均低于治疗前(P < 0.01),且治疗组血清NT-proBNP和cTnI水平均低于对照组(P < 0.05)。治疗组治疗5 d后血清cTnI和CK-MB水平均低于对照组(P < 0.05)。2组病人治疗前后相比,BISAP评分和APACHEⅡ评分均下降(P < 0.05);治疗组治疗后BISAP评分和APACHEⅡ评分均低于对照组(P < 0.05和P < 0.01)。 结论乌司他丁联合参附注射液对重症急性胰腺炎病人心肌损伤有一定的保护作用,能改善病人临床症状,调节cTnI、CK-MB、NT-proBNP水平,具有临床推广的应用价值。 Abstract:ObjectiveTo investigate the protective effects of ulinastatin combined with Shenfu injection on the myocardial injury in patients with severe acute pancreatitis. MethodsNinety patients with severe acute pancreatitis complicated with myocardial injury were randomly divided into the treatment group and control group(45 cases in each group).The control group was treated with conventional therapy combined with ulinastatin, the treatment group was additionally treated with ulinastatin and shenfu injection on the basis of conventional treatment, and the whole course of treatment was 10 days.The clinical symptom recovery time, acute physiology and chronic health score(APACHE Ⅱ) and bedside index of severity in acute pancreatitis(BISAP) in two groups were observed.The fasting venous blood was extracted from the patients, and the serum levels of N-terminal pro-B type brain natriuretic peptide(NT-proBNP), troponin I(cTnI) and creatine kinase MB isoenzyme(CK-MB) in two groups were determined before treatment.After 5 d and 10 d of treatment, the differences of biochemical indexes between two groups were compared. ResultsThe recovery time of abdominal pain, abdominal distention, exhaust, defecation and bowel sounds in treatment group were shorter than those in control group after treatment(P < 0.05).On day 10 after treatment, all indexes in two groups were lower than those before treatment(P < 0.01), and the serum levels of NT-proBNP and cTnI in treatment group were lower than those in control group(P < 0.05).The serum levels of cTnI in treatment group was lower than that in control group after 5 and 10 days of treatment(P < 0.05).The serum level of CK-MB in treatment group was lower than that in control group after 5 days of treatment(P < 0.05).Compared with before treatment, the BISAP score and APACHE Ⅱ score in two groups decreased after treatment(P < 0.05). ConclusionsThe ulinastatin combined with Shenfu injection has a good protective effect on myocardial injury in patients with severe acute pancreatitis, can improve the clinical symptoms of patients, regulate the levels of cTnI, CK-MB and NT-proBNP, and has clinical application value. -
表 1 2组病人症状体征恢复时间比较(x±s;d)
分组 n 腹痛 腹胀 排气 排便 肠鸣音 治疗组 45 6.18±0.76 4.37±0.35 3.42±1.19 4.58±1.85 2.76±0.59 对照组 45 8.15±1.23 6.56±0.93 5.12±1.01 5.79±1.34 3.75±0.36 t — 9.14 14.78 7.31 3.55 9.61 P — < 0.05 < 0.05 < 0.05 < 0.05 < 0.05 表 2 2组病人血清中NT-proBNP、cTnI、CK-MB水平比较(ni=45;x±s)
分组 治疗前 治疗5 d 治疗10 d F P MS组内 NT-proBNP/(pg/mL) 治疗组 531.89±313.51 489.96±219.30 215.44±187.35*# 21.98 < 0.01 60 493.678 对照组 556.71±332.06 499.84±214.15 307.47±178.41*# 12.25 < 0.01 62 651.398 t 0.36 0.22 2.39 — — — P >0.05 >0.05 < 0.05 — — — CTnI/(μg/mL) 治疗组 3.28±2.32 1.56±0.75* 0.30±0.19*# 50.51 < 0.01 1.994 对照组 3.68±2.21 2.17±1.22* 0.39±0.20*# 57.10 < 0.01 2.138 t 0.84 2.86 2.19 — — — P >0.05 < 0.01 < 0.05 — — — CK-MB/(U/L) 治疗组 20.17±28.92 12.06±11.17* 7.69±6.72* 5.38 < 0.01 335.431 对照组 21.63 ±26.21 18.73±17.43 8.32±7.12*# 6.35 < 0.01 347.154 t 0.25 2.16 0.43 — — — P >0.05 < 0.05 >0.05 — — — q检验:与治疗前比较*P < 0.05;与治疗5 d比较#P < 0.05 表 3 2组病人治疗前后APACHEⅡ评分、BISAP评分比较(x±s; 分)
分组 n APACHEⅡ评分 BISAP评分 治疗前 治疗组 45 12.57±4.25 1.97±0.96 对照组 45 12.59±4.67 1.98±0.94 t — 0.02 0.05 P — >0.05 >0.05 治疗后 治疗组 45 6.42±2.74* 1.02±0.72* 对照组 45 8.49±2.86* 1.35±0.83* t — 3.51 2.01 P — < 0.01 < 0.05 组内比较*P < 0.05 -
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