【作者】 张聪；

【导师】 唐朝晖；

【作者基本信息】 华中科技大学 ， 外科学（创伤外科）， 2020， 硕士

【摘要】 第一部分多发伤后伴发急性胃肠功能损伤的影响因素研究目的探讨多发伤患者伤后伴发急性胃肠功能损伤(AGI)的发生状况及可能的相关影响因素。方法对2018年4月至2019年10月间收治430例创伤患者的临床资料进行回顾性分析,依据急性胃肠损伤(AGI)分级标准,统一设计调查表收集AGI状况,观察了AGI发生状况和分析了相关临床资料。采用广义估计方程对AGI的高危因素进行筛选和检验。结果65.3%的多发伤患者伴发AGI(AGI组,281例)。伴发AGI的多发伤患者为AGI组(281例,其中AGI-I级148例,AGI-Ⅱ级76例,AGI-Ⅲ级48例,AGI-IV级9例),不伴发AGI患者为N-AGI组(149例)。与N-AGI组患者相比,AGI组患者ISS评分、APACHE Ⅱ评分、SOFA评分、PCT、IL-6、APTT、D-D二聚体、休克指数、乳酸水平及机械通气比例更高;GCS评分更低,重症监护室留置时间更长(P<0.05)。不同ISS评分、休克指数、乳酸水平的多发伤患者伤后AGI发生率和伴发AGI级别有差异。不同分级AGI患者初始症状差异有统计学意义(P<0.05)。Logistic回归分析提示,ISS评分、休克、IL-6、乳酸水平、APACHE Ⅱ、SOFA、GCS评分及APTT是多发伤患者伤后发生AGI的高危因素。结论多发伤患者伤后AGI发生率较高,其发生与伤后早期存在缺血、缺氧及凝血功能异常及机体应激有关。第二部分严重多发伤后急性胃肠功能损伤与免疫紊乱关系的临床研究目的:探讨严重多发伤患者伤后急性胃肠功能损伤(AGI)与机体免疫紊乱间的关系。方法:选取2018年4月至2019年8月同济医院创伤外科收治的严重多发伤患者205例,以23例健康志愿者为对照。根据有无发生AGI将其分为AGI组及Non-AGI组。通过ELISA法及流式细胞术观察了健康受试者及所有患者伤后1、7、14d外周血IL-6、IL-8、TNF-α、IL-10细胞因子以及淋巴细胞亚群的变化,并进行比较。结果:伴AGI的严重多发伤患者为AGI组(共163例,其中AGI-I级68例,AGI-Ⅱ级47例,AGI-Ⅲ级41例,AGI-IV级7例),不伴发AGI的患者为N-AGI组(42例)。AGI组患者伤后1d的外周血Tc及Th比率,伤后7d的IL-6、TNF-α、IL-8及IL-10水平,Ts、Th/Ts,伤后14d的IL-8与IL-10水平,Ts、Th/Ts比率,与N-AGI组相比差异显著(P<0.05)。伴发重度AGI患者(AGI-Ⅲ及IV)伤后1d的Tc与Th比率,IL-6与TNF-α水平,伤后7,14d的Ts、Th/Ts比率,IL-8与IL-10水平与伴发轻度AGI(AGI-I及Ⅱ)患者相比差异显著(P<0.05)。结论:严重多发伤后机体免疫紊乱状态越重,越易伴发AGI。AGI也可加重患者伤后已存在的免疫紊乱。更多还原

【Abstract】 part Ⅰ-A Retrospective Study of Influencing Factors of Acute Gastrointestinal Injury in Patients with PolytraumaObjective To explore the occurrence and influencing factors of acute gastrointestinal injury(AGI)in patients with multiple injuries.Methods 430 patients with multiple injuries admitted to our hospital from Apr.2018 to October.2019 were enrolled as the observation group.According to theclassification criteriaof acute gastrointestinal injury(AGI),the occurrence of AGI was observed and the clinical data were analyzed.Result 65.3% of patients with multiple injuries were accompanied by AGI(281 cases in AGI group).The multiple injury patients with AGI were in AGI group(281 cases,including 148 cases of AGI-I,76 cases of AGI-Ⅱ,48 cases of AGI-Ⅲ and 9 cases of AGI-IV),and the patients without AGI were in n-agi group(149 cases).Compared with patients in N-AGI group,patients in AGI group had higher ISS,APACHE Ⅱ,sofa,PCT,IL-6,APTT,D-D dimer,shock index,lactate level and mechanical ventilation ratio,lower GCS and longer ICU retention time(P < 0.05).There were differences in the incidence of AGI and the level of AGI in multiple trauma patients with different ISS score,shock index and lactate level.The initial symptoms of patients with different grades of AGI were significantly different(P < 0.05).Logistic regression analysis showed that ISS,shock,IL-6,lactate level,APTT,APACHE Ⅱ,SOFA and GCS were the high risk factors of AGI after multiple trauma.Conclusion The incidence of acute gastrointestinal injury after multiple trauma is higher,which is related to the early existence of ischemia,hypoxia,coagulation dysfunction and organism stress.part Ⅱ-A Clinical Study of the relationship between immune disorder and acute gastrointestinal injury in patients with severe multiple trauma.Objective To discuss the relationship between immune disorder and acute gastrointestinal injury(AGI)in patients with severe multiple trauma.Methods 205 patients with severe multiple injuries admitted to our hospital from Apr.2018 to Aug.2019 were enrolled as the observation group.According to the occurrence of AGI,they were divided into AGI group and N-AGI group.The levels of inflammatory cytokines and lymphocyte subpopulation were detected 1,7,14 days after trauma.Twenty-three healthy persons were used as controls for comparison at the same time.Result Severe multiple injuries with AGI were in AGI group(163 cases,including 68 cases of AGI-I,47 cases of AGI-Ⅱ,41 cases of AGI-Ⅲ,7 cases of AGI-IV),and those without AGI were in N-AGI group(42 cases).The ratio of Tc 、Th at 1 day after trauma,the levels of IL-6、TNF-α、IL-8、IL-10 and the ratio of Ts、Th/Ts at 7day after trauma and the levels of IL-8、IL-10,the ratio of Ts、Th/Ts at 14 day after trauma in AGI group showed a significant difference compared with N-AGI group.(P<0.05).The ratio of Tc、Th,the levels of IL-6、TNF-α at 1 day after trauma and the ratio of Ts、Th/Ts,the levels of IL-8、IL-10 at 7,14 days after trauma in severe AGI(AGI-Ⅲ and IV)group showed a significant difference compared with light AGI(AGI-I and Ⅱ)(P < 0.05).Conclusion AGI is more easily associated with the heavier immune disorders after severe multiple injuries.AGI can also aggravate pre-existing immune disorders after injury.更多还原