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中华重症医学电子杂志

中华重症医学电子杂志 ›› 2019, Vol. 05 ›› Issue (04) : 311 -316. doi: 10.3877/cma.j.issn.2096-1537.2019.04.004

所属专题： 重症营养； 文献；

临床研究

严重多发伤患者血清瓜氨酸水平与肠功能损伤的相关性
庞韦1, 田锐1, 朱冠华1, 王瑞兰1,†()   
  1. 1. 201620　上海，上海交通大学附属第一人民医院ICU
  • 收稿日期:2018-08-14 出版日期:2019-11-28
  • 通信作者: 王瑞兰
  • 基金资助:
    上海市卫生计生系统重要薄弱学科建设计划(2016ZB0205)

Associations between serum citrulline level and intestinal function injury in severe multiple trauma patients

Wei Pang1, Rui Tian1, Guanhua Zhu1, Ruilan Wang1,†()   

  1. 1. Intensive Care Unit, Shanghai First People′s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 201620, China
  • Received:2018-08-14 Published:2019-11-28
  • Corresponding author: Ruilan Wang
  • About author:
    Corresponding author: Wang Ruilan, Email:
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引用本文：

庞韦, 田锐, 朱冠华, 王瑞兰. 严重多发伤患者血清瓜氨酸水平与肠功能损伤的相关性[J]. 中华重症医学电子杂志, 2019, 05(04): 311-316.

Wei Pang, Rui Tian, Guanhua Zhu, Ruilan Wang. Associations between serum citrulline level and intestinal function injury in severe multiple trauma patients[J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2019, 05(04): 311-316.

目的

探究血清瓜氨酸水平在评估多发伤患者急性肠功能损伤中的临床意义。

方法

采用前瞻性研究方法，纳入上海市第一人民医院急诊危重病科自2017年6月至2018年2月收治的40例多发伤患者。根据创伤严重度评分（ISS）分为轻度创伤组（ISS<16分，21例）、重度创伤组（ISS≥16分，19例）。再根据急性胃肠损伤（AGI）分级将患者分为4个亚组，即AGI 0组12例、AGI Ⅰ组9例、AGI Ⅱ组14例、AGI Ⅲ组5例。同时设对照组（健康志愿者，10例），分别于创伤后第1、3、6天采集外周血，应用高效液相色谱法测量血清瓜氨酸水平，应用肠道屏障功能生化指标分析系统测量血二胺氧化酶，D-乳酸，细菌内毒素水平。

结果

重度创伤组、轻度创伤组第1、3、6天血清血清瓜氨酸水平较对照组明显降低（P<0.05），且第1天重度创伤组低于轻度创伤组（P<0.05），第3天轻度创伤组血清瓜氨酸水平较第1天进一步下降，而伤后第6天轻度创伤组、重度创伤组血清瓜氨酸水平仍都低于对照组。不同AGI亚组血清瓜氨酸水平随着分级越高，其水平下降越显著（P<0.05）。第3天AGI 0、AGIⅡ亚组血清瓜氨酸水平较第1天均进一步下降（P<0.05）。血清瓜氨酸水平与ICU住院时间、ISS评分、AGI分级、血浆二胺氧化酶、D-乳酸毒素水平呈负相关。血清瓜氨酸水平与有创呼吸机时间、细菌内毒素水平未见明显相关性。血清瓜氨酸≤19.56 μmol/L可能是预测严重创伤后AGI较好的界值。

结论

严重多发伤患者血清瓜氨酸水平对评估创伤后早期肠功能损伤可能具有一定临床价值。

关键词: 多发伤, 瓜氨酸, 急性胃肠损伤, 肠屏障功能指标
Objective

To study the clinical value of serum citrulline in predicting acute gastrointestinal injury at different time after multiple trauma.

Methods

Forty patients with multiple trauma, admitted to the ICU of Shanghai General Hospital from June 2017 to February 2018, were studied prospectively. These patients were first divided into mild trauma group (ISS<16, n=21) and severe trauma group (ISS≥16, n=19) according to the injury severity score (ISS), and then subdivided into AGI 0 (n=12), AGI Ⅰ (n=9), AGI Ⅱ(n=14) and AGI Ⅲ group (n=5) based on their acute gastrointestinal injury (AGI) grade. 10 healthy people were selected as the control group. On day 1, day 3 and day 6, the levels of citrulline were detected by high-performance liquid chromatography (HPLC), and the levels of diamineoxidase, D-lactate and endotoxin were detected by analysis system of biochemical indexes of intestinal barrier function.

Results

Compared with the control group, serum citrulline levels were decreased significantly in both mild trauma group and severe trauma group on day 1, day 3 day 6 (P<0.05). Serum citrulline levels were lower in severe trauma group than those in mild trauma group on day 1 (P<0.05). In mild trauma group, serum citrulline were decreased further on day 3 compared to serum citrulline on day 1 (P<0.05). Serum citrulline levels were lower in both mild trauma group and severe trauma group than those in control group on day 6. The higher grade of AGI, the lower level of serum citrulline (P<0.05). In all AGI subgroups, serum citrulline levels on day 3 were further decreased compared to day 1(P<0.05). Serum citrulline level was negatively associated with number of ICU days, ISS score, AGI grade, serum diamineoxidase level and D-lactate level. Serum citrulline≤19.56 μmol/L may be the best value of predicting AGI after severe trauma.

Conclusion

Serum citrulline has some clinical value in predicting early intestinal dysfunction in patients with severe multiple trauma.

Key words: Severe multiple trauma, Citrulline, Acute gastrointestinal injure, Indexes of intestinal barrier function
表1 不同创伤严重程度组别临床资料比较（±s）
组别 例数 年龄（岁） ISS评分（分） ICU住院时间（d） 有创呼吸机时间（d） 28 d病死［例（%）］
轻度创伤组 21 42.7±15.4 7.4±2.7 6.1±5.6 0.3±1.0 0（0）
重度创伤组 19 42.8±18.2 23.4±8.3 10.5±6.2 4.8±1.3 2（10.53）
统计值   t=-0.023 t=-8.050 t=-2.353 t=-2.689 -
P值   0.982 0.000 0.024 0.015 0.219
表2 不同创伤严重程度患者血清瓜氨酸水平比较（μmol/L）
组别 第1天 第3天 第6天
例数 ±s 例数 ±s 例数 ±s
对照组 10 29.00±3.80 10 29.00±3.80 10 29.00±3.80
轻度创伤组 21 21.11±4.33a 12 17.42±4.59ac 4 23.10±1.49ad
重度创伤组 19 18.10±3.81ab 19 15.86±3.69a 16 20.66±5.42ad
表3 不同AGI亚组患者血清瓜氨酸水平比较（μmol/L）
组别 第1天 第3天 第6天
例数 ±s 例数 ±s 例数 ±s
AGI 0组 12 24.08±1.66 5 20.18±3.08d 4 24.21±2.92
AGI I组 9 20.93±1.82a 8 19.99±1.40 4 23.48±0.89de
AGI II组 14 18.01±1.88ab 13 15.21±2.30abd 10 19.40±5.69
AGI III组 5 11.52±0.99abc 5 10.39±1.32abc 2 19.11±6.92
表4 血清瓜氨酸水平与ICU住院时间、ISS评分、有创呼吸机时间、AGI分级之间的相关性
指标 第1天 第3天 第6天
ICU住院时间 r=-0.431，P=0.006 r=-0.372，P=0.039 r=0.064，P=0.787
ISS评分 r=-0.487，P=0.001 r=-0.310，P=0.090 r=-0.105，P=0.659
有创呼吸机时间 r=-0.218，P=0.176 r=-0.114，P=0.540 r=-0.267，P=0.255
AGI分级 rs=-0.894，P=0.000 rs=-0.852，P=0.000 rs=-0.481，P=0.032
表5 不同创伤严重程度患者血清二胺氧化酶水平比较（U/ml）
组别 第1天 第3天 第6天
例数 ±s 例数 ±s 例数 ±s
对照组 10 2.60±3.24 10 2.60±3.24 10 2.60±3.24
轻度创伤组 21 12.33±10.42a 12 19.23±17.80a 4 4.89±6.10
重度创伤组 19 22.84±10.72ab 19 16.37±12.23a 16 13.61±12.54ac
表6 不同创伤严重程度患者血清D-乳酸水平比较（μg/ml）
组别 第1天 第3天 第6天
例数 ±s 例数 ±s 例数 ±s
对照组 10 8.50±2.64 10 8.50±2.64 10 8.50±2.64
轻度创伤组 21 30.14±13.59a 12 32.57±6.55a 4 44.66±1.61ad
重度创伤组 19 42.47±10.76ab 19 37.70±7.71a 16 32.24±15.66ac
表7 不同创伤严重程度患者血清细菌内毒素水平比较（EU/L）
组别 第1天 第3天 第6天
例数 ±s 例数 ±s 例数 ±s
对照组 10 4.40±5.66 10 4.40±5.66 10 4.40±5.66
轻度创伤组 21 4.24±4.05 12 4.66±4.52 4 5.59±6.92
重度创伤组 19 7.79±3.68a 19 4.14±3.26b 16 8.12±7.11
表8 血清瓜氨酸水平与血清二胺氧化酶水平、D-乳酸水平、细菌内毒素水平相关分析
指标 第1天 第3天 第6天
血清二胺氧化酶 r=-0.488，P=0.001 r=-0.410，P=0.009 r=-0.254，P=0.114
血清D-乳酸 r=-0.463，P=0.020 r=-0.269，P=0.194 r=-0.409，P=0.042
血清细菌内毒素 r=-0.012，P=0.966 r=-0.069，P=0.806 r=-0.407，P=0.132
图1 血清瓜氨酸水平对急性胃肠损伤预测的受试者工作特征曲线
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