Dr. Wang
Editor|媸You
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Sepsis is a common complication in some critically ill patients in the clinic, which is more common in infection, severe trauma, major burns, and major surgical operations, which can induce septic shock and multiple organ dysfunction syndrome.
The disease can occur at any age and in any context of underlying conditions, and often progresses rapidly and has a very high case fatality rate.
At present, the incidence and mortality rate of sepsis are still at a high level, according to statistics, there are about 20 million sepsis patients worldwide every year, of which up to half of patients with septic shock.
About 26% of those died from sepsis, while another report covering nearly 2 million deaths was reported.
Sepsis-related deaths accounted for 12.6%, and it is inferred that about 1 million sepsis deaths in China that year.
The pathogenesis of this disease is complex, and its pathophysiological process involves inflammation, immune and coagulation dysfunction, mainly caused by immune dysfunction.
In view of this disease, modern medicine mainly adopts fluid resuscitation, vasoactive drugs, glucocorticoids, anticoagulation, renal replacement therapy, mechanical ventilation and other comprehensive treatment methods based on the treatment of the primary disease and standardized anti-infective treatment.
However, it also faces many problems such as the emergence of drug-resistant bacteria, the occurrence of multiple infections, gastrointestinal dysfunction and coagulation dysfunction.
With the deepening of the research on the treatment of sepsis by traditional Chinese medicine, it has been found that traditional Chinese medicine can help improve the clinical efficacy in the treatment of sepsis, reduce the adverse reactions caused by the use of antibiotics and glucocorticoids in large doses or for a long time, reduce complications such as gastrointestinal dysfunction and thrombosis, and reduce the mortality rate.
In this study, the use of lung cleansing and detoxification decoction was used to treat sepsis, and good results were achieved, which are reported as follows.
1. Information and methods
General information: A total of 70 patients with sepsis caused by lung infection admitted to Zhengzhou Sixth People's Hospital from June 2020 to June 2021 were randomly divided into 35 cases in the control group and observation group, with 19 males and 16 females in the control group.
Age 18~70 years old, average age (48.13±5.26) years; Average APACHE II score (22.18±2.34) points.
Observation group: 18 males, 17 females; Age 18~69 years old, average age (47.86±5.12) years; Average APACHE II score (22.24±2.29) points.
There was no significant difference in the general data between the two groups. This study was approved by the ethics committee of the hospital, and the patient truthfully understood the protocol and signed the consent form.
Inclusion Criteria: Refer to the Chinese Guidelines for the Treatment of Severe Sepsis/Septic Shock (2014) for the diagnostic criteria for sepsis.
Traditional Chinese medicine distinguishes that it is hot poison and blazing, and the symptoms are high fever, sweating, thirst and drinking, wheezing and breathing, or irritability, or dizziness, short urine, constipation, red tongue, moss yellowness, pulse number.
Age≥ 18 years but not more than 70 years old; Good compliance; Those who have not participated in other drug clinical trials in the past 3 months or will not participate in other drug clinical trials in the next 1 month.
Exclusion criteria: those with serious underlying diseases such as heart, liver, and kidney that cannot be controlled; Patients with malignant tumors; Those with severe blood diseases; immunocompromised or immunosuppressants; Those who cannot tolerate Chinese medicine decoctions or are allergic to Chinese medicine ingredients; Those in an irreversible state of death; Those with cognitive impairment or mental illness.
Methods: Both groups of patients were given conventional treatment regimens, and the control group underwent empiric anti-infection as soon as possible after the diagnosis was clear, and the anti-infection treatment regimen was adjusted according to the efficacy, etiological basis and drug susceptibility test results.
At the same time, strengthen fluid resuscitation and nutritional support therapy, actively control blood sugar, prevent stress ulcers, inhibit the formation of capillary microthrombolism, correct electrolyte imbalance, acid-base imbalance.
The observation group was given oral detoxification decoction on the basis of the treatment of the control group.
Composition of Lung Cleansing and Detoxification Soup Drugs: Coptis 12g, Scutellaria baicalensis 10g, Huangbai 10g, Gardenia 12g, Mulberry white peel 15g, Zhejiang Fritillary 10g, melon peel 12g, bellflower 10g, rhubarb 8g.
The stool is not thick and simple, and it is fruitful; Thirsty and add plaster and smallpox powder; dizziness and irritability plus buffalo horn, ginseng, forsythia; shortness of breath plus almonds; phlegm dampness inhibition plus gallbladder Nanxing, Zhuru; Stasis internal resistance to Katanshen, Chuanxiong.
Chinese medicines are prepared by the Chinese Pharmacy of Zhengzhou Sixth People's Hospital, and are taken internally twice in the morning and evening. The course of treatment in both groups was 7 days.
Observation index: Two or more attending physicians participated in the comparison of the changes of TCM syndrome scores before treatment, 3rd day, 5th day and 7th day after treatment.
Using the three indexes of APACHEII. system score, infection-related organ failure estimation score and serum procalcitonin, the total score of APACHE was 0~71 points, the higher the score, the more serious the disease and the higher the fatality rate; The total score of the SOFA score is 0~24 points, and the higher the score, the more serious the disease. PCT is detected by immunofluorescence assay.
Evaluations were conducted on Day 1, Day 3, and Day 7.
The fasting venous blood of two groups of patients was collected before and after treatment to detect TNF-α, IL-6 and IL-1β.
At the same time, anticoagulant venous blood was retained to detect peripheral blood CD14+ monocyte human leukocytes, DR antigen and T lymphocyte subset levels.
Results: After the comparison of medical syndrome scores in the group after treatment, the medical syndrome scores of the two groups were significantly lower than before, and the observation group was lower than that of the control group.
II. Discussion
The theory of uncontrolled inflammatory response is considered to be an important basis for the pathogenesis of sepsis, and basic research has confirmed that the imbalance of pro-inflammatory and anti-inflammatory responses will initiate an inflammatory cascade, thereby mediating the occurrence of sepsis.
Pro-inflammatory factors play an important role in the development and development of inflammation, and TNF-α, IL-1, IL-6, IFN-γ, etc. are all important pro-inflammatory factors.
Among them, TNF-α is the most important pro-inflammatory factor in the early stage of inflammation, and it is also the strongest initiator of the body's inflammatory response, which usually rises to a peak quickly in the early stage of the lesion and plays an important role in the immune defense response, while TNF-α also mediates the endotoxin damage effect, thereby affecting the severity of sepsis.
IL-1 is mainly expressed through IL-1β and initiates the inflammatory response with TNF-α, IL-1β is the core inflammatory factor, which can compete with anti-inflammatory factors such as IL-10 and is closely related to multi-organ damage in sepsis.
IL-1 action produces IL-6, an inflammatory mediator that works with TNF-α to promote T lymphocyte proliferation, often predicting sepsis severity by measuring plasma IL-6 levels.
Sepsis is viewed from an immunological perspective, in which the immune response of the body is dysregulated and caused by multi-organ dysfunction after severe infection or traumatic disease.
In the early stage of sepsis, the immune response is mainly reflected in the excessive production and release of pro-inflammatory mediators, resulting in fever, rapid heart rate and shortness of breath.
This process inevitably increases the body's immune damage while removing pathogens, which can further exacerbate the inflammatory response, and in the advanced stage of sepsis, immune response suppression occurs, manifested as a decrease in the number and function of immune cells, macrophage inactivation, antigen presentation ability and lymphocyte proliferative activity decrease.
The release of inhibitory cytokines and apoptosis of lymphocytes can also cause sepsis immunosuppression, and after immunosuppression, the risk of secondary infection in the body is also significantly increased, and the mortality rate is also increased.
CD4+ T lymphocytes can assist in the production of antibodies and participate in humoral immunity, while CD4+ can also assist CD8+ and macrophage function, and also participate in the immune memory process, regulating the immune response through multiple pathways.
Decreased number or function of CD4+ cells increases susceptibility and reactivates dormant viruses, which can also lead to opportunistic bacterial infections.
CD8+ cells are cytotoxic, can inhibit antibody synthesis and T cell proliferation, regulate humoral immunity and cellular immunity, and maintain homeostasis in the internal environment.
In addition to the use of CD4+ and CD8+ cell counts to evaluate cellular immune function, HLA-DR levels have gradually attracted attention in evaluating immune function.
HLA-DR expression plays a key role in antigen presentation and helper T cell processes, and decreased HLA-DR expression often indicates immunosuppression, and studies have found that patients with severe sepsis with low HLADR levels tend to have higher mortality rates.
Given the influence of inflammatory response and immune dysregulation in the pathogenesis, anti-infective therapy, glucocorticoids, and immunotherapy play an important role in the treatment of sepsis.
Long-term use of antibiotics faces problems such as the emergence of drug-resistant bacteria and the occurrence of multiple infections.
Glucocorticoids are highly anti-inflammatory but also accelerate apoptosis specific immune cells, so the routine use of glucocorticoids in the treatment of sepsis remains controversial.
Ulinastatin can antagonize downstream toxic inflammatory mediators, can play a protective effect on multiple organs, and show good clinical efficacy.
Thymus peptide α1 can antagonize apoptosis during lymphocyte maturation and enhance cellular immunity, thereby improving immune function, but the price of ulinastatin and thymosin α1 is high and often difficult for patients to afford.
In terms of anti-inflammatory and immunomodulation, Chinese medicine can play its unique advantages.
In the early stage of sepsis, due to the lack of healthy qi in the body, and the complex feeling of foreign poisonous evil, the evil qi damages the body, injures the veins, and leads to systemic reactions.
With the further deepening of poison and evil, stasis and poison can be knotted together, blocking the veins, releasing a large number of internal poisonous evil, internal and external poison and evil cementation, and combining into diseases.
Therefore, the treatment of sepsis, when clearing heat and detoxification, pay attention to cultivating vitality and taking into account specimens.
In this study, a clear lung detoxification decoction was used for the treatment of sepsis.
Lung cleansing and detoxification decoction is cut from Huanglian detoxification soup, composed of huanglian, shuangqin, huangbai, gardenia, rhubarb, huanglian diarrhea spleen fire in the middle of the coke, and can clear the heart fire, is a jun medicine; Scutellaria scutellaria lung fire in Shangjiao as a medicine; Huangbai diarrhea kidney fire in the lower scorch; The gardenia poured out the fire of three scorches and came out of the bladder.
Yang Sheng is yin and decay, and fire is water decay, so use the rhubarb of great bitterness and cold to suppress the yang and support the yin, and pour its exuberant fire, all as adjuvants.
Modern pharmacological studies have found that Coptis detoxification decoction can reduce the level of serum inflammatory factors through multiple pathways and targets, and the components such as berberine, flavolide and parmatine in the formula can be closely combined with Caspase-3 and other factors, and then the levels of inflammatory factors such as IL-1β, IL-6 and TNF-α can be down-regulated.
Wang Junli et al. found that the serum containing the drug in Coptis detoxification decoction can effectively inhibit the TLR4 signaling pathway, and then inhibit the phosphorylation of nuclear transcription factor-κB inhibitor α and NF-κBp65 protein and NF-κBp65 nuclear translocation, thereby reducing IL-1β and IL-6 secretion.
The results of this study showed that the medical syndrome score, APACHEII. score, SOFA score and serum PCT levels in the post-treatment observation group were significantly lower than those in the control group, suggesting that the treatment of sepsis by lung cleansing and detoxification decoction can effectively reduce the clinical symptoms of patients, control infection, reduce the state of failure, and improve clinical efficacy.
After treatment, serum TNF-α, IL-6 and IL-1β in the observation group were significantly lower than those in the control group, and CD4+ and HLA-DR were significantly higher than those in the control group, while the CD8+ level was not statistically significant compared with the control group, suggesting that this regimen can effectively reduce the level of inflammatory factors, inhibit the inflammatory response, and regulate the body's immune function.
In summary, lung cleansing and detoxification decoction can effectively reduce the level of inflammatory factors in patients with sepsis, regulate immune response, and then improve clinical efficacy, which is worthy of clinical promotion.