Ramsay G, Newman P M, McCartney A C, Ledingham I M
University Department of Surgery, Western Infirmary, Glasgow, Scotland.
Prog Clin Biol Res. 1988;272:237-46.
Patients with multiple organ failure secondary to intraabdominal sepsis are often blood culture negative despite exhibiting the features of septic shock. This study examined the possible central role of endotoxin in such patients. In 15 consecutive intensive care patients with the above clinical picture endotoxin was measured by a chromogenic limulus (LAL) assay; on admission and thereafter 4 hourly. Regular blood cultures and cultures of any primary septic focus were also performed and liver function was assessed by measurement of indocyanine-green clearance from plasma (ICGC). All 15 patients had significant endotoxaemia at least intermittently. No significant difference was observed between survivors (n = 5) and non-survivors (n = 10) in either initial or peak endotoxin levels, although the pattern of endotoxaemia differed with non-survivors exhibiting consistently high or steadily increasing levels. Of 5 patients with an intra-abdominal (I/A) septic focus only one had a positive blood culture while 5 of 10 patients with extra-abdominal (E/A) infection had positive cultures. Despite this the I/A group had higher initial and peak endotoxin levels. 3 patients with Gram-positive septicaemia had significant endotoxaemia in the absence of any gram-negative infection. Changes in ICGC appeared to be of useful prognostic significance. ICGC was significantly lower in the I/A group and in both groups there was a significant negative correlation between ICGC and the level of endotoxaemia. These results suggest that endotoxin may play a central role in the syndrome of multiple organ failure and further suggest that the endotoxin is endogenous (gut-derived) secondary to failure of hepatic filtration.
尽管表现出脓毒性休克的特征，但因腹腔内脓毒症继发多器官功能衰竭的患者血培养常为阴性。本研究探讨了内毒素在此类患者中可能发挥的核心作用。对15例具有上述临床表现的连续重症监护患者，采用显色鲎试剂（LAL）法测定内毒素；入院时及此后每4小时测定一次。同时进行常规血培养及任何原发性脓毒症病灶的培养，并通过测量血浆中吲哚菁绿清除率（ICGC）评估肝功能。所有15例患者至少间歇性地出现明显的内毒素血症。幸存者（n = 5）和非幸存者（n = 10）在初始或峰值内毒素水平上均未观察到显著差异，尽管非幸存者的内毒素血症模式不同，表现为持续高水平或稳步上升。在5例有腹腔内（I/A）脓毒症病灶的患者中，只有1例血培养阳性，而在10例有腹腔外（E/A）感染的患者中有5例血培养阳性。尽管如此，I/A组的初始和峰值内毒素水平更高。3例革兰氏阳性菌败血症患者在无任何革兰氏阴性菌感染的情况下出现明显的内毒素血症。ICGC的变化似乎具有有用的预后意义。I/A组的ICGC显著较低，且两组中ICGC与内毒素血症水平之间均存在显著负相关。这些结果表明，内毒素可能在多器官功能衰竭综合征中起核心作用，进一步表明内毒素是肝脏滤过功能衰竭继发的内源性（源自肠道）物质。
