Faries P L, Simon R J, Martella A T, Lee M J, Machiedo G W
Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Jacobi Medical Center, Bronx, New York 10461, USA.
J Trauma. 1998 Jun;44(6):1031-5; discussion 1035-6. doi: 10.1097/00005373-199806000-00016.
Increased intestinal permeability (IP) and the release of toxic intraluminal materials have been implicated in the systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF) observed in patients after severe trauma. Previous studies of intestinal permeability have failed to demonstrate a correlation between early measurements of IP and indicators of injury severity. This study examines the relationship between standard measures of injury severity and the early (day 1) and delayed (day 4) changes in IP. Associations between IP and the development of SIRS, MOF, and infectious complications were also studied.
The metabolically inactive markers lactulose (L) and mannitol (M) were used to measure IP in 29 consecutive patients who sustained injuries that required admission to the surgical intensive care unit and in 10 healthy control subjects. Measurements were made within 24 hours of admission and on hospital day 4. Severity of injury was assessed by A Severity Characterization of Trauma (ASCOT), Trauma and Injury Severity Score (TRISS), Injury Severity Score (ISS), Revised Trauma Score (RTS), and Acute Physiology and Chronic Health Evaluation (APACHE) II score. Postinjury infections and parameters of SIRS and MOF were recorded.
The IP of healthy volunteers (L/M, 0.025 +/- 0.008) was within the normal range (L/M < or = 0.03), whereas the average IP in injured patients was increased both within 24 hours (L/M, 0.139 +/- 0.172) and on the fourth hospital day (L/M, 0.346 +/- 0.699). No significant correlation between severity of injury and increased IP was seen within 24 hours of injury. A significant correlation was seen on hospital day 4, however, with all severity indices measured (ASCOT: r = 0.93, R2 = 0.87, p < 0.001; TRISS: r = 0.93, R2 = 0.87, p < 0.001; ISS: r = 0.84, R2 = 0.70, p < 0.001; RTS: r = 0.68, R2 = 0.47, p = 0.002; APACHE II score: r = 0.51, R2 = 0.26, p = 0.04). Patients with markedly increased IP (L/M > or = 0.100) experienced a significant increase in the development of SIRS (83 vs. 44%; p = 0.03) and subsequent infectious complications (58 vs. 13%; p = 0.01) and showed close correlation with the multiple organ dysfunction scores (r = 0.87, R2 = 0.76, p < 0.001).
These observations demonstrate that the increased IP observed after trauma correlates with severity of injury only after 72 to 96 hours and not within the initial 24 hours of injury. A large increase in IP is associated with the development of SIRS, multiple organ dysfunction, and an increased incidence of infectious complications.
肠道通透性增加（IP）以及肠腔内毒性物质的释放与严重创伤患者出现的全身炎症反应综合征（SIRS）和多器官功能衰竭（MOF）有关。以往关于肠道通透性的研究未能证明IP早期测量值与损伤严重程度指标之间存在相关性。本研究探讨损伤严重程度的标准测量值与IP早期（第1天）和延迟期（第4天）变化之间的关系。还研究了IP与SIRS、MOF及感染性并发症发生之间的关联。
采用代谢惰性标记物乳果糖（L）和甘露醇（M）对29例因伤需入住外科重症监护病房的连续患者及10名健康对照者进行IP测量。在入院后24小时内及住院第4天进行测量。通过创伤严重程度特征化（ASCOT）、创伤和损伤严重程度评分（TRISS）、损伤严重程度评分（ISS）、修订创伤评分（RTS）及急性生理与慢性健康评估（APACHE）Ⅱ评分评估损伤严重程度。记录伤后感染情况及SIRS和MOF的参数。
健康志愿者的IP（L/M，0.025±0.008）在正常范围内（L/M≤0.03），而受伤患者在24小时内（L/M，0.139±0.172）及住院第4天（L/M，0.346±0.699）的平均IP均升高。受伤后24小时内，损伤严重程度与IP升高之间未见显著相关性。然而，在住院第4天，与所有测量的严重程度指标均存在显著相关性（ASCOT：r = 0.93，R2 = 0.87，p < 0.001；TRISS：r = 0.93，R2 = 0.87，p < 0.001；ISS：r = 0.84，R2 = 0.70，p < 0.001；RTS：r = 0.68, R2 = 0.47, p = 0.002；APACHEⅡ评分：r = 0.51，R2 = 0.26，p = 0.04）。IP显著升高（L/M≥0.100）的患者SIRS发生率显著增加（83%对44%；p = 0.03），随后感染性并发症发生率也显著增加（58%对13%；p = 0.01），且与多器官功能障碍评分密切相关（r = 0.87，R2 = 0.76，p < 0.001）。
这些观察结果表明，创伤后观察到的IP升高仅在72至96小时后与损伤严重程度相关，而在损伤后的最初24小时内并非如此。IP大幅升高与SIRS、多器官功能障碍及感染性并发症发生率增加有关。
