The Clinical Study Of Treating Patients Undergoing Systemic Inflammatory Response Syndrome After Major Or Medium Abdominal Surgery Operation On Terms Of Fortify The Spleen And Replenish Qi Methods

BackgroundThrough the past 50 years,people had gradually realized that surgical intervention is a type of damage caused by stress.The removal and destruction of tissues lead to blood loss,hypoperfusion of tissue,damage of bulk cells and functional disorder of organs,which destroy the normal physiologic function and metabolism in an unexpectedly quick and violent way.Such destruction is especially obvious in abdominal surgery.Surgery,as the same as grave trauma,empyrosis and sepsis,can also result in fever,fast heart rate,shortness of breath,higher white blood count and other resembling systemic inflammatory response syndrome(SIRS).SIRS is the basic cause of multiple organ dysfunction syndrome(MODS),and also the main death cause of severe case.Therefore,it is quite important to give active treatment on SIRS and prevent it from developing into MODS.Through the study of combination of TCM with Western Medicine,many experts approach the differentiation and treatment system on the occurrence and development of SIRS in use of TCM theory.And they make certain progress.But most experts regard SIRS as excess syndrome and heat syndrome.Meanwhile,they treat SIRS with methods like purging fu-organs,expelling the heat-evil, activating the blood and dissolving stasis.Academician Wu xianzhong has said that SIRS and MODS are two hot spots of study and surgery treatment at the moment.At its earlier stage,it can be effectively treated by internal cleaning,offensive purgative method and heat-cleaning and detoxicating method,however,blood deficiency,reperfusion injury and immune suppression are the shared pathological lesions in the middle and later stages of SIRS. During the two stages,those drugs with effect of invigorating and benefiting qi,reinforcing healthy qi and strengthening nature,activating blood and moving qi may improve tissue blood supply,reduce reperfusion lesion and reinforce body immunity,or may not,which is a study and research topic of great potential.In clinical practice,to aim directly at syndromes such as fever,rapid heart rate,breathlessness and higher white cell count at earlier period,the expert of surgery subject in our hospital raises the essential mechanism of heat,toxin and stasis.However,at later period,the syndromes develop into lusterless complexion,lassitude of spirit,no desire to speak, fatigue,shortness of qi,swelling limbs,fatigue of limbs,low voice,weak breathing,loss of appetite,night sweating,pale tongue,white tongue fur, vacuous and weak pulse,so the expert holds that surgery trauma,struggle between healthy qi and pathogenic qi,pathogenic qi conquering healthy qi and wasting qi-blood lead to insufficiency of qi-blood and yin-yang.Actually its essential causes are surgery attack,damage of the spleen and stomach,spleen failing in transportation and lack of source for the production and transformation of qi and blood.And its main pathology is deficiency of spleen qi.It is clear that SIRS is a dynamic group of syndrome from the point of TCM theory.At its earlier period,healthy qi struggle with pathogenic qi. At tbe time,pathogenic qi is excess while healthy qi is not deficient,so the syndromes manifest excess syndrome and heat syndrome.However,healthy qi is declining and finally be defeated by pathogenic qi,therefore the body carries deficient syndrome,which develops rapidly.Therefore,the surgical department in the Guangdong Provincial Hospital of Traditional Chinese Medicine has made specific study of this topic and discovered that patients with SIRS at the later period mainly shows deficient syndrome(68%proportion) and the main pathological mechanism is deficiency of spleen qi under the clinic TCM syndrome research of 106 cases of patients with operation on abdominal region.And the clinic syndrome of SIRS at later period is divided into liver depression and spleen deficiency,and also deficiency of spleen qi.A small number of patients show qi stagnation and damp-heat in middle jiao,both of which are closely related to the physiologic function of spleen.In the recent years,a great number of documents have reported that Huangqi Si junzi Tang(HQSJZT) has multiple regulation functions. Also,they show that HQSJZT can improve immune function system,retrieve functional disorder of transportation and transmission caused by deficiency of spleen.Moreover,Huangqi has functions such as replenish qi and consolidate the superficial resistance,water-draining and swelling-dispersing, detoxification and promoting granulation.Huangqi is immunomodulator with wide applications,but it is a tonic type of Chinese herbal medicine according to its property and meridian.Modern medicine proves that astragalus polysaccharides can accelerate the change of T lymphocyte in burned mice and promote macrophage to produce interleukin -1 as to strengthen the immune function of the body.Besides,to the infective shock mice,astragalus polysaccharides can suppress the production of proinflammatory cytokine TNF and IL-6 to against excessive systemic inflammatory response and increase survival rate.In short,SIRS patients with abdominal surgery share the essential pathogenesis of deficiency of spleen qi,and experimental studies have proved that traditional Chinese medicine which can fortify the spleen and replenish qi plays positive role in improving immune functional system,preventing the excessive release of inflammatory mediators and declining inflammatory response.Therefore,it is necessary to further study the influence of traditional Chinese medicine which can fortify the spleen and replenish qi on SIRS patients after abdominal operation.ObjectiveOn the basis of researching the syndrome rules and the advancement of treatment by TCM among patients who had undergone abdominal surgeries and then got SIRS,Hierarchical Cluster Method combining with experts' differentiation of symptoms and signs is adopted and the TCM pathological essence of the SIRS patients is concluded.Radio-immunity method is employed to test the levels of adrenaline and noradrenaline which are microcosmic syndrome differentiation indexes that reflect splenasthenic syndrome so as to prove that the main pathological factor of the SIRS patients after surgeries is splenasthenic syndrome;and on the basis of this conclusion,Chinese crude drug(astragalus mongholicus injectio) that can invigorate the spleen and benefit qi is adopted to treat these patients.Then a control study on the curative effects between astragalus mongholicus injectio and a traditional western medicine(Ulinastain for Injection) is conducted to inquire into the influences of Chinese crude drug that can invigorate the spleen and benefit qi on clinical indexes(body temperature,heart rate and leukocyte count), IL-6,IL-8,IL-10,and TNF- a of SIRS patients who have undergone major or medium abdominal surgeries.MethodsProspective random test design is used in this research.The 106 cases are those patients in Surgical Department of Guangdong Hospital of TCM who were respectively in hospital between October 2006 and January 2009,including 58 males and 48 females who aged 14～75 with a mean age of 50.3±8.46.All these patients have received selective operation treatment of abdominal surgery by the experienced specialists whose professional titles are above physician-in-charge.Among these 106 patients,40 of them received operation on liver,gall and pancreas,25 of them on stomach and small intestine,31 of them on coion and 10 of them on retroperitoneal tumor.The selected cases correspond with over two diagnostic criteria of SIRS while the following cases are ruled out:(1) those whose manifestation of signs was SIRS before operations;(2) those who received concentrated red blood cells≧400ml during operations;(3) those who got wound injection or alimentary fistula or other concurrent diseases after operations;(4) those whose cardio respiratory function was proved to be abnormal before operations;(5) those who got anemia (Hb(100g/L) before operations.Three days after operations,four methods of examination for TCM-inspection,listening,smelling and questioning are conducted on these patients to collect their clinical data that are typed into the database and to fill in the syndrome survey form.All the 58 clinical syndromes of TCM are regarded as variables and on the basis of the frequency of occurrences of the patients' syndromes,cluster method is employed and the pathological features of this group of patients are concluded.In the third morning after operation,blood is drawn from these patients on an empty stomach. And radio-immunity method is applied to examine adrenaline(E) and noradrenaline(NE) in the blood.Then the result is compared with that of the patients who had also received operations on abdominal region but did not get SIRS.In addition,the serological levels of adrenaline and noradrenaline of patients with different types of syndrome after operations on abdominal region are compared to see whether there is any significant difference.Finally,these 106 patients are classified into group with spleen deficiency and group without spleen deficiency according to their types of syndrome.The first group is treated with a Chinese crude drug that can invigorate the spleen and benefit qi-astragalus mongholicus injection 10ml/time and twice a day in 5 successive days,while the other group with Ulinastain for Injection 200,000U/time and twice a day in 5 successive days.Both groups are also provided with treatments of conventional anti-infection and fluid replacement,A control group is established for routinely monitoring the heart rates,breathing frequencies, body temperatures,urinary productions,WBC,the time of SIRS' s improving and the case fatality rate of patients in each group.Before and after the treatment,venous blood is collected to test the levels of tumor necrosis factorα((TNF-α) of the serum,IL-6,IL-8,and IL-10.If the group mean and pairing mean meet normal distribution,T-test is used when comparing,and when P≤0.05,it indicates that there is a significant difference.Effects1.After analyzing the types of syndrome on TCM of these 106 patients who got SIRS after receiving major or medium operations on abdominal region,we discovered that their main types of syndrome is deficiency syndrome(which takes 68%) and the main pathomechanism of which is deficiency of spleen-Qi, which is closely related with the spleen' s physiological function.2.For those whose type of syndrome is spleen deficiency,their serological levels of adrenaline and noradrenaline are significantly lower when compared with those of the control group and the other groups with different syndromes. According to the statistical analysis,there is a significant difference.3.There is no significant difference between the influence of astragalus mongholicus injection(a Chinese crude drug that can invigorate the spleen and benefit qi) on the body temperatures,heart rates,leukocyte counts of these patients as well as the early occurrence of negative fluid balance in them and that of the traditional drug(Ulinastain for Injection) for treating SIRS,but the difference is significant when the influence of astragalus mongholicus injection on the aforementioned factors of these patients is compared with those of the control group(P≤0.05).4.There is no significant difference between the influence of astragalus mongholicus injection(a Chinese crude drug that can invigorate the spleen and benefit qi) on the serological levels of inflammatory mediators(TNF-a, IL-6,IL-8,IL-10) in these patients and that of the traditional drug(Ulinastain for Injection) for treating SIRS,but the difference is significant when the influence of astragalus mongholicus injection on the aforementioned factors of these patients is compared with those of the control group(P≤0.05).Conclusions1.The main latter manifestation of patients who got SIRS after receiving major or medium operations on abdominal region is the pathomechanism of TCM-deficiency of spleen-Qi.2.Astragalus mongholicus injection(a Chinese crude drug that can invigorate the spleen and benefit qi) can improve the clinical symptom of the SIRS patients whose type of syndrome is deficiency of spleen-QI after operations.It' s of positive significance on these patients' body temperatures,heart rates,leukocyte counts as well as the early occurrence of negative fluid balance in them.3.Astragalus mongholicus injection(a Chinese crude drug that can invigorate the spleen and benefit qi) shows antagonistic action towards inflammatory mediators(TNF-a,IL-6,IL-8,IL-10,ect) in patients who got SIRS and whose type of syndrome is spleen deficiency after operations. It can reduce the inflammatory mediators to avoid the organism' s excessive inflammatory reaction,so that the organism is under protection,the occurrence of multi-organ dysfunction syndrome is avoided and the case fatality rate of the seriously ill patients is lowered.4.Astragalus mongholicus injection(a Chinese crude drug that can invigorate the spleen and benefit qi) can speed up the postoperative rehabilitation of the SIRS patients,which provides a new train of thought for the treatment on TCM during the perioperative period.