对慢性危重脓毒症患者进行表型分析的可能性

D. Cheboksarov, M. V. Petrova, O. V. Ryzhova, O. P. Artyukov
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The purpose of this work is the theoretical determination of phenotypic groups for chronic critical patients. Methods and materials: The search for Russian publications was carried out in the database on the RSCI website, and foreign publications were searched in the PubMed and Google Scholar databases in the period of 1998–2022. When analyzing the PubMed database, the query «sepsis phenotype» resulted in 62,371 links. The works on the keywords «chronic critical illness» were also studied. The publications describing the sepsis phenotypes, the diagnosis of sepsis and septic shock, as well as the clinical picture of a chronic critical condition (illness) were analyzed, with a total of 45 scientific articles. Discussion: It is also worth noting that the study by C. Seymour, latent class analysis, and other works devoted to the treatment of sepsis consider a large number of mainly non-surgical patients, without dividing them by the main nosology and foci of infection. Meanwhile, the main axis of neurohumoral immunity, i.e. the brain — gastrointestinal tract, is disrupted in chronic critical patients. These patients, as well as patients undergoing repeated sepsis caused by a nosocomial infection, are not considered separately in any of the studies. Furthermore, neither the study by C. Seymour, nor the latent class analysis examines any instrumental method for assessing the infection focus (radiography or computed tomography of the lungs). Much attention is paid to the acid-base state of patients, but the state of the main buffer systems is not described in terms of the presence of concomitant or competing diseases, and an indication of an increase in creatinine and blood urea nitrogen can only indirectly indicate kidney dysfunction and, as a consequence, a disorder in the bicarbonate bufer system. 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引用次数: 0

摘要

理解败血症的主要障碍是对这种疾病的定义过于宽泛,涵盖了一系列广泛的临床和病理生理征象。这些特征的不同组合可以自然地组合成表型,这些表型具有不同程度的不良后果风险,并可能对治疗做出不同的反应。确定表型的科学工作主要集中在重症监护室的病人身上。此外,目前还没有关于慢性危重症脓毒症患者分类和表型的前瞻性或回顾性研究。这很可能是因为 "慢性危重病人 "这一术语非常新颖,最近才在俄罗斯和国外的科学文献中被广泛报道。这项工作的目的是从理论上确定慢性危重病人的表型组别。方法和材料:在俄罗斯科学院网站的数据库中搜索了俄罗斯的出版物,在 PubMed 和 Google Scholar 数据库中搜索了 1998-2022 年间国外的出版物。在对PubMed数据库进行分析时,查询 "脓毒症表型 "可获得62371个链接。此外,还研究了以 "慢性危重病 "为关键词的著作。分析了描述败血症表型、败血症和脓毒性休克诊断以及慢性危重症(疾病)临床表现的出版物,共计 45 篇科学文章。讨论还值得注意的是,C. Seymour 的研究、潜类分析以及其他致力于脓毒症治疗的著作考虑了大量主要是非手术患者,而没有按照主要病名和感染灶进行划分。与此同时,慢性危重病人的神经-体液免疫主轴,即脑-胃肠道,被打乱了。这些患者以及因鼻源性感染导致反复败血症的患者在任何研究中都没有被单独考虑。此外,无论是 C. Seymour 的研究,还是潜类分析,都没有研究评估感染病灶的任何仪器方法(肺部放射摄影或计算机断层扫描)。研究对患者的酸碱状态给予了很大关注,但并没有从是否存在并发症或竞争性疾病的角度来描述主要缓冲系统的状态,而肌酐和血尿素氮升高的迹象只能间接表明肾功能失调,从而导致碳酸氢盐缓冲系统紊乱。结论根据上述情况,对于有宿主反应选择的慢性危重病人,应更新急性脓毒症患者的基本分类,同时考虑到免疫系统的特殊性。此外,由于椎基底动脉病变的患者更容易发生吸入性肺炎和严重败血症,而额叶病变的患者则极少发生此类肺炎,因此建议根据脑损伤的部位对慢性危重病人进行单独表型。因此,下丘脑病变会导致神经体液对各种病原体的免疫反应发生变化。因此,慢性危重败血症患者不仅应根据已知的表型系统进行分类,还应根据脑损伤的定位和胃肠道的功能进行分类。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
The possibility of phenotyping patients with sepsis in a chronic critical condition
The main obstacle to understanding sepsis is an excessively broad definition of this disease, which covers an extensive set of clinical and pathophysiological signs. Different combinations of these traits can naturally combine into phenotypes that have different degrees of risk of an adverse outcome, and may respond differently to treatment. Scientific work on the determination of phenotypes has focused mainly on patients in the intensive care unit. In addition, there have been no prospective or retrospective studies on the classification and phenotyping of sepsis patients in a chronic critical condition. Most likely, this is due to the fact that the term «chronic critical patient» is quite novel and has recently been widely covered in both Russian and foreign scientific literature. The purpose of this work is the theoretical determination of phenotypic groups for chronic critical patients. Methods and materials: The search for Russian publications was carried out in the database on the RSCI website, and foreign publications were searched in the PubMed and Google Scholar databases in the period of 1998–2022. When analyzing the PubMed database, the query «sepsis phenotype» resulted in 62,371 links. The works on the keywords «chronic critical illness» were also studied. The publications describing the sepsis phenotypes, the diagnosis of sepsis and septic shock, as well as the clinical picture of a chronic critical condition (illness) were analyzed, with a total of 45 scientific articles. Discussion: It is also worth noting that the study by C. Seymour, latent class analysis, and other works devoted to the treatment of sepsis consider a large number of mainly non-surgical patients, without dividing them by the main nosology and foci of infection. Meanwhile, the main axis of neurohumoral immunity, i.e. the brain — gastrointestinal tract, is disrupted in chronic critical patients. These patients, as well as patients undergoing repeated sepsis caused by a nosocomial infection, are not considered separately in any of the studies. Furthermore, neither the study by C. Seymour, nor the latent class analysis examines any instrumental method for assessing the infection focus (radiography or computed tomography of the lungs). Much attention is paid to the acid-base state of patients, but the state of the main buffer systems is not described in terms of the presence of concomitant or competing diseases, and an indication of an increase in creatinine and blood urea nitrogen can only indirectly indicate kidney dysfunction and, as a consequence, a disorder in the bicarbonate bufer system. Conclusions: Based on the above, the basic classifications for patients with sepsis in an acute state should be updated for chronic critical patients with host response options, taking into account the peculiarities of the immune system. Moreover, it is recommendable to phenotype chronic critical patients separately, considering the localization of brain damage, since patients with vertebrobasilar lesions are more prone to aspiration pneumonia and severe sepsis, while this type of pneumonia is extremely rare in patients with frontal lobe lesions. Accordingly, hypothalamic lesion leads to a change in the neurohumoral immune response to various pathogens. Thus, chronic critical patients with sepsis should be classified not only according to already known phenotyping systems, but also based on the localization of brain damage and the functionality of the gastrointestinal tract.
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