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壹生身份认证协议书
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作者：武警特色医学中心综合重症医学科 蔡湘龙 李国强
脓毒症是一种严重感染导致的综合征，临床常见、高发，也是重症监护病房（ICU）住院和死亡的常见病因之一。全球每年患有脓毒症的病人数约1900万，其中约600万的患者死亡，病死率超过25%[1]。一项在22个亚洲国家和地区的386个成人ICU中进行的前瞻性队列研究显示[2]，脓毒症是亚洲ICU病人的常见病因，病死率约22.4%；我国研究表明，ICU患者中脓毒症的占比为20.6%，90 d病死率为35.5%[3]。目前的国际共识将脓毒症定义为由宿主对感染反应失调引起的危及生命的器官功障碍[4]，在过去的几十年里，大量的研究增加了对其病理生理学的理解，脓毒症病死的主要驱动因素是过度的全身炎症反应，针对此，一系列相关学说出现，2003年提出“细胞因子峰值假说”、2004年提出“阈值免疫调节假说”(2004年)及2011年提出“白细胞趋化动力学模型”等，基于此，有学者提出[5]，可以应用血液净化的方式进行治疗，其潜在靶点主要包括：
①清除血液循环中的病原体(细菌、真菌及病毒等)；
②清除血液循环中的炎性因子；
③清除血液循环中的内毒素和其他损伤相关分子模式等。
血液灌流（HP）是与血液透析、血液滤过和血浆置换相并列的一类血液净化技术。1948年，Muirhead和Reid首次提出“血液灌流”这一概念。HP是利用体外循环将病人的血液引入一个或多个装有固体吸附剂的灌注装置，通过吸附作用捕获血液中的有毒物质或者病态物质，然后将净化后的血液回输入患者体内。它对中/大分子量物质、蛋白结合型物质具有较高的清除效率，目前已广泛应用于药物中毒、自身免疫性疾病、尿毒症等疾病。吸附材料是HP疗法的核心，近年来，研究者们致力于开发新型HP吸附剂，以进一步提升吸附性能和改善生物相容性。目前临床常用于脓毒症治疗和研究的血液灌流器有：多黏菌素B血液灌流器(Polymyxin B blood perfusion，PMX-HP，日本)、细胞因子吸附柱（美国）、HA330/380血液灌流器（健帆生物科技，中国）、Seraph-100血液灌流器（美国），此外，还有整合在肾脏替代治疗（continuous renal replacement therapy，CRRT）管路上的高吸附膜（美国）等。
在过去的近70年里，脓毒症的治疗强调病灶源头的控制、及时给予有效的抗生素和血管活性药物进行血压管理等，但尽管进行了很好的感染控制、应用了广谱抗生素，仍有较大比例的病人死于脓毒症/脓毒性休克[6,7]。对于这类病人，病原体、病原体产物及血浆中高水平的炎症介质是导致不良预后的直接原因[8]。20世纪70年代就有学者开始了HP吸附内毒素的研究，随后扩展至对其他病原体相关分子模式（pathogen-associated molecular patterns，PAMPs）、损伤相关分子模式（damage associated molecular patterns，DAMPs）以及病原体等的吸附。在操作方式上，目前有可以单独运行进行全血灌流，也有串联、整合在CRRT等体外治疗管路的回路上，合并进行器官支持治疗和吸附治疗。HP已在临床应用多年，数十万例病例被治疗，近500余篇研究被报道，涉及单、多中心观察、试验性研究，具有较好的安全性，然而，虽大部分研究显示其可以使患者有益，但也有部分研究报告了阴性结果[9,10]，故须明确HP治疗对于脓毒症病人具有哪些方面的作用，以及什么类型脓毒症病人、在病情什么阶段、具有什么样表现时，以哪种方式进行HP治疗会使其获益。
未完待续
武警特色医学中心综合重症医学科科主任，医学博士，主任医师，硕士研究生导师,从事临床工作30余年,在呼吸支持技术为主的各种抢救治疗中有独特的见解，在复杂的有创机械通气技术及床旁呼吸力学监测、无创机械通气、ECMO、MODS 的救治(包括连续血滤及人工肝技术)有较深入的研究;并在各种中毒抢救，体外清除技术(全血灌流、血浆吸附流、持续床旁血液滤过、血浆置换)在中毒领域有深厚的造诣;担任中国毒理学会中毒与救治专业委员会副主任委员、全军重症医学专业委员会委员、全军热射病防治专家组专家、全军热射病天津市医师协会急诊医师分会常务委员、天津市医学会重症医学专业委员会委员、天津市中西医结合学会呼吸病专业委员会委员、中华医学会呼吸病学分会呼吸危重症委员、天津市医师协会重症医学医师分会第三届委员会常委等职务。
承担各级科研课题5项，在发表论文40 余篇，国家实用新型专利9项。多次执行重大行动卫勤保障任务，省部级科技进步奖一等奖1项，三等奖2项，医疗成果三等奖2项，6次荣立个人三等功;所带领的综合重症医学科团队被表彰为“基层建设先进单位”、“优秀党支部”、武警部队、56后勤部及特色医学中心“四铁”先进单位，2022年提名全军“四铁”先进单位，3次荣立集体三等功。
武警特色医学中心综合重症医学科主治医师，医学硕士，从事临床工作10年，对于中毒、脓毒症、多脏器功能障碍综合征等疾病的重症救治有一定的临床和科研经验，发表核心期刊论文数篇。
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本文由中国医学论坛报社呼吸与危重症编委会编委宋立强教授组稿
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