1、危重症病患与低血脂血症,武汉市第一医院,脂质的主要生理功能,甘油三酯,胆固醇,能量储存,能量产生,甾体激素合成,细胞膜,胆酸,脂肪 甘油 脂肪酸糖 磷酸丙糖 -氧化 丙酮酸 乙酰CoA H2O TCA CO2 能量,低脂血症,危重病,罗春华 李国静等.危重病患者血脂检测结果114例分析.陕西医学杂志,2008,37(12),南向珍,潘国权,何时军,严纯雪.感染性休克患儿的血脂变化与预后关系的探讨.中国急救医学,2006,26(5),C Michael Dunham et al： Following severe injury, hypocholesterolemia improves with
2、 convalescence but persists with organ failure or onset of infection Critical Care 2003, 7:R145-R153 (DOI 10.1186/cc2382),C Michael Dunham et al： Following severe injury, hypocholesterolemia improves with convalescence but persists with organ failure or onset of infection Critical Care 2003, 7:R145-
3、R153 (DOI 10.1186/cc2382),C Michael Dunham et al： Following severe injury, hypocholesterolemia improves with convalescence but persists with organ failure or onset of infection Critical Care 2003, 7:R145-R153 (DOI 10.1186/cc2382),1、可预测感染： These data suggest that persistent or progressive hypocholest
4、erolemia may be a more sensitive indicator of the onset of infection than is WBC response.,C Michael Dunham et al： Following severe injury, hypocholesterolemia improves with convalescence but persists with organ failure or onset of infection Critical Care 2003, 7:R145-R153 (DOI 10.1186/cc2382),邹国英,黄
5、露萍,任碧琼.革兰阴性菌感染患者血脂测定的临床意义 .现代检验医学杂志,2005,20(6),2、可预测预后： We consider the serial measurements of cholesterol and triglycerides as clinically re- levant to assess the morbidity of a patient and thereby to estimate the patients out- come. Kamolz LP et al, Burns. 2003 Dec;29(8):810-5 Serum cholesterol an
6、d triglycerides: potential role in mortality prediction Burns. 2003 Dec;29(8):810-5,C Michael Dunham， Michael H Fealk and Wilbur E Sever III ： Following severe injury, hypocholesterolemia improves with convalescence but persists with organ failure or onset of infection Critical Care 2003, 7:R145-R15
7、3 (DOI 10.1186/cc2382),低血脂损伤机制,低血脂损伤机制,炎症反应,P-选择素和细胞粘附分子-1,一氧化氮,细胞免疫,SIRS反应 MODF,1、抑制炎性介质的产生:,all lipoprotein classes have been shown to bind LPS and to attenuate the biological response to LPS in vitro and in rodents. Moreover , triglyceride-rich lipoproteins protect rodents against death from LPS
8、and bacterial sepsis.Berbe JF et al. Apolipoproteins modulate the inflammatory response to lipopolysaccharide J Endotoxin Res. 2005;11(2):97-103.,对 P-选择素和细胞间黏附分子-1 的作用:,rHDL reduced the degree of histological tissue injury in the lung, liver and intestine and attenuated the expression of P-selectin
9、and intercellular adhesion molecule-1 in the renal glomerulus . We propose that the mechanisms of these beneficial effects of HDL may be related to direct inhibition of adhesion molecule expression McDonald M C, Dhadly P, Cockerill G W, et al. Reconstituted High-density Lipoprotein Attenuates Organ
10、Injury and Adhesion Molecule Exprossion in A Rodent Model of EndotoxicShock J . Shock, 2003, 20( 6) : 551 -557.,3、对一氧化氮( NO)的作用：,HDL may reduce coronary risk via direct NO-mediated vasodilatory effects on the coronary circulation Levkau B, Hermann S, Theilmeier G, et al. High-density Lipoprotein Sti
11、mulates Myocardial Perfusion in Vivo J . Circulation, 2004, 110( 21) : 3355 3359.,4、低脂血症对机体免疫功能的影响：,危重症患者血脂代谢变化的相关机制,确切机制尚未完全清楚, 可能是多因素作用的结果。血脂代谢主要包括氧化供能、消耗与利用增加及合成减少等。,1、氧化供能： 腺垂体激素分泌（生长激素、糖皮质激素、甲状腺激素、胰高血糖素）增加,通过增强腺苷环化酶的作用使甘油三酯水解为游离脂肪酸, 在应激早期为外周组织提供能量，从而使甘油三酯水平下降。,2、消耗与利用增加:（1）、应激时机体释放大量类固醇激素以及维持细胞膜稳定（2）、新细胞合成利用胆固醇增加（3）、脂蛋白由于结合及中和脂多糖, 从而使脂蛋白的消耗增加,3、合成减少（1）、危重症患者由于血浆蛋白和肝脏蛋白合成指数下降及失血性血液稀释, 导致脂蛋白的合成减少。（2）、由于肝细胞受到干扰素-、白介素-1及白介素-6的影响,载脂蛋白的合成减少。,临床治疗过程中积极合理的营养支持治疗,谢谢,
