烧伤后能量代谢改变和病理过程及早期切痂调控的实验研究
摘要
新陈代谢是机体生命活动的基本特征，新陈代谢包括物质代谢和与之相伴随的能量代谢。生物体内物质代谢过程中所伴随的能量释放、转移和利用等，即为能量代谢(energy metabolism)的范畴。能量代谢的异常，可直接影响到机体相关细胞、组织和器官生物功能的正常运行。高代谢常用于描述严重创伤、脓毒症所伴随的能量消耗增加，其中严重烧伤后能量消耗增加最为明显。临床实践和研究观察到，严重烧伤后全身性代谢反应剧烈，机体营养储备大量消耗，加之摄入、吸收及利用障碍，不能满足机体需要，病人在短期内可出现严重的营养不良、免疫功能下降、对感染的易感性增高、创面愈合迟缓，甚至危及生命。因此，研究烧伤病人能量代谢的变化的特点，对了解烧伤疾病的病理生理改变，给予有效的干预措施，避免或减轻并发症，加速创面愈合，提高治愈率有重要意义。
烧伤创面不论感染与否均是多种炎性介质的重要来源，并通过直接或间接的途径，引起神经内分泌系统的改变。深度烧伤创面尽早植皮封闭创面，不仅有利于恢复皮肤屏障功能，而且有助于减少过高的能量消耗。本研究第一部分首先将炎性介质对心、肝、骨骼肌三大重要器官细胞能量代谢的影响和病理基础及早期切痂的调控作用进行了研究和分析。
我们采用Wistar大鼠背部30％TBSAⅢ度烫伤模型，动态观察了早期切痂组(伤后24小时)和延迟切痂组(伤后96小时)伤后
中文龈要 军医进修学院硕士论文
不同时间点的血浆LPS和TN’F．a水平，并与之相应地测定了心、肝、
骨骼肌组织 All，含量和 ATP酶活性，同时进行了细胞内线粒体的病
理形态学检查。
结果表明：
1．烧伤后机体与代谢紧密相关的心、肝、骨骼肌组织存在明显
的能量代谢紊乱。
2．大鼠烫伤后LPS、TN’FJ均明显升高，达峰值后缓慢下降，
早期手术切除焦痴可使两指标获得较快下降。
3．心、肝、骨骼肌组织ATP含量在烫伤早期即明显降低，此
后逐步回升，早期手术切除焦痴可使组织ATP水平较快恢
复。
4．大鼠烫伤后组织ATP含量的降低与血浆LPS、TN’F．a的升高
时间基本一致，变化规律呈显著负相关，表明组织ATP含量
的降低与烫伤后循环体液中的炎性介质增高有关。
5．严重烫伤后细胞内能量代谢相关的细胞器变化显著：心肌、
肝脏、骨骼肌细胞内线粒体密度降低，体积增大，明显肿胀，
崎数量减少、断裂，峭膜不清晰，基质电子密度减低。同时，
ATP合成酶的活性和数量由于其反应部位的损伤而下降，超
微结构和合成酶的改变说明烧伤后能量产生环节发生障碍。
上述线粒体形态的改变构成细胞能量代谢紊乱的病理基础。
早期切痴可使线粒体结构和酶活性得到较快恢复。
为了进一步证实早期切痴对神经内分泌系统的调控及由此导致
的整体代谢水平的改善，我们进行了第二部分的实验研究：采用贵
州小型猪背部30％h SA 111度烧伤模型，动态观察了早期切痴组和
延迟切痴组伤后不同时间点的血浆肾上腺素、胰岛素、胰高血糖素、
3
中艾扬要 军医进修学院硕士论文
皮质醇、生长激素（GH）和胰岛素样生长因子－1（IGF－l）的变化，同时
利用代谢车测定了静息能量消耗（REE）水平。
结果表明：
1．烧伤早期REE缓慢持续升高，至伤后48h后迅速升高，并维持于
较高状态。休克期切痴组封闭创面后REE即呈下降趋势，尽管至
实验观察期末仍未降至伤前水平，但己明显低于延迟切痴组。
2．烧伤后三大营养底物体内氧化分解供能的比例较伤前有所调整，
脂肪氧化供能明显增强，蛋白质氧化有所增强，糖氧化受抑制，
调整的结果表明，脂动员增强与烧伤后能耗增加存在较重要联
系。
3．对烧伤后交感一肾上腺髓质和下丘脑一垂体一肾上腺皮质轴兴
奋为主的神经内分泌反应中产生的“应激激素”的观察表明，早
期切痴植皮手术不会加重烧伤后的应激状态。
4．小型猪烧伤模型的代谢研究主要以全身病理生理变化为基础，同
时也对心、肝、肾、空肠等组织?
Metabolism is the basic character of life. Burn and other severe injuries are associated with pronounced metabolic changes in most organs and tissues. The abnormity of energy metabolism could affect the normal function of organs and tissues. As our general understanding has advanced in leaps and bounds in various areas of biomedical research over the past decades, we have been able to look deeper and deeper into the phenomenon of thermal insult, in which the important pathophysiological consequences of burn injury is related to toxins released from bura devitalized skin which may be one of principal causes of systemic inflammatory response. The metabolic response to bum is characterized by protein and lipid catabolism, total body protein loss, peripheral insulin resistance, and increased energy expenditure. However, the fundamenta! studies on the field of operation adjust are rarely reported in domestic and foreign literatures. The present study was performed to evaluate the effects of escharectomy during burn shock stage on energy metabolism.
In the first part of this study, a series of experimental
studies related to energy metabolism and operation were carried on. One hundred and twelve male Wistar rats were subjected to a 30% total body surface area full-thickness thermal injury. The rats were randomly divided into two groups: escharectomy during burn shock stage group (group A) and escharectomy after bura shock stage group(group B). The contents of adenosine triphosphate (ATP) and the activities and quantities of ATPase. in the heart, liver and skeletal muscle and the levels of LPS, TNF- a in plasma were sequentially determined and analyzed at different time point. Results:
1. The results showed that the contents of ATP in the heart, liver and skeletal muscle decreased rapidly post burn. The contents of ATP in group A were higher than group B obviously (P<0.01) .
2. The images scanned under microscope were analyzed by image analysis system, the results showed the activities and quantities of ATPase in the heart, liver and skeletal muscle decreased at the same time post bum, but they were higher in group A at the end of experiment than group B.
3. Significant negative correlations between the contents of ATP in viscera and levels of LPS, TNF- a in plasma were noted.
4. The damage of mitochondrial structure of heart, liver and skeletal muscle was observed by electron microscope post bum. The decrease of mitochondrial
crystal membrane density of burned rats was tightly related to dysfunctipn of mitochondrial respiration and energy synthesis. But the mitochondrial structure were rebuilt rapidly in the rats who accepted escharectomy during burn shock stage.
Our before-mentioned research indicated that energy disturbance appears in cellular metabolism post burn, which includes not only energy supply but also energy application, and escharectomy during burn shock stage could relieve hypermetabolism after extensive burn to some degree. But little research related to the changes of irritability of nerve-incretion system post escharectomy during burn shock stage has been carried out. Thus the main purpose of the second part of this study is to find out the influence of escharectomy during burn shock stage on irritability and to determine the changes of resting energy expenditure (REE) in normal and post burn stage, and the effect of escharectomy during burn shock stage on energy expenditure.
In the second part of this study, 30% TBSA HI degree burn swine model was used. Sixteen male minipigs were randomly divided into two groups: escharectomy during burn shock stage group (group A) and escharectomy after burn shock stage group (group B). REEs were monitored by means of Metabolic cart (Medical Graphics Corporation, USA). The sequential changes in plasma levels of insulin, glucagon, cortisol, growth hormone (GH) and Insulin-like growth factor (IGF-1) were analyzed.
Results:
1. The levels of REE increased immediately post burn. REE decreased early in g
烧伤创面不论感染与否均是多种炎性介质的重要来源，并通过直接或间接的途径，引起神经内分泌系统的改变。深度烧伤创面尽早植皮封闭创面，不仅有利于恢复皮肤屏障功能，而且有助于减少过高的能量消耗。本研究第一部分首先将炎性介质对心、肝、骨骼肌三大重要器官细胞能量代谢的影响和病理基础及早期切痂的调控作用进行了研究和分析。
我们采用Wistar大鼠背部30％TBSAⅢ度烫伤模型，动态观察了早期切痂组(伤后24小时)和延迟切痂组(伤后96小时)伤后
中文龈要 军医进修学院硕士论文
不同时间点的血浆LPS和TN’F．a水平，并与之相应地测定了心、肝、
骨骼肌组织 All，含量和 ATP酶活性，同时进行了细胞内线粒体的病
理形态学检查。
结果表明：
1．烧伤后机体与代谢紧密相关的心、肝、骨骼肌组织存在明显
的能量代谢紊乱。
2．大鼠烫伤后LPS、TN’FJ均明显升高，达峰值后缓慢下降，
早期手术切除焦痴可使两指标获得较快下降。
3．心、肝、骨骼肌组织ATP含量在烫伤早期即明显降低，此
后逐步回升，早期手术切除焦痴可使组织ATP水平较快恢
复。
4．大鼠烫伤后组织ATP含量的降低与血浆LPS、TN’F．a的升高
时间基本一致，变化规律呈显著负相关，表明组织ATP含量
的降低与烫伤后循环体液中的炎性介质增高有关。
5．严重烫伤后细胞内能量代谢相关的细胞器变化显著：心肌、
肝脏、骨骼肌细胞内线粒体密度降低，体积增大，明显肿胀，
崎数量减少、断裂，峭膜不清晰，基质电子密度减低。同时，
ATP合成酶的活性和数量由于其反应部位的损伤而下降，超
微结构和合成酶的改变说明烧伤后能量产生环节发生障碍。
上述线粒体形态的改变构成细胞能量代谢紊乱的病理基础。
早期切痴可使线粒体结构和酶活性得到较快恢复。
为了进一步证实早期切痴对神经内分泌系统的调控及由此导致
的整体代谢水平的改善，我们进行了第二部分的实验研究：采用贵
州小型猪背部30％h SA 111度烧伤模型，动态观察了早期切痴组和
延迟切痴组伤后不同时间点的血浆肾上腺素、胰岛素、胰高血糖素、
3
中艾扬要 军医进修学院硕士论文
皮质醇、生长激素（GH）和胰岛素样生长因子－1（IGF－l）的变化，同时
利用代谢车测定了静息能量消耗（REE）水平。
结果表明：
1．烧伤早期REE缓慢持续升高，至伤后48h后迅速升高，并维持于
较高状态。休克期切痴组封闭创面后REE即呈下降趋势，尽管至
实验观察期末仍未降至伤前水平，但己明显低于延迟切痴组。
2．烧伤后三大营养底物体内氧化分解供能的比例较伤前有所调整，
脂肪氧化供能明显增强，蛋白质氧化有所增强，糖氧化受抑制，
调整的结果表明，脂动员增强与烧伤后能耗增加存在较重要联
系。
3．对烧伤后交感一肾上腺髓质和下丘脑一垂体一肾上腺皮质轴兴
奋为主的神经内分泌反应中产生的“应激激素”的观察表明，早
期切痴植皮手术不会加重烧伤后的应激状态。
4．小型猪烧伤模型的代谢研究主要以全身病理生理变化为基础，同
时也对心、肝、肾、空肠等组织?
Metabolism is the basic character of life. Burn and other severe injuries are associated with pronounced metabolic changes in most organs and tissues. The abnormity of energy metabolism could affect the normal function of organs and tissues. As our general understanding has advanced in leaps and bounds in various areas of biomedical research over the past decades, we have been able to look deeper and deeper into the phenomenon of thermal insult, in which the important pathophysiological consequences of burn injury is related to toxins released from bura devitalized skin which may be one of principal causes of systemic inflammatory response. The metabolic response to bum is characterized by protein and lipid catabolism, total body protein loss, peripheral insulin resistance, and increased energy expenditure. However, the fundamenta! studies on the field of operation adjust are rarely reported in domestic and foreign literatures. The present study was performed to evaluate the effects of escharectomy during burn shock stage on energy metabolism.
In the first part of this study, a series of experimental
studies related to energy metabolism and operation were carried on. One hundred and twelve male Wistar rats were subjected to a 30% total body surface area full-thickness thermal injury. The rats were randomly divided into two groups: escharectomy during burn shock stage group (group A) and escharectomy after bura shock stage group(group B). The contents of adenosine triphosphate (ATP) and the activities and quantities of ATPase. in the heart, liver and skeletal muscle and the levels of LPS, TNF- a in plasma were sequentially determined and analyzed at different time point. Results:
1. The results showed that the contents of ATP in the heart, liver and skeletal muscle decreased rapidly post burn. The contents of ATP in group A were higher than group B obviously (P<0.01) .
2. The images scanned under microscope were analyzed by image analysis system, the results showed the activities and quantities of ATPase in the heart, liver and skeletal muscle decreased at the same time post bum, but they were higher in group A at the end of experiment than group B.
3. Significant negative correlations between the contents of ATP in viscera and levels of LPS, TNF- a in plasma were noted.
4. The damage of mitochondrial structure of heart, liver and skeletal muscle was observed by electron microscope post bum. The decrease of mitochondrial
crystal membrane density of burned rats was tightly related to dysfunctipn of mitochondrial respiration and energy synthesis. But the mitochondrial structure were rebuilt rapidly in the rats who accepted escharectomy during burn shock stage.
Our before-mentioned research indicated that energy disturbance appears in cellular metabolism post burn, which includes not only energy supply but also energy application, and escharectomy during burn shock stage could relieve hypermetabolism after extensive burn to some degree. But little research related to the changes of irritability of nerve-incretion system post escharectomy during burn shock stage has been carried out. Thus the main purpose of the second part of this study is to find out the influence of escharectomy during burn shock stage on irritability and to determine the changes of resting energy expenditure (REE) in normal and post burn stage, and the effect of escharectomy during burn shock stage on energy expenditure.
In the second part of this study, 30% TBSA HI degree burn swine model was used. Sixteen male minipigs were randomly divided into two groups: escharectomy during burn shock stage group (group A) and escharectomy after burn shock stage group (group B). REEs were monitored by means of Metabolic cart (Medical Graphics Corporation, USA). The sequential changes in plasma levels of insulin, glucagon, cortisol, growth hormone (GH) and Insulin-like growth factor (IGF-1) were analyzed.
Results:
1. The levels of REE increased immediately post burn. REE decreased early in g
引文
1 姚咏明，田惠民，王亚平，等．过氯酸新法预处理血浆定量检测微量内毒素的鲎试验方法及其应用．上海医学检验杂志，1993；8：31—33．
2 王宁，李桦．反相高效液相色谱法测定生物样品中的腺嘌呤核苷酸．药学学报．1990；25：223—226．
3 姜平，刘正清，文建亚．大鼠甲状腺毒症心肌肥大的ATP酶研究．中华现代医学杂志，2000；10．211—213
4 Schoenenberger GA,Cueni LB,Bauer V,et al.Isolation and characterization of a cutaneous lipoprotein with lethal effects products by thermal energy in mouse skin.Biochem Biophys Res Commun,1971;42:975-982.
5 William W,Turner JR.Evaluation of energy expenditure in burn patients.J AM Dietic Assoc.1986;86:331-333
6 郭振荣．烧伤后代谢与营养．见：盛志勇等主编．危重烧伤治疗与康复学．北京：科学出版社，2000．317
7 Allgower M,Burri C,Harder F et al.Unsolved problems of severely burned patients.In Toxic Factors in burns.Chelsea College,University of London,1976,European Research Office;Tech Report ERO-4-75;pp47
8 Meakins J L,Marshall J C.The gastrointestinal tract:The"motor"of MOF.Arch Surg,1986,121:197—201.
9 Tracey K J,Cerami A.Tumor necrosis factor:A updated review of its biology.Crit Care Med,1993,21:S415—418.
10 胡梅清，魏湧．三羧酸循环与氧化磷酸化．见：魏湧主编．医用生物化学．北京．世界图书出版公司，1992．135
11 耿稚江．线粒体医学的最新研究进展．国外医学情报．2000，21：83—87
12 欧阳彬，王吉浦．L-NIL对脓毒血症模型小鼠细胞能量代谢及存活率的影响．中国胃肠外科杂志，1999，2：158—161
13 Lamers JMJ,Ruigrok TJC.Deminished Na~＋/K~＋ and Ca~(2＋)pump activities in Ca~(2＋)depleted heart:possible role in the development of Ca~(2＋)overload during the Ca~(2＋)paradox.Eur Heart J,1983,4(Suppl H):73—76.
14 Mizobata Y,Prechek D,Rounds JD,et al.The duration of infection modifies mitoehondrial oxidative capacity in rat skeletal muscle.J Surg Res 1995;59:165～173
15 Ckouser ED,Dorinsky P.Metabolic consequences of sepsis correlation with altered intracellular calcium homeostasis.Clin Chest Med 1996;170:249～261
16 Leclercq PF,Sibille B,Hamant S,et al.Inhibition of glycerol metabolism in hepatocytes isolated from endotoxic rats.Biochem J 1997;325:519～525
17 Adamson GM,Billings RE.Tumor necrosis factor:receptor binding and expression of receptors in cultured mouse hepatocytes.J Pharmacol Exp Ther 1994;269:367～373
18 沈洪兴，王光毅，于宝君，等．严重烫伤大鼠心、肝、肾组织Na~＋，K~＋-ATP酶、Ca~(2＋)-ATp酶活性的变化．第二军医大学学报，1998，19：247—250．
19 高文祥，柳君泽，蔡明春．缺氧大鼠脑线粒体能量代谢的研究．中国病理生理杂志．2000，16：729—730
20 楼淑芬，宋举峰，陈宗荣．烧伤焦痂毒性物质D1对大鼠肝线粒体H＋-ATP酶活性及能量偶联的影响．1999，15：285-289
2 王宁，李桦．反相高效液相色谱法测定生物样品中的腺嘌呤核苷酸．药学学报．1990；25：223—226．
3 姜平，刘正清，文建亚．大鼠甲状腺毒症心肌肥大的ATP酶研究．中华现代医学杂志，2000；10．211—213
4 Schoenenberger GA,Cueni LB,Bauer V,et al.Isolation and characterization of a cutaneous lipoprotein with lethal effects products by thermal energy in mouse skin.Biochem Biophys Res Commun,1971;42:975-982.
5 William W,Turner JR.Evaluation of energy expenditure in burn patients.J AM Dietic Assoc.1986;86:331-333
6 郭振荣．烧伤后代谢与营养．见：盛志勇等主编．危重烧伤治疗与康复学．北京：科学出版社，2000．317
7 Allgower M,Burri C,Harder F et al.Unsolved problems of severely burned patients.In Toxic Factors in burns.Chelsea College,University of London,1976,European Research Office;Tech Report ERO-4-75;pp47
8 Meakins J L,Marshall J C.The gastrointestinal tract:The"motor"of MOF.Arch Surg,1986,121:197—201.
9 Tracey K J,Cerami A.Tumor necrosis factor:A updated review of its biology.Crit Care Med,1993,21:S415—418.
10 胡梅清，魏湧．三羧酸循环与氧化磷酸化．见：魏湧主编．医用生物化学．北京．世界图书出版公司，1992．135
11 耿稚江．线粒体医学的最新研究进展．国外医学情报．2000，21：83—87
12 欧阳彬，王吉浦．L-NIL对脓毒血症模型小鼠细胞能量代谢及存活率的影响．中国胃肠外科杂志，1999，2：158—161
13 Lamers JMJ,Ruigrok TJC.Deminished Na~＋/K~＋ and Ca~(2＋)pump activities in Ca~(2＋)depleted heart:possible role in the development of Ca~(2＋)overload during the Ca~(2＋)paradox.Eur Heart J,1983,4(Suppl H):73—76.
14 Mizobata Y,Prechek D,Rounds JD,et al.The duration of infection modifies mitoehondrial oxidative capacity in rat skeletal muscle.J Surg Res 1995;59:165～173
15 Ckouser ED,Dorinsky P.Metabolic consequences of sepsis correlation with altered intracellular calcium homeostasis.Clin Chest Med 1996;170:249～261
16 Leclercq PF,Sibille B,Hamant S,et al.Inhibition of glycerol metabolism in hepatocytes isolated from endotoxic rats.Biochem J 1997;325:519～525
17 Adamson GM,Billings RE.Tumor necrosis factor:receptor binding and expression of receptors in cultured mouse hepatocytes.J Pharmacol Exp Ther 1994;269:367～373
18 沈洪兴，王光毅，于宝君，等．严重烫伤大鼠心、肝、肾组织Na~＋，K~＋-ATP酶、Ca~(2＋)-ATp酶活性的变化．第二军医大学学报，1998，19：247—250．
19 高文祥，柳君泽，蔡明春．缺氧大鼠脑线粒体能量代谢的研究．中国病理生理杂志．2000，16：729—730
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