摘要
目的 本课题针对南方战区湿热环境和现代野战外科伤口特点，根据中草药对创面具有独特疗效，以民间伤科验方为基础筛选出具有抗菌消炎、止血祛瘀、消肿止痛作用的组方，制成透皮给药剂型，继而观察这些敷料在湿热环境下对伤口愈合、并发症、伤残率及死亡率等的影响，为南方战区特殊环境下伤口敷料的研制提供实验依据。
方法 (1)昆明小鼠240只和8种野战创伤创面常见感染菌，以析因设计法将中药组方分为6个实验组，分别进行止血、镇痛、消肿和抑菌中药药理学实验，筛选出优化因素组合；然后，SD大鼠30只分为3组对优选中药敷料组合进行生物学评价。(2)先选出成膜性好的膜基质组合，然后以均匀设计法，以综合评定指标对6种基质的7个不同水平参数进行优化，最后筛选出最佳膜基质的配比和中药提取液配制密闭性功能敷料。(3)猪10只，分为2组，后肢为软组织挫伤加切割伤，背部全层皮肤缺损伤。以密闭性功能敷料为实验组，常规处理为对照组，置入湿热环境8 h，继续饲养22 d。监测其生命体征，细菌学定量，血浆β-EP的变化，组织干湿重，伤口组织病理变化，伤口愈合情况和创伤转归的情况。
结果 (1)Ⅰ～Ⅲ号方的粉剂和提取液剂6个实验组在止血、止痛、消肿、抑菌与生理盐水组的比较均有显著差异(P＜0.01)。经过两两均数比较，Ⅰ号方提取液组的凝血时间、消肿值低于其他组，平均抑菌率高于其他组，最小抑菌浓度(NIC)为0.00625～0.025 g/1，而在止痛功效上Ⅲ号方提取液组扭体的次数明显低于其它各组(P＜0.01)。Ⅰ号方提取液组与云南白药组在止痛、消肿、抑菌方面比较差异显著(P＜0.01)，其功效优于云南白药组，而止血方面则无显著差异(P＞0.05)。
(2)成膜性好的膜基质组合为聚乙烯醇(X_1)、羧甲基纤维素钠/甲
基纤维素(X:)、明胶(X3)、高岭土(X;)、甘油(X;)。6种基质的7个
参数水平和综合评分结果，经过多元回归分析，经方差分析F二13.271，
P=O.000<0.01，方程有统计学意义，回归方程有效。经过多次重复试验，
确定中药膜的最佳配比X，=5.0，XZ=3.0，X。=10，X;=2.0，X。=5.0，
X6=0 .02。
(3)湿热环境下实验组和对照组结果的比较:①对体温的影响在创
伤前、热暴露阶段两组动物体温比较差异无显著意义(P>0.05)，热暴
露后(损伤1~sd)两组的比较有显著差异(P<0.01);两组组内比较，
伤前与热暴露时及热暴露后时段比较有显著差异(P 暴露时与热暴露后比较有显著差异(P<0.01)。②背部伤口细菌学定量在
热暴露4h时、热暴露sh时、热暴露后(伤后24h)两组的比较有显
著差异(P(0.01)，且对照组伤后24h伤口细菌总数为(1.89士3.46)火
105n/g组织。腿部细菌学定量在热暴露sh时、热暴露后(伤后24h)
两组的比较有显著差异(P<0 .01)，且对照组在热暴露sh伤口细菌总数
(l .04士0.58) x 105个/g组织。③对组织含水量的影响，在伤前、热暴
露时两组的比较无显著差异(P>0 .05)，热暴露后(伤后24h)比较有显
著差异(P<0.01)。组织病理学观察结果，与伤前比较，热暴露时和伤后
24h肌纤维稍肿胀，肌间隙增宽，对照组较实验组明显。④对猪血浆p
一EP的影响，两组创伤前比较无显著差异(P>0 .05)，伤后清醒0.sh、
热暴露时和热暴露后(损伤后24h)差异有显著意义(P<0.01);组内
比较，对照组创伤前分别与伤后清醒0.sh、热暴露时及术后24h，伤
后清醒0.sh与热暴露时，热暴露时与创伤后24h两两比较有显著差异
(P<0.01)，而实验组的创伤前分别与伤后清醒0.sh比较有显著差异
(P<0.05)，与热暴露时比较差异有非常显著意义(P<0.01)，与创伤后
24h比较差异无显著意义(P>0 .05)。对呼吸频率及心率的影响，两组
的比较，在创伤前差异无显著意义(P>0.05)，热暴露时差异有非常显著
意义(P<0 .01);组内比较，创伤前与热暴露时比较差异有非常显著意义
(P 对照组。⑥动物的生存情况，7d后称体重，两组伤前和伤后两组组间
比较差异无显著意义(P>0 .05)，对照组伤前与伤后比较差异有非常显著
意义(P<0.01)。对照组动物存活率为20%，实验组动物存活率为100%。
—3—
结论(1)1号方提取液组在止血、消肿、抑菌、止痛总体功效上
优于其他组。所筛选优化组合I号方提取液剂能够有效地促进创伤创面
的愈合修复。经过药理学和生物学的综合评价，选定I号方提取液剂型
为密闭性野战功能敷料的主方。(2)选出成膜率高、外观质量好的膜基
质组合为PvA，CMC一NA，明胶，高岭土，甘油，HA等组成，在此基础上
采用均匀试验设计优选基质的各种参数为中药透皮给药系统剂型，其最
佳组合每1009敷料液中比例为PVA二5%，CMC一NA=3%，明胶二10
%，高岭土二2%，甘油二5%，消泡剂=0.02%，中药提取液=50%，蒸
馏水=24.98%。(3)湿热环境下密闭性功能敷料护理伤口的作用:①密
闭性功能敷料能隔离和抑制伤口细菌生长。②具有协同镇痛作用，明显
抑制血浆p一EP、心率、呼吸的高峰值，减轻机体的应激反应。③对急性
伤口局部
Objective: According to the unique curative effects of traditional Chinese herbs and civilian medical prescriptions in dealing surgical wounds, the project aims to develop an occlusive function dressing (OFD), which is bacteriostatic, hemostatic, analgesic and detumescent and obviously penetrative, coinciding with the characteristic of south war zone where is hot and humid environment (HHE) and modern battle surgery. The wound healing, complication, disabled rate and death rate were systematically observed in animal models using the selected OFD, which may provide some useful experimental data for the manufacture of nursing dressings specifically to south war zone.
Methods: (1) Six experimental groups were set. To optimize all the factors to form an ideal prescription, hemostatic, analgesic, bacteriostatic pharmacy experiments of the selected traditional Chinese herbs were studied using factorial analysis statistics model. The biological evaluation of the selected dressing was analyzed through three groups of SD mice (each n=10). (2) The suitable membrane matrix components were defined. The best ratios of membrane matrix and herbs for the OFD were scanned by six different matrixes in seven different parameters level according to well-distributed regulation design. (3) Closed soft tissue injuries and cut injuries model in hindlimbs often pigs was established and two groups, OFD and control, were set. The pigs continued to be bred 22 days, exposing to Tdb(33.0?.5) 癈, Twb(32.3+ 0.15) C, rH(68+3)% for 8 hours every day. The vital signs, the amounts of bacteria, the changes of bata-endorphin of plasma (P-EP), the wet and dry weight of injuried tissue, the pathologic chang
es of wounds, the informations of wound healing were systematically analyzed.
Result:(l) The hemostatic, analgesic, detumescent and bacteriostatic effects are significant different in all six power and extract groups compared
with saline control (P<0.01). By comparing with each factor, The hemostatic and detumescent effects of the I-extract was significant lower and the bacteriostatic rate was higher than those of other groups. The minimum inhibitory concentration (MIC) in these six groups were from 0.00625 g/1 to 0.025 g/1. The mean analgesic time of the Ill-extract group was obviously delayed and the mean body-twisting frequency was lower compared with those in other groups (P<0.01), while the hemostatic effect did not showed any difference (P>0.05).
(2) The best components for forming membrane matrix were polyvinyl alcohol, CMC-Na, gelatin, kaolin and glycerin. By multiple regression analysis, seven parameters of six different matrixes showed significant difference (F=13.271, P<0.01) and the regression equations is effective. The suitable components of the matrix Xi=5.0, X2=3.0 , X3 =10, X4=2.0, X5 =5.0, X6=0.02 were defined after many repeated experiments.
(3) In HHE, the results of experiment and control groups were compared as followed: ?Before injuried, there is no difference in body temperature in HHE state (P>0.05), while there was significant difference since the first day to the 5th day after injuried in HHE state (PO.01). There were different in body temperature before injuried compared with those in HHE state or the period after HHE in the same group (PO.01). ?The bacterial quantity in the wounds were lower in experimental group at the 4th and 8th hour in HHE and 24 hours after injuried than those in control (P<0.01). (3) There was no difference in tissue water content before injuried compared with that in HHE state (P>0.05), while significant difference 24 hours since injuried (P<0.01). The muscle fiber slightly swelled and muscle grudge became wider in HHE state and 24 hours after injuried compared with those in control. (4) There was no significant difference in the level of plasma B-EP before injuried (P>0.05), while it showed significant difference at o.5h after injuried, in HHE state or after HHE between the two groups (P<0.01). In experimental group, there was significant difference before injuried than
that
引文
[1] Richard Bs. A review of orthopedic injuries in three recent U.s military conflicts[J]. Military Medicine.2000; 165(6):463-466.
[2] 赵东升，裴国献，魏海宽等．湿热环境火器伤细菌学定量观[J]．第一军医大学学报，2001，21(1)：8-9．
[3] Witkowski JA, Parish LC. Occlusive therapy in historical perspective[J]. Int J Dermatol. 1998;37(7):555-8.
[4] Linda BN. helping wound heal[J]. FDA Consumer, 2002,23(1): 1-5.
[5] 张洁，牛星焘，李冬．密闭性敷料与凡士林油纱条对皮片供皮区创面愈合的比较研究[J]．中华整形外科杂志．2000；16(6)：351-3．
[6] James, Trish P, Pamela A, et al. Risk factors and clinical impact of central line infection in the surgical intensive care unit[J]. Arch surg, 1998; 133:1241-5.
[7] 汪雅萍，陈同钧．十一种中草药对细菌的体外抑菌作用分析[J]．上海医学检验杂志，1999，14(4)：206-207．
[8] 李亚洁，蔡文智．密闭性敷料的研究和进展．国外医学护理学分册．2002，21(3)：105-108．
[9] 路晓钦，高月．中药复方现代化药理研究方法进展[J]．中药新药与临床药理 2002，13(1)：59-62．
[10] 舒洪权．复方紫草浸膏抗炎止血作用的实验研究[J]．甘肃中医学院，2002，19(3)：7-9．
[11] 万海同，余道军，雷烨等．金平感颗粒抗炎、止痛作用的实验研究[J]．中药药理与临床 2002，18(3)：39-40．
[12] 刘体全，郝勇，王利青等．氮酮对厌氧菌的体外抗菌活性研究[J]．中国公共卫生，1998，14(4)：238．
[13] 李仲兴，王秀华，岳云升等．用新方法进行秦皮对308株临床菌株的体外抑菌活性研究[J]．中医药研究，2000；16(5)：5-8．
[14] 唐瑛，张汉华，邢素兰等．实验研究中药药物绷带治疗急性软组织损伤的实验研[J]．中国实验方剂学杂志．1997，4(5)：5-6．
[15] 沈映君主编．中药药理学。北京：人民卫生出版社，192-280．
[16] 韩新高．浅析中药止血药的机理和应用[J]．基层中志，2000，14(6)：55-56．
[17] 唐迎香．谈止痛中药的应用规律[J]．中国中药杂志．1997；22(4)：244-7．
[18] 冯素萍，毋玉梅．创伤感染病原菌耐药性与抗生素使用情况调查分析[J]．中医正骨，1998：10(2)：72-76．
[19] 王正国主编．野战外科学．北京，人民军医出版社．1999，598—72．
[20] 盛炎炎，朱传琴，丁锷．创伤膏消肿止痛的实验研究[J]．中国中医骨伤科杂志，1997：5(1)：1-3
[21] Hunt TK. Basic principles of wound healing: Growth factor and macrophage interaction[J]. J Trauma,1990;30(12): 129.
[22] 徐莲英，陶建生，冯怡等．中药制剂发展的回顾[J]．中成药，2002，22(1)：6-22．
[23] 董方言主编．现代实用中药新剂型新技术．北京：人民卫生出版社 2001：1-8，129-41，673-679．
[24 郑俊民主编．经皮给药新剂型．北京：人民卫生出版社，1997：119-132．
[25] 李卫民，高英，陆森和等．均匀设计方法在筛选丹皮与薄荷最佳配比中的应用[J]．中药实验方剂学杂志，2002，8(3)：26-28．
[26] 高景莘，余涛．正确运用均匀设计法和正交设计法[J]．基层中药杂志，2002，16(5)：25-26．
[27] 王鹏，王玉珠，沈建民．均匀设计及其在药学中的应用[J]．沈阳学院学报．1989，6(4)：305-308．
[28] 付小兵，王德文主编．创伤修复基础．北京：人民军医出版社，1997：73-75．
[29] Kannon GA, Garrett AB. Moist wound healing with occlusive dressings. A clinical review. Dermatol surg. 1995; 21(7): 583-90.
[30] 程相文，杨碧青，梁碧霞等．战伤急救现代高技术局部战争中战伤特点与急救[J]．海南医学2002，13(7)：69．
[31] 施新猷主编．现代医学实验动物学．北京：人民卫生出版社，2000：
138-141，505-513．
[32] 付小兵，孙同柱，盛志勇．几种用于创伤修复研究的动物模型[J]．中华实验外科杂志，1999，16(5)：479-480．
[33] Hauser C J, Zhou X, Joshi P, et al. The immune microenvironment of human fracture/soft tissue hematomas and its relationship to systemic immunity[J]. J Trauma,1997,42(5):895-903.
[34] 李利平，马恩庆．烧伤创面细菌定量方法与意义[J]．中国烧伤创疡杂志，1998，10(4)：53-56．
[35] 罗炳德，闫文生，万为人等．热性发热兔血浆脂多糖(LPs)浓度与生理反应的变化[J]．中国应用生理学杂志，1998，14(2)：166-169．
[36] Lawrence JC. Dressings and wound infection [J]. Am J surg, 1994,167(1):21.
[37] 郑雪平．中药促进创口愈合的研究近况[J]．中医外治杂志，2000，9(3)：8-9．
[38] 张金山，冯金花，安建雄．急腹症与慢性脊神经痛患者血浆β-EP含量研究[J]．中国疼痛医学杂志，1998：4(1)：19-23．
[39] Hawranko AA, serafini M,smith DJ. Anti-analgesia and reduced antinociception from supraspinally administered beta-endorphin in stressed rats: dependence on spinal cholecystokinin via cholecystokinin Breeeptors[J]. Neurosci Lett 1999; 28 (2): 101-4.
[40] 雷亚峰．驱风止痛膏对大鼠外伤瘀血模型血浆β-EP的变化分析[J]．安徽中医临床杂志．2000，12(1)：29．
[41] Huang Ys Jiang JW Wu GC et al. Effect of melatonin and electroacupuncture (EA) on NK cell activity interleukin-2 production and POMC-derived peptides in traumatic rats[J]. Acupunct Electrother Res, 2002; 27(2): 95-105.
[42] 王学敏，刘滨婴，徐惠芳．不同镇痛方法对老年人术后应激反应的影响[J]．上海医学，25(增刊)：118．120．
[43] Pokele M. Effect of opioid induced analgesia on beta-endorphin cortisol and glucose responses in neonates with cardio respiratory problems[J]. Biology of the Neonate,1993; 64: 360-7.
[44] Homayoun P, Parkins NE, soblosky J, et al. Cortical impact injury in rats promotes a rapid and sustained increase in polyunsataurated free fatty acids and diacylglycerols[J]. Neurochem-Res.2000;25(2):269-76.
[45] 王文俭，辛艳茹，贺秀棣等．消肿止痛膏在家兔中的药效学实验[J]．中国临床药学杂志 2000，9(6)：344-7．
[46] 李秀兰．在创面愈合中毛细血管通透性的动态研究．中国骨伤，1994，7(2)：5-7．
[47] 张凤春，陈云峰，苏彦珍．地龙促进大白兔背部创伤伤口收缩的实验研究[J]．中国中药杂志．1998，23(9)：561-562．
[48] Cutting KF. The causes and prevention of maceration of the skin[J]. Prof Nurse.2001; 17(3): 177-8.
[49] 王正国．创伤愈合与组织修复．创伤医学基础．北京：人民卫生出版社，1999：111-113．
[50] Hutchinson JJ, McGuekin M.Ocelusive dressings: a microbiologic and clinical review[J]. Am J Infect Control. 1990; 18(4):257-68.
[51] 张洁，牛星焘，李冬．密闭性敷料与凡士林油纱条对皮片供皮区创面愈合的比较研究[J]．中华整形外科杂志．2000：16(6)：351-3．
[52] Atiyeh Bs, El-Musa KA, Dham R. scar quality and physiologic barrier function restoration after moist and moist-exposed dressings of partial-thickness wounds[J].Dermatol surg 2003; 29(1): 14-20.
[53] 高纪和，王慧生，王志华等．中药涂膜剂治疗创伤的临床与实验研究[J]．天津中医学院学报，1998，17(3)：42-43．
[54] Vander Meer W, Verwiel JM, Gidding CE, et al. Bacteria in blood smears: overwhelming sepsis or trivial contamination. Aeta Haematol. 2002,107(4):220-3.