Article(id=1210676789316285342, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1210676785113600955, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.2021.05.16, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1606147200000, receivedDateStr=2020-11-24, revisedDate=1614960000000, revisedDateStr=2021-03-06, acceptedDate=null, acceptedDateStr=null, onlineDate=1766577439860, onlineDateStr=2025-12-24, pubDate=1622131200000, pubDateStr=2021-05-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1766577439860, onlineIssueDateStr=2025-12-24, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1766577439860, creator=13701087609, updateTime=1766577439860, updator=13701087609, issue=Issue{id=1210676785113600955, tenantId=1146029695717560320, journalId=1189873630562394117, year='2021', volume='46', issue='5', pageStart='425', pageEnd='530', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1766577438858, creator=13701087609, updateTime=1766718730270, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1211269404306838321, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1210676785113600955, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1211269404306838322, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1210676785113600955, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=525, endPage=530, ext={EN=ArticleExt(id=1210676789635052457, articleId=1210676789316285342, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Research progress of intravascular cooling in clinical treatment of heatstroke, columnId=1190243275882729994, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Review, runingTitle=null, highlight=null, articleAbstract=

Heatstroke is a disease with high morbidity and mortality that causes a patient's core body temperature to be higher than 40.5℃ and combined with organ dysfunction when human body exposed to high temperature, high humidity and slow air circulation environment or after strenuous exercise. Early diagnosis and early cooling can significantly improve patient prognosis, increase patient survival rate and reduce complications. The cooling measures include extravascular cooling which mainly refers to physical cooling of body surface and intravascular cooling is mainly for patients who are not suitable for physical cooling or whose diagnosis and treatment are delayed due to lack of resources, especially for patients with heatstroke, which has a better cooling effect and can improve the prognosis of patients. Currently, the commonly used intravascular cooling measures in clinical practice mainly include intravascular infusion cooling, intravascular temperature management devices cooling and continuous blood purification.This article reviews the classification, mechanism, clinical application, advantages and disadvantages of intravascular cooling.

, correspAuthors=Lei Su, authorNote=null, correspAuthorsNote=
*E-mail:
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重症中暑(HS)指在高温、高湿且空气流通缓慢的环境下或剧烈运动后导致患者核心体温高于40.5℃,同时合并脏器功能损伤的一种疾病,其发病率及致死率均较高。早期诊断、早期降温可明显改善患者预后,提高生存率,减少并发症。重症中暑的降温措施可分为血管外降温及血管内降温,血管外降温主要为体表物理降温,血管内降温主要用于不适宜物理降温或因资源短缺导致诊治不及时的患者,尤其对重症中暑降温效果较好,能明显改善患者预后。目前临床上常用的血管内降温措施主要包括血管内输注降温、血管内温度管理装置降温及持续血液净化等。该文主要从血管内降温的类别、机制、临床应用及优缺点等方面进行综述。

, correspAuthors=苏磊, authorNote=null, correspAuthorsNote=
苏磊,E-mail:
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夏诗语,硕士研究生,主要从事重症中暑的基础与临床研究

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血管内降温在重症中暑临床救治中的作用研究进展
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夏诗语 1 , 林国东 2 , 苏磊 1, 2, *
解放军医学杂志 | 综述 2021,46(5): 525-530
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解放军医学杂志 | 综述 2021, 46(5): 525-530
血管内降温在重症中暑临床救治中的作用研究进展
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夏诗语1, 林国东2, 苏磊1, 2, *
作者信息
  • 1广东药科大学临床医学院,广州 510080
  • 2解放军南部战区总医院重症医学科/全军热区创伤救治与组织修复重点实验室,广州 510010
  • 夏诗语,硕士研究生,主要从事重症中暑的基础与临床研究

通讯作者:

苏磊,E-mail:
Research progress of intravascular cooling in clinical treatment of heatstroke
Shi-Yu Xia1, Guo-Dong Lin2, Lei Su1, 2, *
Affiliations
  • 1School of Clinical Medicine of Guangdong Pharmaceutical University, Guangzhou 510080, China
  • 2Department of Intensive Care Unit/Key Laboratory of Hot Zone Trauma Care and Tissue Repair of Chinese PLA, General Hospital of Southern Theatre Command, Guangzhou 510010, China
出版时间: 2021-05-28 doi: 10.11855/j.issn.0577-7402.2021.05.16
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重症中暑(HS)指在高温、高湿且空气流通缓慢的环境下或剧烈运动后导致患者核心体温高于40.5℃,同时合并脏器功能损伤的一种疾病,其发病率及致死率均较高。早期诊断、早期降温可明显改善患者预后,提高生存率,减少并发症。重症中暑的降温措施可分为血管外降温及血管内降温,血管外降温主要为体表物理降温,血管内降温主要用于不适宜物理降温或因资源短缺导致诊治不及时的患者,尤其对重症中暑降温效果较好,能明显改善患者预后。目前临床上常用的血管内降温措施主要包括血管内输注降温、血管内温度管理装置降温及持续血液净化等。该文主要从血管内降温的类别、机制、临床应用及优缺点等方面进行综述。

重症中暑  /  物理降温  /  致伤机制  /  血管内降温

Heatstroke is a disease with high morbidity and mortality that causes a patient's core body temperature to be higher than 40.5℃ and combined with organ dysfunction when human body exposed to high temperature, high humidity and slow air circulation environment or after strenuous exercise. Early diagnosis and early cooling can significantly improve patient prognosis, increase patient survival rate and reduce complications. The cooling measures include extravascular cooling which mainly refers to physical cooling of body surface and intravascular cooling is mainly for patients who are not suitable for physical cooling or whose diagnosis and treatment are delayed due to lack of resources, especially for patients with heatstroke, which has a better cooling effect and can improve the prognosis of patients. Currently, the commonly used intravascular cooling measures in clinical practice mainly include intravascular infusion cooling, intravascular temperature management devices cooling and continuous blood purification.This article reviews the classification, mechanism, clinical application, advantages and disadvantages of intravascular cooling.

heatstroke  /  physical cooling  /  injury mechanism  /  intravascular cooling
夏诗语, 林国东, 苏磊. 血管内降温在重症中暑临床救治中的作用研究进展. 解放军医学杂志, 2021 , 46 (5) : 525 -530 . DOI: 10.11855/j.issn.0577-7402.2021.05.16
Shi-Yu Xia, Guo-Dong Lin, Lei Su. Research progress of intravascular cooling in clinical treatment of heatstroke[J]. Medical Journal of Chinese People’s Liberation Army, 2021 , 46 (5) : 525 -530 . DOI: 10.11855/j.issn.0577-7402.2021.05.16
中暑是指机体在炎热环境或运动时热量累积量超过了自身体温调节能力引起的急性疾病[1-2]。核心体温超过40.5℃且伴随中枢神经系统、凝血系统功能障碍甚至多器官衰竭可定义为重症中暑(heatstroke,HS)[3]。全球气候变暖、气温上升导致HS高发,呈现高发病率、高病死率的态势[4]。据不完全统计,2003年法国热浪造成了15 000余人死亡[5];2009—2010年美国有8251人次因中暑就诊于急诊科[6];2019年在日本出现的为期11 d的热浪中,发生了34 147例与中暑相关的急救事件[7]。目前治疗HS的主要手段包括早期降温及脏器保护,其中早期降温是影响患者预后的重要干预措施[8],降温的主要措施分为血管外降温及血管内降温。血管内降温能有效提高HS患者的生存率,本文就HS的血管内降温研究进展进行综述。
HS主要表现为暴露于炎热环境或过度体力活动后出现高热反应及神经系统异常,根据热量失衡机制分为经典型重症中暑(classic heatstroke,CHS)及劳力型重症中暑(exertional heatstroke,EHS)[1]。CHS是患者暴露于热环境后因机体散热机制不良所致[9],多发生于老年人或婴幼儿,患者皮肤常呈干燥状态,可能会出现潮红或苍白,合并其他基础疾病的老年CHS患者病死率高达50%[10]。而EHS与机体运动有关,是由于代谢产热超过生理散热机制的耐受范围而造成热损伤,多发生于运动员、劳动者、士兵及身体耐受力不佳者,典型的EHS患者皮肤呈潮湿状态,甚至大汗淋漓[11],其病死率(约10%)低于CHS[12],若合并低血压则高达33%[13]。通过早期诊断及治疗,HS的病死率可降至5%以下[10],因此,患者一旦出现发热合并神经系统症状时,应排除HS后再考虑其他疾病[1]
HS的主要致病机制是由于体温调节失常、体温升高导致的细胞毒性作用及炎症反应[14]。核心体温升高会触发内皮细胞、白细胞及上皮细胞的协同应激反应,以避免组织损伤、促进细胞修复,但该反应随着血浆及组织中热激蛋白分子伴侣家族以及促炎、抗炎细胞因子水平的变化而变化,长时间的高热导致急性生理变化,直接造成细胞毒性作用加剧,从而致使炎症反应失调。HS相关的炎症反应类似于全身性炎症反应综合征(systemic inflammatory response syndrome,SIRS),会导致病情迅速恶化,序贯出现弥散性血管内凝血(disseminated intravascular coagulation,DIC)、多器官功能障碍综合征(multiple organ dysfunction syndrome,MODS)甚至死亡。另外HS可引起肠血流量减少,导致胃肠道缺血,降低细胞活力及细胞壁通透性,使内毒素及可能的病原体穿透生理屏障进入体循环,最终加速HS的病情进展[1]
HS救治涉及两个关键点:第一是早期降温,第二是早期的脏器保护[14],尤其是早期降温对改善HS患者的预后具有重要意义。早期降温通常是指在30 min内将患者核心体温降至39.0℃以下,2 h内降至38.5℃以下,以减少高温对机体的持续打击[15]。研究发现,EHS的降温速率大于0.1℃/min可明显改善患者预后[16],而CHS多发生于老年人或婴幼儿,剧烈的温度变化会引起患者不适感加重或诱发其他并发症,因而对此类人群的降温速率没有严格要求。
主要包括冷水浸泡降温、大血管冰敷降温、冰毯机降温,以及风扇和雾化等蒸发技术降温。冷水浸泡降温的速率一般可达0.20~0.35℃/min,是缓解健康成年人EHS最有效的方式之一,但存在以下弊端[17-18]:(1)使用冷水浸泡降温时,皮肤受到寒冷刺激容易产生剧烈肌颤,通过战栗产热的方式来对抗皮肤感受器的寒冷刺激,造成降温速度缓慢;(2)周围血管收缩及肌颤会加重横纹肌溶解,造成肾小管堵塞,进一步加重肾损伤;(3)对年老体弱且合并其他基础疾病的患者可造成二次打击;(4)体温调节机制不完善的儿童或非常肥胖的成年患者,降温速率会有所不同;(5)冷水浸泡降温的患者有溺水的风险,且降温过程中无法及时使用心脏除颤仪,易造成病情延误。大血管冰敷降温是将冰袋放置于颈部、腹股沟、腋窝等血流丰富处通过热传导降温。使用冰毯机降温时一般将冰毯机设定为起始温度38.5℃,停机温度37.5℃,毯面温度4℃,使患者平卧于毯面上配合冰枕及冰帽通过热传导降温,但上述二者均可能使皮肤血管收缩,降温效果变差,应配合有效按摩,使降温速率为0.034℃/min左右,否则易造成局部冻伤[19]。在战时、热带雨林地区训练场景、自然灾害救援现场、远程竞技比赛或热浪来袭等特殊环境下受灾人数较多时,受限于环境或后勤储备能力,常无法广泛使用冷水浸泡降温或冰毯机降温,仅能使用大血管冰敷、风扇及雾化蒸发技术降温,但大血管冰敷降温速率较慢,且需要额外辅助,风扇及雾化蒸发技术降温效果较弱且不稳定,难以达到理想的降温效果[1]。另外,一些方式不能准确地评估中心温度如测量鼓膜、口腔、颞叶、腋窝等部位,会混淆医师对病情的判断,延误降温时机,使降温效果变差[15]。开始降温8~10 min可能会出现核心体温无变化,甚至不降反升的情况,后期也会因降温无法控制造成低体温状态,因此应使用敏感的直肠测温仪实时监测患者体温[20]
临床上使用的非甾体类解热镇痛药如阿司匹林、吲哚美辛、对乙酰氨基酚等主要通过抑制前列腺素或降低体温调定点而发挥作用,对中暑导致的高热无效,盲目使用还可能加重凝血功能障碍及肝损伤[10,13]。Audet等[21]发现,吲哚美辛可加重中暑,对肠道具有高度破坏性,大剂量使用会导致全身性炎症反应加重,增加并发症的发生风险。丹曲洛林可用于治疗恶性高热,能通过减少肌质网内钙离子的释放,在骨骼肌兴奋-收缩耦联水平上发挥作用,但针对CHS患者的临床随机对照试验显示丹曲洛林无法提升降温速率,且未能改善患者预后[13]。有研究报道氯丙嗪对HS有较好的降温效果,与常规物理降温配合使用能明显缩短高热持续时间,使体温更快降至正常,但氯丙嗪具有很强的镇静作用,可能会加重患者的意识障碍,大剂量使用还可能出现呼吸抑制[22]。另外,氯丙嗪相关的锥体外系症状可导致患者肌张力增强、肌肉震颤,进一步加重患者的横纹肌溶解[23],且对肝脏的损害作用也限制了其在临床的应用。
目前临床上仍在使用的空腔脏器降温方法主要是胃腔及直肠灌洗降温法。胃腔灌洗需将4℃生理盐水(10 ml/kg)在1 min内经胃管快速注入,1 min后吸出,反复多次。直肠灌洗需将200~500 ml的4℃生理盐水以15~20 ml/min的速度注入肠腔,深度不小于6 cm,1~2 min后放出,反复多次,速度不宜过快[19]。姚欣等[24]使用结肠灌注治疗机插入中暑犬直肠10 cm进行灌注降温,结果发现其降温效果优于冰敷。
血管内降温措施包括输注降温、温度管理装置降温及持续血液净化,多用于院前急救、途中转运及监护病房的中暑治疗中,对于合并中枢功能受损、MODS及DIC的HS患者具有较好的疗效。
赵洪达等[25]使用静脉输注降温治疗HS患者取得了较好的效果。王洋[26]及廖达林等[27]的研究也证实了血管内输注降温的治疗效果。2019年发布的《中国热射病诊断与治疗专家共识》推荐在60 min内通过开放静脉通道输注25 ml/kg或总量1000~1500 ml的4℃生理盐水至患者体内进行血管内输注降温,其中快速输注是治疗的关键,若救治现场无4℃生理盐水也可用室温生理盐水替代[19]。Mok等[28]将290例中暑患者分为冰敷加4℃生理盐水静脉输注降温组与仅冰敷降温组,结果显示冰敷加4℃生理盐水静脉输注降温组的住院时间减少,肌酐峰值降低,且患者的平均动脉血压、肾功能及酸碱平衡也得到了显著改善。Morrison等[29]为了对比4℃及22℃生理盐水对高热患者的降温效果,在30 min内将上述两种生理盐水(2 L)快速注入12例高热患者体内,发现二者均可有效降低患者核心体温,但4℃生理盐水的降温速率较快,为0.066℃/min,且降温速率与患者体重、体表面积、体脂率有一定相关性,12例患者均未出现明显的寒战。Kliegel等[30]采用血管内输注降温治疗26例心脏骤停患者,结果13例存活且无明显神经系统症状,仅2例的肺部影像学表现出轻度肺水肿,其他指标如血清电解质、血红蛋白及血小板计数无明显变化。2019年,美国野外医学会在《预防及治疗热病的实践指南》中将静脉输注降温作为治疗EHS的1B级推荐方案,口服或静脉补液都能减轻中暑患者的心血管损伤及热应激作用,但对于有精神失常及癫癎发作风险的中暑患者,静脉输注降温可最大程度地减少吸入风险及随后的气道损害[13]。另外,CHS患者应用血管内输注降温后降温速率较快,在紧急情况或中暑流行期能及时抢救患者,也可避免老年人及婴幼儿使用冷水浸泡降温溺亡的风险[1]。血管内输注降温不仅可降低中暑患者的核心体温,还能恢复其血压及组织灌注,维持血流动力学稳定[20]。使用该方式降温时应注意以下几点:(1)对合并有冠心病的患者,应控制输入液体量,预防肺水肿;(2)及时监测血压、心率、尿色、尿量及凝血功能等[13],对血压较低的患者还应进行有创血流动力学监测[20];(3)对发生急性肾损害(acute kidney injury,AKI)的患者,大量补液会加剧组织细胞损害,需评估患者病情,选用合适的利尿剂,密切监测患者的尿量及血流动力学变化。
Yokobori等[31]使用血管内冷却装置(endovascular cooling device,ECD)治疗中暑患者,方法是将一个装有两个气球的热交换导管插入中暑患者股、颈或锁骨下静脉,在导管与气球的闭环系统中循环可调节温度的生理盐水,从而达到调节体温的目的。该方法与常规降温方法结合治疗HS能更好地进行温度管理,而精确降温能减少过度炎症反应及随后发生的不良事件。Bursey等[32]报道1例患者经50 min的标准降温后,核心体温未充分下降,且合并有中枢神经系统损伤,但使用ECD治疗30 min后,患者的体温迅速降至38.9℃,45 min后体温降至37.5℃,降温速率达0.08℃/min。ECD较多应用于院前心脏骤停的亚低温治疗中,能比体表降温更有效地保护患者的中枢神经功能,降低亚低温的诱导时间,防止脑损害、过度降温及心率失常[33]。Walker等[34]也证实了ECD能减缓脑部新陈代谢,抑制兴奋性细胞死亡,同时减少脑血流量,降低颅内压,减轻氧化性损伤,减少脑部炎症反应,从而保护中枢神经功能。但有研究提出使用ECD降温会增加血栓形成的风险,因此需密切监测患者的凝血功能,可通过静脉注射肝素及抗凝血酶预防血栓形成,肝素的用量需根据患者情况进行调整[35]。ECD是一项有创降温措施,其临床应用增加了护理难度及管理风险,但该方法能迅速降低患者的核心体温,维持亚低温状态,已被应用于心搏骤停后的脑复苏、急性心肌梗死、急性脑卒中、恶性高热及癫癎等多种危重疾病的亚低温治疗[36]。ECD具有其他降温方式难以达到的降温速度快、测温准确及控温能力强等优点,临床上可将其作为HS降温措施的备选方案[33]
持续性血液净化治疗是我国HS治疗中重要的脏器保护手段,血流速度越快,置换液量越大,降温越迅速。常用的持续静脉-静脉血液透析滤过(CVVHDF)模式能实现更高的透析/置换液流速,降温更快[19]。该模式是由简单血浆交换(PE)、连续血液透析滤过(CHDF)、血浆渗滤(PDF)及持续性血浆透析滤过(CPDF)逐级发展而来的。Wakino等[37]报道中暑患者使用低温透析液(35℃)进行高流速(18 000 ml/h)CHDF后,体温在3 h内降至38.0℃以下,并保持低于38.0℃,从而达到降温目的。Fan等[38]报道了1例应用CHDF治疗的EHS患者,使用32℃透析液使患者核心体温从40.3℃快速降到38.5℃以下,然后将透析液温度调整为35℃,流速保持在12 000 ml/h,患者次日体温维持在37.5℃以下。Inoue等[39]也报道了1例应用CPDF成功治愈的EHS合并多器官衰竭患者,CPDF冷透析液热交换使患者核心体温从40℃以上迅速降至正常,且透析膜的滤过作用能使患者血浆中的炎性因子水平下降,有效阻止全身性炎症反应及多器官功能障碍。Chen等[40]的研究也证实CHDF、PDF及CPDF可用于治疗HS合并多器官功能衰竭。CHDF使用高渗透性聚丙烯腈中空纤维膜(APF-10S)进行高流速透析时可去除大分子量物质如肌红蛋白及炎性因子,还可去除尿酸等小分子量的有毒物质,而低温透析液的大量流动使患者体温迅速下降。有研究者提出CHDF可造成微量元素流失,应注意及时补充[41]。PDF由PE及CHDF疗法演变而来,可纠正电解质平衡紊乱并控制液体量。PDF使用选择性等离子体膜血浆分离器,该膜的孔径较小(0.01 mm),白蛋白的筛分系数为0.3,可有选择地滤除低分子量或中等分子量的白蛋白结合物质,更好地清除炎性因子。CPDF结合了CHDF及PDF的优点,还有助于纠正电解质紊乱、酸碱平衡、渗透压及体液失衡,是治疗HS合并多器官衰竭的主要方案[39]。由于持续性血液净化治疗需要大量的低温置换液,所以该疗法较昂贵,且需要进行有创操作,增加了感染的风险。
Cattaneo等[42]在体外研究中将10℃的冷却液以100 ml/min的速度持续注入新型4囊冷却导管内,此方法可在2 min内使模拟正常颈总动脉流量模型内部温度降低1.6℃,使模拟远端大脑中动脉闭塞后的颈总动脉低流量模型的内部温度降低2.2℃,验证了新导管系统冷却颈动脉血流的可行性。Willms等[43]采用自动输液器对12例急性脑损伤及高热发作患者进行治疗,该设备的温度探测头置于患者食管中,一端连接普通液体,根据患者连续体温测量值、液体及温度目标自动调节液体输入时的温度及速率,结果治疗成功且无不良事件发生,证实了该新型自动输液器在临床降温中的有效性。这些新的血管内降温技术及装备都可运用于HS患者的救治,如用于紧急救援的灾难现场及军事训练中。血管内降温治疗比物理降温速度更快、效果更稳定,且更易于控制,能更安全可靠地对患者进行高效复苏。
中暑尤其是HS是一种高致死率疾病,早期降温是降低其病死率的关键措施。目前,临床上多使用血管外降温方式,尤其是体表物理降温。冰敷、风扇及蒸发等基础体表物理降温方式早期方便快捷但降温效果不稳定;冷水浸泡降温虽有明确的降温效果但对设备及环境要求较高,且不适用于儿童及老年人。在血管外降温失败的情况下,血管内降温可及时补救并持续作用于治疗的中后期:输注降温简单快捷,血管温度管理装置降温效果稳定,血液净化在降温的同时可以清除炎性因子进而改善患者预后。使用血管内降温可能会导致血流动力学不稳定,增加血栓形成风险,因此其临床应用仍较为谨慎,但目前已经有多种应对措施可以降低血管内降温带来的相关风险[35,44]
综上所述,针对HS的早期救治,血管内降温未来有着较为广阔的临床应用前景。新型血管内降温技术及装置的研发应用可能会提高HS的救治率,改善中暑患者的预后,但仍需进一步研究以明确其临床效果及实用价值。
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doi: 10.11855/j.issn.0577-7402.2021.05.16
  • 接收时间:2020-11-24
  • 首发时间:2025-12-24
  • 出版时间:2021-05-28
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  • 收稿日期:2020-11-24
  • 修回日期:2021-03-06
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    1广东药科大学临床医学院,广州 510080
    2解放军南部战区总医院重症医学科/全军热区创伤救治与组织修复重点实验室,广州 510010

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2种不同金属材料的力学参数

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total species (%)

Genus
种数
Number of
species
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鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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