暴发性胰腺炎急性反应期治疗经验

Therapeutic experience of fulminant acute pancreatitis in acute response stage

目的探讨暴发性胰腺炎(FAP)急性反应期治疗的对策。方法将64例FAP患者分为死亡组(27例)和治愈组(37例)。分析急性反应期内休克时间、肠道功能恢复时间和液体复苏参数;机械通气前24 h氧合指数(PaO2／FiO2)及肺泡动脉氧差(AaDO2)、持续血液滤过(CVVH)应用率、腹腔间隔室综合征(ACS)发生率和疾病严重度。其次,分析外科干预方式及时间对预后的影响。结果死亡组休克持续时间、肠道功能恢复时间较治愈组显著延长(P<0．05);入院至入院后72 h的晶体量两组无显著差异,而治愈组输注的胶体总量和胶晶比值显著高于死亡组,且第三间隙液体潴留量显著低于死亡组(P<0．05);入院日治愈组的液体输注速率显著高于死亡组(P<0．05)。机械通气前24 h死亡组PaO2／FiO2和AaDO2较治愈组呈负性变化(P<0．05)。发病72 h内,治愈组CVVH应用率显著高于死亡组(P<0．05);入院72小时内死亡组ACS发生率高于治愈组(P<0．05);入院后3 d内,死亡组的APACHEⅡ评分显著高于治愈组(P<0．05)。7～14 d内接受手术患者的治愈率显著高于7 d内和14 d后接受手术的治愈率(P<0．05);手术组第1次手术时间较穿刺引流组显著提前(P<0．01),且治愈率明显低于穿刺引流组(P<0．05)。结论缩短缺氧时间、控制持续全身炎症反应综合征(SIRS)及合理的外科干预是FAP急性反应期治疗的关键。

Objective To investigate therapeutic strategy of fulminant acute pancreatitis （FAP） in acute response stage. Methods Sixty-four patients were divided into Death group （27 patients ） and Survival group （37 patients）. The time course of shock and recovery of enteral function, parameters of fluid resuscitation, PaO2/FiO2 and AaDO2 at 24 hours prior to mechanical ventilation, rate of continuous venovenous hemofiltration（CVVH） and abdominal compartment syndrome （ACS）, severity of the disease in the acute response stage were investigated. And the effect of surgical manner and time on the prognosis was also analyzed. Results Compared with Survival group, the time course of shock and recovery of enteral function in Death group were prolonged significantly （ P 〈 0.05 ）. Between the groups, there was no difference in the amount of crystal fluid infused from admission to 72 hours after, but the amount of colloid fluid infused and ratio of amount of colloid and crystal fluid in Survival group were higher（ P 〈 0. 05 ）. The amount of fluid retention in third space from admission to 72 hours after in Death group was higher than that of Survival group significantly （ P 〈 0.05 ）. The fluid infusing rate in Survival group in the first day of admission was faster than Death group （P 〈 0. 05）. PaO2/FiO2 and AaDO2 in 24 hours prior to mechanical ventilation in Death group were negatively changed significantly. Within 72 hours after the onset of the disease, the rate of CVVH in Survival group was higher than Death group. Incidence rate of ACS and the APACHE Ⅱ scores within 72 hours after admission in Death group were higher than in Survival group. The cure rate of the patients operated in the day 7 to day 14 after admission was higher than that of patients operated prior and post this period. Time for the first operation in operated patients was earlier than patients received minimally invasive drainage （MID） and its cure rate was lower than that of MID Group. Conclusions It is the key point to shorten the time course of ischemia, to control persistent systemic inflammatory response syndrome （SIRS） and to adopt reasonable surgical intervention in acute response stage for FAP.