重症胆管炎合并多脏器功能障碍综合征的诊治体会(附30例病例分析)

The clinical characteristic of acute obstruction severe cholangitis(AOSC) complicated with multiple organ dysfunction syndrome(MODS)

目的 :总结探讨重症胆管炎 (AOSC)合并多脏器功能障碍综合征 (MODS)的临床特征及综合处理方法。方法 :对本院ICU近四年来收治 30例AOSC的主要临床特征及诊治要点进行回顾分析。结果 :本组病例中累及单一、两个、三个、四个及五个脏器功能障碍的发生率分别为 2 3 3%、 2 6 7%、 12 5 %、 16 7%和 2 0 0 % ,其死亡率分别为 0、 12 5 %、 2 0 0 %、 6 6 7%及 10 0 % ;MODS发生率为 76 7% ,总病死率为 36 7%。循环系统功能障碍发生率最高 ,其他依次为呼吸、血液、肝脏、肾脏、消化道、神经及代谢系统。凡病人年龄≥ 6 0岁、入院 2 4h内A PACHEⅡ评分≥ 16分、血红蛋白 <10 0g/L、血小板计数 <10 0× 10 9/L、血浆白蛋白 <30g/L、血浆直接胆红素≥ 10 0 μmol/L、发病至治疗时间≥ 72h及入院时有休克者 ,易产生MODS ,其病死率相对为高。结论 :成功抢救AOSC的重要措施包括及时解除胆道梗阻、有效地控制感染以去除MODS的始动和促使因子 ,并在监护病房内对病人进行严密监护和各脏器功能及营养代谢支持治疗 ,以降低MODS的发生率及病死率。

Aim:To investigate the clinical characteristic and systemic modalities of patients with AOSC complicated with MODS.Methods:Retrospectively,we analyzed the main clinical characteristic and therapeutic modalities of 30 cases with AOSC in our ICU in recent 4 years.Results:The morbidity of one,two,three,four and five organ dysfunction involved were 23 3%,26 7%,16 7%,20% and 13 3% respectively and their mortality were 0%,12 5%,16 7%,40%,66 7% and 100% respectively during their hospitalization in this group.The morbidity of MODS was 76 7% and the total mortality was 36 7%.The occurrence rate of each organ dysfunction descended in the order of circulation,respiration,blood,liver,kidney,digestive tract,nerve and metabolic system.Patients whose age ≥60 years,APACHE Ⅱ score≥16 within 24 h after admission,or hemoglobin <100g/L,platelet count <100×10 9/L,plasma albumin <30g/L,plasma direct bilibubin ≥100 umol/L,clinical intervention time after onset ≥72h and those had shock were easy to develop MODS and at risk of death.Conclusion:The key to treat AOSC successfully,is to relieve the obstruction of biliary tract timely and to control the infection effectively,for both of them could reject the trigger factors of MODS.Putting patients in ICU for the monitoring and supporting of every organs function,also giving a nutritive and metabolic support,would reduce the morbidity and mortality of MODS.