重症儿童血清淀粉酶或脂肪酶升高与胰腺损伤的关系

Relationship between changes of increased amylase or lipase levels and pancreas injury in critically ill children

目的 观察血清淀粉酶和脂肪酶升高在重症儿童中的发生率及其与胰腺损伤关系.方法 按照协助组制定的纳入和排除标准前瞻性收集2012年1月至2014年3月来自全国17所三级甲等医院儿科重症监护病房的患儿临床资料.根据血清淀粉酶或脂肪酶水平,将患儿分为正常组（血清淀粉酶和脂肪酶正常）,轻度升高组（1倍＜血清淀粉酶或脂肪酶升高＜3倍）,显著升高组（血清淀粉酶或脂肪酶升高≥3倍）,采用t检验、方差分析、x2检验或非参数检验比较各组间临床表现、胰腺彩色超声、生化指标、器官损伤及衰竭情况、机械通气、脓毒症严重程度、病死率并进行生存分析.对影响淀粉酶或脂肪酶升高的危险因素进行多因素Logistic回归分析.结果 （1）共纳入3 380例患儿（男2 140例、女1 240例）,其中正常组2 607例,轻度升高组569例,显著升高组204例.淀粉酶或脂肪酶升高在重症儿童中的发生率为22.87％ （773/3 380）.（2）3组间低血压、呕吐、腹部压痛、腹肌紧张、腹膜刺激征阳性、肠鸣音减弱、肝脏增大、抽搐及意识障碍发生率差异均具有统计学意义（χ^2=32.264、12.071、13.959、7.979、13.774、12.459、9.443、40.805、99.183,P均＜0.05）.（3）正常组、轻度升高组、显著升高组胰腺彩色超声异常比例分别为0.90％ （4/443）、14.06％ （9/64）、20.83％（5/24）,差异有统计学意义（χ^2=52.925,P=0.000）.（4）3组间碱剩余、白细胞计数、降钙素原、血钙、丙氨酸转氨酶、天冬氨酸转氨酶、肌酐、尿素氮、乳酸脱氢酶、肌酸激酶同工酶异常发生率差异均有统计学意义（x2=59.485、27.634、125.564、102.258、10.175、27.338、80.616、140.521、72.830、72.136,P均＜0.05）.（5）3组间心肌损伤、肝脏损伤、肾损伤、急性呼吸窘迫综合征、颅高压综合征、应激性溃疡、凝血功能障碍、循环功能障碍、严重脓毒症、多器官功能障碍（MODS）、有创机械通气比例及病死率差异均具有统计学意义（χ^2=8.826、17.864、49.061、96.221、106.918、80.559、30.355、99.183、196.412、133.887、154.239、9.206,P均＜0.01）.（6）淀粉酶和脂肪酶正常患儿生存表中位数为75 d,淀粉酶或脂肪酶升高患儿生存表中位数为24d.（7）年龄、抽搐、意识障碍、碱剩余、降钙素原、血钙、机械通气、严重脓毒症及MODS是患儿淀粉酶或脂肪酶升高的危险因素（OR=1.155、1.491、2.237、0.949、0.604、1.008、0.660、1.907、0.836,P均＜0.05）.结论 高淀粉酶血症或高脂肪酶血症在儿童危重症发生率不如成人,胰酶升高是危重症病情发展过程中的伴随表现,可能由于胰腺损伤所致,胰酶越高病情越危重,预后越差.

Objective To observe the occurrence rate of elevated serum amylase and lipase in critically ill children,to explore the relationship between elevated pancreatic enzymes and pancreatic injury,and the effect of elevated pancreatic enzymes on state of illness and the prognosis.Method The data of cases treated in pediatric intensive care unit（ICU） of 17 children＇s hospitals were collected prospectively from January 2012 to March 2014 according to the inclusion and exclusion criteria.The cases were divided into three groups：the control group （amylase or lipase were normal）,mildly elevated group （1 time 〈 increase of serum amylase or 〈 3 times increase of lipase）,highly elevated group （serum amylase or lipase increased 〉 3 times）.Clinical manifestations,pancreatic ultrasound,biochemical indicators,state of organ damage and failure,mechanical ventilation,severity of sepsis,mortality rate and survival were compared among different groups using t test,analysis of variance,chi-square test or non-parametric test.The risk factors of elevated amylase or lipase were analyzed by Logistic regression analysis.Result （1） The 3 380 cases （2 140 boys and 1 240 girls） were divided into three groups：normal group （2 607 cases）,mildly elevated group （569 cases）,highly elevated group （204 cases）.The occurrence rate of elevated serum amylase and lipase in critically ill children was 22.87% （773/3 380）.（2） The differences of occurrence rates of hypotension,vomiting,abdominal tenderness,muscle tension,positive peritoneal irritation,decreased bowel sounds,liver enlargement,seizures and unconsciousness among the three groups were statistically significant （χ^2 =32.264,12.071,13.959,7.979,13.774,12.459,9.443,40.805,99.183,P 〈0.05 for all these comparisons）.（3） The rates of abnormal pancreatic ultrasound in control group,mildly elevated group and highly elevated group were 0.90% （4/443）,14.06% （9/64）,20.83% （5/24） （χ^2 =52.925,P =0.000）.（4） The differences of occurrence rates of BE,white blood cell count,procalcitonin,calcium,alanine aminotransferase,aspartate aminotransferase,creatinine,urea nitrogen,lactate dehydrogenase,CKMB among the three groups were statistically significant （χ^2 =59.485,27.634,125.564,102.258,10.175,27.338,80.616,140.521,72.830,72.136,P all 〈0.05）.（5） The differences of occurrence rates of myocardial damage,liver injury,kidney injury,acute respiratory distress syndrome,intracranial hypertension syndrome,stress ulcer,coagulation disorders,circulatory dysfunction,severe sepsis,multiple organ dysfunction （MODS） among the three groups were statistically significant（χ^2=8.826,17.864,49.061,96.221,106.918,80.559,30.355,99.183,196.412,133.887,154.239,9.206,P all 〈 0.01）.（6） The median of survival table of children with normal pancreas was 75 days,the median of survival table of children with elevated amylase or lipase was 24 days.（7） The risk factors of elevated amylase or lipase were age,convulsions,consciousness,BE,PCT,calcium,mechanical ventilation,severe sepsis and MODS（OR =1.155,1.491,2.237,0.949,0.604,1.008,0.660,1.907,0.836,P all 〈 0.05）.Conclusion The occurrence rate of hyperamylasemia or high lipase levels in critically ill children were lower than adults,elevated pancreatic enzymes was accompanied by the progression of critical illness,pancreatic enzymes elevated probably due to pancreatic damage,which positively correlated with severity of the disease and the prognosis.