重症急性胰腺炎早期液体治疗对预后的影响

Effect of fluid balance on the prognosis of severe acute pancreatitis in early stage

目的研究重症急性胰腺炎（SAP）早期治疗时液体平衡状态对预后的影响，探讨SAP早期液体复苏治疗的最佳策略。方法选择2014年1月至2015年12月收入或转人大连医科大学附属第一医院重症监护病房（ICU）的成人SAP病人83例，根据预后将病人分为好转组（71例）和死亡组（12例），比较两组连续肾脏替代治疗（CRRT）开始时间、CRRT持续时间、入ICU第1～7天液体平衡量等指标，通过多因素Logistic回归分析判断影响预后的独立因素。结果与好转组相比，死亡组开始CRRT时间更晚（P〈0．05），机械通气时间、CRRT持续时间及住院时间更长（P〈0．05）；入住ICU前7d液体平衡量均存在差异，第1～3天好转组液体正平衡量高于死亡组（P〈0．05），第4～7天液体正平衡量明显低于死亡组（P〈0．05），且第5～6天好转组液体呈负平衡；多因素Logistic回归分析结果显示，CRRT开始时间（P=0．007，OR=0．491）、第5天液体平衡量（P=0．017，OR=2．233）、第3天液体平衡量（P=0．019，OR=2．402）是SAP预后的独立危险因素。结论早期充足的液体复苏及CRRT、循环稳定后尽早采取限制性补液措施可改善SAP病人的预后。

Objective To investigate the effect of fluid balance on the prognosis in early stage of severe acute pancreatitis （SAP）, and to explore the best strategy of early fluid resuscitation in SAP. Methods Eighty-three adult SAP patients were admitted or transferred to the intensive care unit （ICU） of the First Affiliated Hospital of Dalian Medical University from January 2014 to December 2015 ,and divided into two groups： improved （71 cases） and death groups （12 eases） according to the outcome. The clinical characteristics, including the continuous renal replacement therapy （CRRT） starting time, CRRT lasting time, daily fluid balance and so on, were compared and analyzed through the multi Logistic regression analysis to determine the independent prognostic factors. Results CRRT started later （P〈0. 05）, and the duration of mechanical ventilation, CRRT and hospital stay were lon- ger in the death group than in the improved group （P〈0. 05）. In the early 7 days, there was different in the fluid balance between two groups, and the positive equilibrium fluid volume from day 1 to 3 in the improved group was higher than in the death group （P〈0. 05）. The positive equilibrium fluid volume from day 4 to 7 in the improved group was significantly lower than in the death group （P〈0. 05）, and during 5-6 days there was a negative liquid balance. The results of multivariate analysis showed that the starting time of CRRT （P= 0. 007,OR = 0. 491） ,the fluid balance in the fifth （P= 0. 017,OR = 2. 233） and the third days （P = 0. 019,OR = 2. 402） were the independent risk factors of SAP. Conclusions Early adequate fluid resuscitation and CRRT,negative fluid balance as soon as possible after the stability of hemodynamics may improve the prognosis of patients with SAP.