基于术后2h血白细胞计数的即刻干预治疗腔内碎石术后感染性休克的动物实验及临床研究

Effect of initial intervention based on white blood cell count measured within 2 hours postoperatively to treat uroseptic shock induced by upper urinary tract endoscopic lithotripsy （UUTEL） ： animal experiments and clinical study

目的探讨基于术后2 h内血白细胞计数的即刻综合干预是否可以逆转腔内碎石术致感染性休克的发病过程。方法2015年5－7月选取新西兰雌兔24只，月龄2～3个月，体重2.0～2.5kg。构建尿源性感染性休克动物模型。随机数表法分为3组，每组8只。第1组不用抗生素和液体复苏。第2组术后2 h予亚胺培南西司他丁钠15 mg/kg抗感染和生理盐水5 ml/kg液体复苏；第3组术后6 h予敏感抗生素和液体复苏，方法同第2组。观察动物术后10 h的平均动脉压及72 h的存活率。回顾性分析2008年1月至2015年6月收治的46例上尿路结石腔内碎石术后2 h内血白细胞计数〈2.85×109个/L患者的临床数据，依据干预时间分为两组。A组19例，术后常规抗感染及输液治疗，在术后出现血压下降时，加强抗感染（碳青霉烯类）、液体复苏和小剂量激素治疗。B组27例，发现白细胞明显下降时立刻加强抗感染（碳青霉烯类）、液体复苏和小剂量激素治疗。比较两组的感染性休克发生率、气管插管比例、重症监护室停留时间、术后总住院时间、住院费用及病死率。结果动物实验中，第1组术后72 h内全部死亡，中位存活时间11 h；第2组未出现休克，72 h内全部存活；第3组术后72 h内存活6只。46例患者中18例发生急性感染性休克，A组15例，B组3例。气管插管例数A组11例，B组1例，差异有统计学意义（P〈0.05）。A组18例转入重症监护室，停留时间为（10.8±5.4）d；B组6例转入重症监护室，停留时间为（7.5±2.8）d，两组转入重症监护室例数差异有统计学意义（P〈0.05），停留时间差异无统计学意义（P〉0.05）。A、B组术后平均住院时间分别为（19±9.8）d和（7±4.7）d，住院费用分别为（94 583±51 623）元和（35 389±16 342）元，差异均有统计学意义（均P〈0.05）。A组死亡1例，B组无死亡病例。结论依据术后2 h内血白细胞计数的即刻干预可以逆转上尿路腔内碎石术致感染性休克的发病过程，改善预后。

Objective To investigate whether initial intervention based on WBC measured within 2 hours postoperatively can reverse the uroseptic shock induced by UUTEL. Methods From May, 2015 to July 2015,24 female New Zealand rabbits, weighing 2. 0-2. 5 kg,born 2-3 months, used as uroseptic shock model. Their ureters were ligated and followed by injection of Escheriehia eoli solution into the renal pelvis. Then, those animals were randomly assigned into control group（ the first group）and experimental groups （the second group,the third group）. Each group had 8 rabbits initially. The first group did not receive sensitive antibiotic or fluid resuscitation. The second group received imipenem and cilastatin sodium 15mg/kg and normal saline 5 ml/kg 2 hours postoperatively. The third group received sensitive antibiotic and fluid resuscitation the same dosage as the second group 6 hours postoperatively. Mean arterial pressure（MAP） was recorded for 10 hours and survival rate of all groups for 72h postoperatively was recorded.. The clinical data of 46 patients whose WBC count less than 2. 85 × 10^9/L within two hours after UUTEL were analyzed retrospectively. These patients were divided into two groups based on the time of intervention. Group A including 19 patients received routine antibiotic, fluid therapy, low-dose corticosteroids when there was symptom of shock. Group B including 27 patients immediately received resuscitation bundle protocol when there was a drastic decrease in WBC. The incidence of septic shock, the rate of intubation, length of stay in ICU, length of stay in hospital postoperatively, hospitalization cost and survival rate of these two groups were compared. Results All 8 rabbits of the first group died within 72 h, postoperatively and the median time of survival was 11 h. None of the second group rabbits developed shock and all rabbits survived 72 h after operation. 6/8 rabbits of the third group survived 72 h after operation. 15 patients in Group A and 3 patients in Group B experienced acute uroseptic shock （P 〈 0. 05 ）. 11 patients in Group A and one patients in Group B underwent tracheal intubation （ P 〈 0.05 ） . 18 patients in Group A and 6 patients in Group B were transferred to ICU（P〈0.05）, and their length of stay in ICU was （10.8 ±5.4）d and （7.5 ±2.8）d, respectively（ P 〉 0. 05 ）. The length of stay in hospital and hospitalization cost of Group A and B were （ 19 ± 9.8 ）dvs.（ 7±4.7 ）d（P〈0.05）, （94 583±51623） RMB vs. （35 389±16342） RMB respectively （P 〈 0. 05 ）. One patient in Group A died due to acute uroseptic shock and none of Group B died. Conclusions Our animal model and clinical cohort study showed that initial intervention based on WBC measured within 2 hours postoperatively can reverse the uroseptic shock induced by UUTEL and improve the prognosis.