不同部位急性胃肠道穿孔所致脓毒性休克的临床分析

Clinical analysis of septic shock caused by acute upper and lower gastrointestinal perforation

目的研究不同部位胃肠道穿孔所致脓毒性休克的临床特征.方法回顾性分析2018年1月至2019年12月贵州医科大学附属医院重症医学科收治的消化道穿孔致脓毒性休克患者的临床资料.收集患者一般资料,入重症监护病房(ICU)24 h内降钙素原(PCT)、急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、序贯器官衰竭评分(SOFA),入ICU 72 h腹水培养结果,ICU住院期间去甲肾上腺素(NE)使用最大剂量和时间,机械通气时间、ICU住院时间、急性肾损伤(AKI)发生情况及需要行连续性肾脏替代治疗(CRRT)情况,以及28 d预后等.以屈氏韧带为界,将胃、十二指肠穿孔者纳入上消化道组,将空肠、回肠、阑尾、结肠及直肠穿孔者纳入下消化道组,比较两组之间的临床特征.结果上消化道穿孔致脓毒性休克33例,下消化道穿孔致脓毒性休克30例.两组性别、年龄差异无统计学意义.上消化道组腹水培养病原菌主要为白假丝酵母菌(45.5%)、屎肠球菌(18.2%)及大肠埃希菌(18.2%);下消化道组大肠埃希菌(46.2%)及屎肠球菌(30.8%)为主要致病菌.上消化道组与下消化道组在PCT、ICU住院时间、机械通气时间、NE最大剂量及使用时间等方面差异均有统计学意义〔PCT(μg/L):17.69(3.83,26.62)比32.82(4.21,100.00),ICU住院时间(h):149.0(102.5,302.0)比115.5(30.8,214.5),机械通气时间(h):106.0(41.5,183.0)比57.5(25.0,122.3),NE最大剂量(μg·kg-1·min-1):1.2(0.5,2.0)比0.7(0.5,1.2),NE总使用时间(h):72.0(21.0,145.0)比26.5(18.0,80.5),均P<0.05〕,而APACHEⅡ和SOFA评分差异无统计学意义〔分:30.0(24.5,35.0)比28.0(25.0,33.5),10.67±4.14比9.50±3.33,均P>0.05〕.与下消化道组比较,上消化道组患者更易发生AKI(78.8%比53.3%,P<0.05)以及需要接受CRRT治疗(39.4%比16.7%,P<0.05),但28 d病死率差异无统计学意义(39.4%比43.3%,P>0.05).结论不同部位胃肠道穿孔所致脓毒性休克的病原菌、病情严重程度、ICU住院时间等特征不尽相同.上消化道穿孔致脓毒性休克患者更常见真菌感染,休克程度更重,更易发生AKI及需要CRRT治疗,机械通气时间及ICU住院时间也更长;而下消化道穿孔致脓毒性休克患者的PCT升高更明显.

Objective To analyze the clinical characteristics of septic shock caused by upper and lower gastrointestinal perforation.Methods Clinical data of patients with septic shock due to gastrointestinal perforation admitted to the department of critical care medicine of the Affiliated Hospital of Guizhou Medical University from January 2018 to December 2019 were analyzed retrospectively.The general information;procalcitonin(PCT),acute physiology and chronic health evaluationⅡ(APACHEⅡ)and sequential organ failure assessment(SOFA)scores during the first 24 hours in intensive care unit(ICU);results of ascites culture during the first 72 hours in ICU;the maximum dosage and total time of norepinephrine(NE)in ICU;mechanical ventilation time,the length of ICU stay,occurrence of acute kidney injury(AKI),continuous renal replacement therapy(CRRT)and 28-day mortality were collected.The patients were divided into upper gastrointestinal tract group(stomach and duodenum)and lower gastrointestinal tract group(jejunum,ileum,appendix,colon and rectum),with a boundary of Treitz.The clinical features between the two groups were compared.Results There were 33 patients in the upper gastrointestinal tract group and 30 patients in the lower gastrointestinal tract group.There was no significant difference in gender and age between the two groups.The main pathogens in the ascites cultures in the upper gastrointestinal tract group were Candida albicans(45.5%),Enterococcus faecalis(18.2%)and Escherichia coli(18.2%).Escherichia coli(46.2%)and Enterococcus faecalis(30.8%)were the main pathogens in the lower gastrointestinal tract group.There were significant differences in PCT,the length of ICU stay,mechanical ventilation time,the maximum dosage and total time of NE between the upper gastrointestinal tract group and lower gastrointestinal tract group[PCT(μg/L):17.69(3.83,26.62)vs.32.82(4.21,100.00),the length of ICU stay(hours):149.0(102.5,302.0)vs.115.5(30.8,214.5),mechanical ventilation time(hours):106.0(41.5,183.0)vs.57.5(25.0,122.3),the maximum dosage of NE(μg·kg-1·min-1):1.2(0.5,2.0)vs.0.7(0.5,1.2),the total time of NE(hours):72.0(21.0,145.0)vs.26.5(18.0,80.5),all P<0.05],while there was no statistically differences in APACHEⅡor SOFA scores[APACHEⅡ:30.0(24.5,35.0)vs.28.0(25.0,33.5),SOFA:10.67±4.14 vs.9.50±3.33,both P>0.05].Compared with the lower gastrointestinal tract group,patients in the upper gastrointestinal tract group were more likely to have AKI(78.8%vs.53.3%,P<0.05)and require CRRT(39.4%vs.16.7%,P<0.05),but there was no significant difference in the 28-day mortality(39.4%vs.43.3%,P>0.05).Conclusions The clinical characteristics of septic shock caused by upper and lower gastrointestinal perforation are not the same.Patients with septic shock caused by upper gastrointestinal perforation are more likely to suffer from fungal infection,with more severe shock,more likely to have AKI and require CRRT,and significantly longer mechanical ventilation and the length of ICU stay.While patients with septic shock caused by lower gastrointestinal perforation showed higher PCT.