重症急性胰腺炎早期液体平衡对预后的影响

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

目的探讨重症急性胰腺炎(SAP)患者早期液体复苏与预后的相关性。方法采用回顾性分析方法,选取2018年6月至2020年12月云南楚雄彝族自治州人民医院重症医学科收治的SAP患者为研究对象,所有患者均依病情按照相关诊疗规范给予相同的常规治疗,根据患者不同的预后分为死亡组与存活组。分析两组患者性别、年龄、入院时急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)和Ranson评分的差异;以24 h为1个观察日,分别记录死亡组与存活组患者入院后第1个24 h、第2个24 h、第3个24 h的液体入量、出量、净平衡情况,并计算第1个24 h液体入量与72 h液体总入量的比值(FV_(24 h-1 st)),以33%为标准,比较两组患者达到FV_(24 h-1 st)>33%的比例。比较两组之间各指标的差异,分析SAP患者早期液体平衡对预后的影响。结果研究共纳入89例患者,死亡组41例,存活组48例。入重症监护病房(ICU)时死亡组与存活组年龄(岁:57.6±15.2比49.5±15.2)、性别(男性:61.0%比54.2%)、APACHEⅡ评分(分:18.0±2.4比17.3±2.3)和Ranson评分(分:6.3±1.4比5.9±1.2)比较差异均无统计学意义(均P>0.05)。死亡组入ICU后第1个24 h、第2个24 h、第3个24 h的液体入量明显高于存活组,差异有统计学意义(mL:4138±832比3535±1058,3883±729比3324±516,3786±490比3212±609,均P<0.05),且死亡组第1个24 h的液体入量>4100 mL。经治疗后死亡组入ICU后3个24 h段液体出量有增多的趋势,但仍低于存活组入院后3个24 h段的液体出量,差异有统计学意义(mL:1242±465比1795±819,1536±579比2080±524,1610±585比2932±752,均P<0.01)。由于死亡组入ICU后3个24 h段液体总入量均高于存活组,液体总出量均低于存活组,最终死亡组3个24 h段液体净平衡仍高于存活组(mL:2896±782比1740±725,2347±459比1243±795,2176±807比338±289,均P<0.01)。死亡组与存活组FV_(24 h-1 st)>33%的比例差异无统计学意义〔56.1%(23/41)比54.2%(26/48),P>0.05〕。结论液体复苏是早期救治SAP的重要手段,但也存在诸多的不良反应,患者入院后24~72 h内液体的入量、出量、净平衡和FV_(24 h-1 st)等液体复苏指标与SAP患者的预后有关,可作为评估SAP预后的指标。优化的液体复苏策略能更好地改善SAP患者的预后。

Objective To observe the correlation between early fluid resuscitation and prognosis in patients with severe acute pancreatitis(SAP).Methods SAP patients admitted to the department of critical care medicine of the People's Hospital of Chuxiong Yi Autonomous Prefecture of Yunnan Province from June 2018 to December 2020 were enrolled and analyzed retrospectively.All patients were given the routine treatment according to their condition and relevant diagnostic According to their different prognosis,enrolled patients were divided into death group and survival group.The differences in gender,age,acute physiology and chronic health evaluationⅡ(APACHEⅡ)and Ranson score on admission between the two groups were analyzed.Taking 24 hours as an observation day,the fluid inflow,outflow,and net balance at the first,second,and third 24 hours after admission were recorded,and the ratio of the fluid inflow at the first 24 hours to the total fluid inflow in 72 hours(FV_(24 h-1 st))was calculated as a study index.Using 33%as the standard,compare the proportion of patients in the two groups who achieved FV_(24 h-1 st)>33%.The differences of various indicators between the two groups were compared,and the effect of early fluid balance on the prognosis of SAP patients was analyzed.Results Eighty-nine patients were included in the study(41 in the death group,48 in the survival group).There were no statistically significant differences on age(years old:57.6±15.2 vs.49.5±15.2),gender(male:61.0%vs.54.2%),APACHEⅡscore(18.0±2.4 vs.17.3±2.3),and Ranson score(6.3±1.4 vs.5.9±1.2)between the death group and the survival group at the time of admission on the intensive care unit(ICU)(all P>0.05).The fluid intake of the death group in the first 24 hours,the second 24 hours and the third 24 hours after admission to ICU was significantly higher than that of the survival group,and the difference was statistically significant(mL:4138±832 vs.3535±1058,3883±729 vs.3324±516,3786±490 vs.3212±609,all P<0.05),and the fluid inflow in the death group at the first 24 hours was greater than 4100 mL.After treatment,the fluid outflow of the death group at the three 24-hour periods after admission on the ICU was an increasing trend,but it was still significantly less than that of the survival group at the three 24-hour periods(mL:1242±465 vs.1795±819,1536±579 vs.2080±524,1610±585 vs.2932±752,all P<0.01).Due to the fact that the total fluid inflow and total fluid outflow in the three 24-hour periods in the death group were more than those in the survival group,the net fluid balances in the three 24-hour periods in the death group were still significantly more than those in the survival group finally(mL:2896±782 vs.1740±725,2347±459 vs.1243±795,2176±807 vs.338±289,all P<0.01).There was no difference in FV_(24 h-1 st) between the death group and survival group[FV_(24 h-1 st)>33%:56.1%(23/41)vs.54.2%(26/48),P>0.05].Conclusions Fluid resuscitation is an important method for early treatment of SAP,but it also has many adverse reactions.Fluid resuscitation indexes such as fluid inflow,outflow,net balance,and FV_(24 h-1 st) within 24 to 72 hours after admission are related to the prognosis of patients with SAP,and can be used as indicators to evaluate the prognosis of SAP.The optimized fluid resuscitation strategy can improve the prognosis of patients with SAP.