CAJ | 학술논문

目的分析危重型急性胰腺炎(CAP)的临床特点,探讨腹腔压力(IAP)、APACHEⅡ评分对CAP患者预后预测的价值.方法筛选2010年1月至2013年3月发病96 h内入住南京军区南京总医院普外科ICU的18～75岁AP患者,其中47例符合根据决定因素的AP分类(determinant-based classification,DBC)中的CAP诊断标准.对这些患者在入院24 h内行APACHEⅡ评分,并测量IAP.记录器官功能衰竭发生情况、中转手术引流例数、入住ICU时间、总住院时间.应用受试者工作特征曲线下面积(AUC)分析IAP、APACHEⅡ评分预测患者预后和中转手术的价值,及其与入住ICU时间、总住院时间的相关性.结果 47例患者入院24h的平均APACHEⅡ评分为13分,平均IAP为16.9 mmHg(1mmHg =0.133 kPa),血培养阳性22例.发生呼吸系统衰竭45例次(96％),肾功能衰竭34例次(72％),心血管功能衰竭22例次(47％),其中出现2、3个器官系统功能衰竭的患者分别为16、19例.17例(36％)患者接受手术引流.院内病死18例(38％).平均入住ICU 31 d,平均总住院时间38 d.IAP水平和APACHEⅡ评分随衰竭器官系统数量的增加逐渐升高,差异具有统计学意义(P＜0.001).IAP水平预测患者病死的AUC为0.80(95％ CI 0.41 ～0.76),以16.1 mmHg为阈值,其敏感性、特异性分别为83％和62％;APACHEⅡ评分预测的AUC为0.58(95％ CI0.38～0.73),以13.5分为阈值,其敏感性、特异性分别为44％和73％.IAP水平预测患者病死的敏感性高于APACHEⅡ评分,两者预测中转手术的敏感性均较低,与患者入住ICU时间、总住院时间均无相关性.结论 CAP具有极高的手术率和病死率.早期监测IAP可以有效预测预后较差的CAP患者.
목적 분석위중형급성이선염(CAP)적림상특점,탐토복강압력(IAP)、APACHEⅡ평분대CAP환자예후예측적개치.방법 사선2010년1월지2013년3월발병96 h내입주남경군구남경총의원보외과ICU적18～75세AP환자,기중47례부합근거결정인소적AP분류(determinant-based classification,DBC)중적CAP진단표준.대저사환자재입원24 h내행APACHEⅡ평분,병측량IAP.기록기관공능쇠갈발생정황、중전수술인류례수、입주ICU시간、총주원시간.응용수시자공작특정곡선하면적(AUC)분석IAP、APACHEⅡ평분예측환자예후화중전수술적개치,급기여입주ICU시간、총주원시간적상관성.결과 47례환자입원24h적평균APACHEⅡ평분위13분,평균IAP위16.9 mmHg(1mmHg =0.133 kPa),혈배양양성22례.발생호흡계통쇠갈45례차(96％),신공능쇠갈34례차(72％),심혈관공능쇠갈22례차(47％),기중출현2、3개기관계통공능쇠갈적환자분별위16、19례.17례(36％)환자접수수술인류.원내병사18례(38％).평균입주ICU 31 d,평균총주원시간38 d.IAP수평화APACHEⅡ평분수쇠갈기관계통수량적증가축점승고,차이구유통계학의의(P＜0.001).IAP수평예측환자병사적AUC위0.80(95％ CI 0.41 ～0.76),이16.1 mmHg위역치,기민감성、특이성분별위83％화62％;APACHEⅡ평분예측적AUC위0.58(95％ CI0.38～0.73),이13.5분위역치,기민감성、특이성분별위44％화73％.IAP수평예측환자병사적민감성고우APACHEⅡ평분,량자예측중전수술적민감성균교저,여환자입주ICU시간、총주원시간균무상관성.결론 CAP구유겁고적수술솔화병사솔.조기감측IAP가이유효예측예후교차적CAP환자.
Objective To describe the clinical characteristics of critical acute pancreatitis (CAP) and the predictive value of intra abdominal pressure and APACHE Ⅱ score in this group of patients.Methods From January 2010 to March 2013,acute pancreatitis patients between 18 to 75 years old present to the SICU,Department of General Surgery,General Hospital of Nanjing Military Area Command within 96 hours of symptoms onset were screened and forty-seven patients who met the diagnostic criteria of critical acute pancreatitis according to the determinant-based classifications were included in this study.The APACHE Ⅱ score was calculated within 24 h of admission,intra abdominal pressure was measured.Moreover,occurrence of organ dysfunction,need of surgical intervention,length of ICU and hospital stay was also recorded.Receiver operating characteristic curve was used to evaluate predictive accuracy of intra abdominal pressure and APACHE Ⅱ score for mortality and need of surgery.In addition,the correlation between intra abdominal pressure,APACHE Ⅱ score and length of hospital and ICU stay were also analyzed.Results Among the 47 study patients,the median APACHE Ⅱ score and intra abdominal pressure were 13 and 16.9 mmHg,respectively.Positive blood culture was detected in 22 patients.Respiratory dysfunction occurred in 45 cases (96％),while renal dysfunction occurred in 34 patients (72％) and cardiovascular dysfunction in 22 (47％).Double organ dysfunction and triple organ dysfunction happened in 16 and 19 patients,respectively.Seventeen (36％) patients needed surgical intervention.The mortality of critical acute pancreatitis patients was as high as 38％ (18/47).The median length of ICU and hospital stay was 31 and 38 days,respectively.Both APACHE n score and intra abdominal pressure increased significantly as the number of organ dysfunction increased,the difference was statistically significant (P ＜0.001).For the prediction of mortality,intra abdominal pressure performed better than APACHE Ⅱ score with an area under curve of 0.80 (95％ CI 0.41-0.76) compared with 0.58 (95％ CI0.38-0.73).Taking 16.1 mmHg as the cut-off value,the sensitivity and specificity of intra abdominal pressure in predicting mortality were 83％ and 62％,respectively compared with 44％ and 73％,respectively for APACHE Ⅱ score (13.5 as the threshold).However,both of the parameters had limited accuracy in the prediction of needs for operation and no correlation was found between the two parameters and the length of ICU and hospital stay.Conclusions Critical acute pancreatitis is an extremely severe type of acute pancreatitis with very high mortality and rate of surgical intervention.Early intra abdominal pressure measurement can well predict the poor prognosis of this entity.