目的 探讨重症急性胰腺炎(SAP)早期脉搏指示连续心排血量(PiCCO)监测指导下的液体复苏对患者疗效的影响.方法 采用前瞻性研究方法,选择安徽医科大学第二附属医院重症医学科2011年10月至2013年10月收治并应用PiCCO指导容量复苏治疗的18例SAP患者为研究组;同时回顾性收集2009年1月至2011年9月收治的未进行PiCCO监测治疗的25例SAP患者为对照组.比较两组患者复苏液体量及临床资料等.结果 与对照组比较,研究组在入重症监护病房(ICU)后0～6、0～24、24 ～ 48 h复苏液体量及0～72h复苏液体总量均明显增多(mL:2 133±1 593比1 024±421,t=3.337,P=0.002;5 960±2 951比3 767±854,t=3.531,P=0.001:4 709±1 508比3 863±1 122,t=2.112,P=0.031; 14601±5 095比11 409±2 667,t=2.673,P=0.007);研究组需行血液净化比例明显下降[5.56％(1/18)比44.00％(11/25),x2=7.688,P=0.006],全身炎症反应持续时间明显缩短(d:3.54±2.44比5.62±3.62,t=2.113,P=0.041),液体复苏24 h急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分下降显著(分:11±4比14±5,t=2.104,P=0.042),72 h血乳酸下降程度明显(mmol/L:3.10±0.55比2.40±1.12,t=2.442,P=0.019),ICU住院时间明显缩短(d:10±9比20±10,t=3.371,P=0.002);但需应用血管活性药物的比例[16.67％(3/18)比24.00％(6/25),x2=0.340,P=0.560]、需行有创机械通气治疗的比例[50.00％(9/18)比52.00％(13/25),x2=0.017,P=0.897]、72 h尿素氮下降程度(mmol/L:-0.33±4.71比-0.09±5.37,t=0.152,P=0.880)和继发腹腔感染比例[16.67％(3/18)比16.00％(4/25),x2=0.003,P=0.953]无明显差异.研究组患者病死率低于对照组[5.56％(1/18)比20.00％(5/25)],但差异无统计学意义(x2=1.819,P=0.178).根据2012亚特兰大共识SAP分类标准对两组患者液体复苏48 h后重新评估,研究组转为中重症急性胰腺炎的比例明显高于对照组[33.33％(6/18)比8.00％(2/25),x2=4.435,P=0.034].研究组18例患者平均留置PiCCO导管4.5 d,均未发生导管相关并发症.结论 SAP患者72 h内在PiCCO监测指导下可安全使用更多的液体进行容量复苏;PiCCO指导容量复苏能够更好地改善患者组织灌注,减少血液净化应用率,不增加有创机械通气治疗风险,缩短ICU住院时间,但不影响病死率.
目的 探討重癥急性胰腺炎(SAP)早期脈搏指示連續心排血量(PiCCO)鑑測指導下的液體複囌對患者療效的影響.方法 採用前瞻性研究方法,選擇安徽醫科大學第二附屬醫院重癥醫學科2011年10月至2013年10月收治併應用PiCCO指導容量複囌治療的18例SAP患者為研究組;同時迴顧性收集2009年1月至2011年9月收治的未進行PiCCO鑑測治療的25例SAP患者為對照組.比較兩組患者複囌液體量及臨床資料等.結果 與對照組比較,研究組在入重癥鑑護病房(ICU)後0～6、0～24、24 ～ 48 h複囌液體量及0～72h複囌液體總量均明顯增多(mL:2 133±1 593比1 024±421,t=3.337,P=0.002;5 960±2 951比3 767±854,t=3.531,P=0.001:4 709±1 508比3 863±1 122,t=2.112,P=0.031; 14601±5 095比11 409±2 667,t=2.673,P=0.007);研究組需行血液淨化比例明顯下降[5.56％(1/18)比44.00％(11/25),x2=7.688,P=0.006],全身炎癥反應持續時間明顯縮短(d:3.54±2.44比5.62±3.62,t=2.113,P=0.041),液體複囌24 h急性生理學與慢性健康狀況評分繫統Ⅱ(APACHEⅡ)評分下降顯著(分:11±4比14±5,t=2.104,P=0.042),72 h血乳痠下降程度明顯(mmol/L:3.10±0.55比2.40±1.12,t=2.442,P=0.019),ICU住院時間明顯縮短(d:10±9比20±10,t=3.371,P=0.002);但需應用血管活性藥物的比例[16.67％(3/18)比24.00％(6/25),x2=0.340,P=0.560]、需行有創機械通氣治療的比例[50.00％(9/18)比52.00％(13/25),x2=0.017,P=0.897]、72 h尿素氮下降程度(mmol/L:-0.33±4.71比-0.09±5.37,t=0.152,P=0.880)和繼髮腹腔感染比例[16.67％(3/18)比16.00％(4/25),x2=0.003,P=0.953]無明顯差異.研究組患者病死率低于對照組[5.56％(1/18)比20.00％(5/25)],但差異無統計學意義(x2=1.819,P=0.178).根據2012亞特蘭大共識SAP分類標準對兩組患者液體複囌48 h後重新評估,研究組轉為中重癥急性胰腺炎的比例明顯高于對照組[33.33％(6/18)比8.00％(2/25),x2=4.435,P=0.034].研究組18例患者平均留置PiCCO導管4.5 d,均未髮生導管相關併髮癥.結論 SAP患者72 h內在PiCCO鑑測指導下可安全使用更多的液體進行容量複囌;PiCCO指導容量複囌能夠更好地改善患者組織灌註,減少血液淨化應用率,不增加有創機械通氣治療風險,縮短ICU住院時間,但不影響病死率.
목적 탐토중증급성이선염(SAP)조기맥박지시련속심배혈량(PiCCO)감측지도하적액체복소대환자료효적영향.방법 채용전첨성연구방법,선택안휘의과대학제이부속의원중증의학과2011년10월지2013년10월수치병응용PiCCO지도용량복소치료적18례SAP환자위연구조;동시회고성수집2009년1월지2011년9월수치적미진행PiCCO감측치료적25례SAP환자위대조조.비교량조환자복소액체량급림상자료등.결과 여대조조비교,연구조재입중증감호병방(ICU)후0～6、0～24、24 ～ 48 h복소액체량급0～72h복소액체총량균명현증다(mL:2 133±1 593비1 024±421,t=3.337,P=0.002;5 960±2 951비3 767±854,t=3.531,P=0.001:4 709±1 508비3 863±1 122,t=2.112,P=0.031; 14601±5 095비11 409±2 667,t=2.673,P=0.007);연구조수행혈액정화비례명현하강[5.56％(1/18)비44.00％(11/25),x2=7.688,P=0.006],전신염증반응지속시간명현축단(d:3.54±2.44비5.62±3.62,t=2.113,P=0.041),액체복소24 h급성생이학여만성건강상황평분계통Ⅱ(APACHEⅡ)평분하강현저(분:11±4비14±5,t=2.104,P=0.042),72 h혈유산하강정도명현(mmol/L:3.10±0.55비2.40±1.12,t=2.442,P=0.019),ICU주원시간명현축단(d:10±9비20±10,t=3.371,P=0.002);단수응용혈관활성약물적비례[16.67％(3/18)비24.00％(6/25),x2=0.340,P=0.560]、수행유창궤계통기치료적비례[50.00％(9/18)비52.00％(13/25),x2=0.017,P=0.897]、72 h뇨소담하강정도(mmol/L:-0.33±4.71비-0.09±5.37,t=0.152,P=0.880)화계발복강감염비례[16.67％(3/18)비16.00％(4/25),x2=0.003,P=0.953]무명현차이.연구조환자병사솔저우대조조[5.56％(1/18)비20.00％(5/25)],단차이무통계학의의(x2=1.819,P=0.178).근거2012아특란대공식SAP분류표준대량조환자액체복소48 h후중신평고,연구조전위중중증급성이선염적비례명현고우대조조[33.33％(6/18)비8.00％(2/25),x2=4.435,P=0.034].연구조18례환자평균류치PiCCO도관4.5 d,균미발생도관상관병발증.결론 SAP환자72 h내재PiCCO감측지도하가안전사용경다적액체진행용량복소;PiCCO지도용량복소능구경호지개선환자조직관주,감소혈액정화응용솔,불증가유창궤계통기치료풍험,축단ICU주원시간,단불영향병사솔.
Objective To evaluate the therapeutic effect of early fluid resuscitation under the guidance of pulse indicator continuous cardiac output (PiCCO) on patients with severe acute pancreatitis (SAP).Methods Clinical data of 18 SAP patients (research group),who had undergone fluid resuscitation under the guidance of PiCCO in the Department of Critical Care Medicine of the Second Affiliated Hospital of Anhui Medical University from October 2011 to October 2013,were analyzed prospectively.At the same time,clinical data of 25 cases (control group) that had undergone fluid resuscitation without the guidance of PiCCO from January 2009 to September 2011 were collected retrospectively.The volume of fluid and clinical data were compared between two groups.Results During the first 6 hours,0-24 hours,24-48 hours,and 0-72 hours after intensive care unit (ICU) admission,the research group received larger volume of fluid than that of the control group (mL:2 133 ± 1 593 vs.1 024 ± 421,t=3.337,P=0.002; 5 960 ±2 951 vs.3 767 ± 854,t=3.531,P=0.001; 4 709 ± 1 508 vs.3 863 ± 1 122,t=2.112,P=0.031 ; 14 601 ± 5 095 vs.11 409 ± 2 667,t=2.673,P=0.007).Compared with the control group,the incidence of application of blood purification was lowered [5.56％ (1/18) vs.44.00％ (11/25),x2=7.688,P=0.006],the duration of the systemic inflammatory response syndrome (SIRS) was shortened (days:3.54 ± 2.44 vs.5.62 ± 3.62,t=2.113,P=0.041),acute physiology and chronic health Ⅱ (APACHE Ⅱ) score was significantly declined at 24 hours after admission (11±4 vs.14 ± 5,t=2.104,P=0.042),the blood lactic acid was decreased more significantly after 72 hours (mmol/L:3.10 ±0.55 vs.2.40 ± 1.12,t=2.442,P=0.019),and the length of ICU stay was shortened (days:10 ±9 vs.20 ± 10,t=3.371,P=0.002) in research group.But there was no significant difference in the percentage of the use of vasoactive drugs [16.67％ (3/18) vs.24.00％ (6/25),x2 =0.340,P=0.560],the incidence of invasive mechanical ventilation [50.00％ (9/18) vs.52.00％ (13/25),x2 =0.017,P=0.897],72-hour urea nitrogen changes (mmol/L:-0.33 ± 4.71 vs.-0.09 ± 5.37,t=0.152,P=0.880),and the percentage of abdominal infection [16.67％ (3/18) vs.16.00％ (4/25),x2=0.003,P=0.953] between research group and control group.The mortality in research group was lower than that in control group [5.56％ (1/18) vs.20.00％ (5/25)] without statistical difference (x2=1.819,P=0.178).According to the 2012 Atlanta classification,patients were re-evaluated after 48 hours fluid resuscitation.Six patients in research group developed moderately severe acute pancreatitis,and the incidence was significantly higher than that in control group [33.33％ (6/18) vs.8.00％ (2/25),x2=4.435,P=0.034].The time of mean PiCCO installation was 4.5 days in 18 cases of the research group,and no related complications occurred.Conclusions The PiCCO device may be a useful adjunct for fluid resuscitation monitoring in patients with SAP within 72 hours.Early fluid resuscitation under the guidance of PiCCO may be helpful in improving tissue perfusion,reducing the application of blood purification,as well as shortening length of ICU stay.This program did not increase the risk of invasive mechanical ventilation,and no obvious change in mortality rate was observed.
