重症急性胰腺炎早期目标指导的液体治疗

摘要

目的 探讨重症急性胰腺炎(severe acute pancreatitis,SAP)早期2种不同液体治疗策略对患者预后的影响.方法 回顾性分析首都医科大学宣武医院2000年1月至2010年1月期间收治的80例SAP患者,2000年1月至2004年12月期间收治的患者采用传统液体治疗方法(简称传统治疗组,n=34),2005年1月至2010年1月期间收治的患者采取早期目标指导的液体治疗策略(简称早期目标治疗组,n =46),比较2组间急性生理与慢性健康状况评分(APACHEⅡ)、器官功能不全评分(Marshall)、多器官功能不全综合征(multiple organ dysfunction syndrome,MODS)发生率、胰腺感染率和病死率的差异.结果 与传统治疗组相比,早期目标治疗组患者液体治疗第3天的APACHEⅡ和Marshall评分有显著降低(分别为APACHEⅡ:8.22±3.89 vs 11.35±4.27,P=0.017; Marshall:4.48 ±2.21 vs6.82 ±3.15,P=0.021).另外,早期目标治疗组患者入院1周内MODS发生率、胰腺感染率和住院病死率也较传统治疗组有所降低(分别为MODS:52％ vs 62％,P=0.393；胰腺感染率:37％vs44％,P=0.653；病死率:17％ vs 24％,P=0.576),但其差异无统计学意义.结论 本研究有限的病例结果提示,早期目标指导的液体治疗可在一定程度上缓解SAP病情,但能否改善SAP患者预后有待临床进行前瞻性随机对照研究.%Objective Appropriate and timely initial fluid resuscitation in severe acute pancreatitis (SAP) is critical. The aim of this retrospective study was to evaluate the effects of difference between fluid therapy on an early goal-directed approach to resuscitation basis and the standard fluid therapy of adequate resuscitation on the prognosis of SAP. Methods The clinical data of SAP patients admitted to surgical intensive care unit within 72 hours after onset of symptoms between January 2000 and January 2010 were analyzed retrospectively. A total of eighty patients with a confirmed diagnosis of SAP were divided into two groups based on whether adopting the early goal-directed fluid resuscitation strategies or not. Patients admitted between January 2000 and December 2004 did not adopt the early goal-directed fluid resuscitation strategies, therefore, were allocated into standard fluid therapy group ( n = 34 ) ; the other patients admitted between January 2005 and January 2010 adopted the early goal-directed fluid resuscitation strategies and were allocated into early goal-directed fluid therapy group (n=46). With the exception of the fluid therapy strategies, the patients in the two groups received standard treatment for SAP. The acute physiology and chronic health evaluation II score (APACHE II ) and multiple organ dysfunction score ( Marshall) , rate of multiple organ dysfunction syndrome ( MODS) within the first week of hospital admission, pancreatic infection, and in-hospital mortality were compared between the two groups. Results Compared with the standard fluid therapy group on day 3 after admission, APACHE II score and Marshall score decreased significantly in the early goal-directed fluid therapy group (APACHE II score; 8. 22 ± 3. 89 versus 11.35 ±4.27, P=0.017; Marshall score: 4.48±2.21 versus 6. 82 ±3. 15, P=0.021, respectively). In addition, patients in the early goal-directed fluid therapy group experienced a trend toward lower rate of MODS within the first week of hospital admission, pancreatic infection and in-hospital mortality ( rate of MODS; 52% versus 62% , P = 0. 393; rate of pancreatic infection; 37% versus 44% , P =0. 653;in-hospital mortality; 17% versus 24% , P = 0. 576, respectively) that did not reach statistical significance. Conclusion Although early goal-directed fluid therapy for SAP in acute response stage may have ameliorated the patient's condition and improved outcome to a certain degree, carefully designed clinical trials should be performed in a randomized controlled manner to assess the role of such fluid resuscitation in SAP.