急性重症胰腺炎时监测胃粘膜下pH值的临床意义

探讨在急性重症胰腺炎时通过动态监测胃粘膜下ＰＨ值,从而早期发现局部组织器官缺氧情况,及时采取措施预防器官功能衰竭的发生。方法对在临床观察期间收住院的４０例急性重症胰腺炎患者在入院后立刻经鼻插入ＴＲＩＰ－ＮＧＳ导管并测定Ｐｈｉ,以后每隔１２小时测量一次Ｐｈｉ。结果并发器官功能衰竭的急性重症胰腺炎患者在器官功能衰竭前１－３天Ｐｈ８即有显著降低,而同期测得的全身氧供指标并未发生明显。结论Ｐｈｉ具有操作简     

pHi监测在急性重症胰腺炎患者中的应用及意义

目的：探讨胃粘膜内ＰＨ值监测在急性重症胰腺炎患者中的应用及其临床意义。方法：对在鉴定观察期间收住院的４０例急性重症胰腺炎在入院后立刻经鼻插入ＴＲＩＰ－ＮＧＳ导管并测定ｐＨｉ,以后隔隔１２ｈ测量一次ｐＨｉ。结果：并发器官功能衰竭的急性重症胰腺炎患者在器官功能衰竭前１－３ｄｐＨｉ即有显著降低,而同期测得的全身氧供指标并未发生明显异常。结论：在急性重症胰腺炎患者中进行ｐＨｉ监测具有操作简便,结果可靠等优     

肠内营养的时间选择对重症急性胰腺炎患者营养状况和临床结局的影响研究

目的探讨不同肠内营养时间选择对重症急性胰腺炎患者营养状况和临床结局的影响,为临床护士对重症急性胰腺炎患者何时进行肠内营养提供时间选择。方法以48 h为时间节点,对205例重症急性胰腺炎患者追踪血清白蛋白指标动态变化和临床结局变化。结果 48 h以内进行肠内营养患者的血清白蛋白计数在第5天及第10天持续显著上升,胰腺感染、多器官功能障碍综合征、肺炎和呼吸功能衰竭的发生降低,住院时间缩短,住院费用减少(P0.01或P0.05),但菌血症指标无统计学意义(P0.05)。结论对重症急性胰腺炎患者而言,48 h内早期启动肠内营养,可以降低胰腺感染、多器官功能障碍综合征、肺炎和呼吸衰竭的发生,缩短住院时间和降低住院费用。     

乌司他丁治疗重症急性胰腺炎的疗效对比研究

目的:探讨乌司他丁(UTI)对重症急性胰腺炎的临床疗效。方法:回顾性对比分析71例重症急性胰腺炎应用乌司他丁和其它非手术方法的治疗效果。结果:治疗组患者受损器官的功能恢复时间明显短于对照组。结论:乌司他丁配合常规方法治疗重症急性胰腺炎对改善受损器官的功能及预防多器官功能不全综合征(MODS)的发生有肯定的作用。     

重症急性胰腺炎并发多器官功能障碍及预后关系的临床研究

目的探讨重症急性胰腺炎并发多器官功能障碍及预后关系的临床研究。方法回顾分析2008年1月-2010年12月收治的51例重症急性胰腺炎患者的临床资料。结果其中出现全身炎症反应综合征者46例(90.20%),多器官功能障碍36例(70.59%),重症急性胰腺炎并发多器官功能障碍者治愈好转20例,未合并者治愈好转13例。死亡18例。结论引起重症急性胰腺炎患者死亡的最主要因素是多器官功能障碍,早预防、早发现、综合治疗多器官功能障碍有助于降低重症急性胰腺炎患者死亡率。     

急性重症胰腺炎患者生长抑素干预前后pHi监测及其临床意义

目的 :探讨胃黏膜 p H值 (p Hi)在急性重症胰腺炎患者生长抑素干预前后的变化及其临床意义。方法 :按有无生长抑素 (施他宁 )干预将 4 6例急性重症胰腺炎患者分为生长抑素治疗组 (2 0例 )和无生长抑素治疗组 (对照组 ,2 6例 ) ,2组基础治疗相同。在治疗前、治疗后第 3日和第 7日用胃张力计导管法测定 2组患者p Hi,同时每日评价 2组患者器官功能 ,在患者器官功能衰竭最严重时测定 p Hi,比较 p Hi与器官功能衰竭的相关性。结果 :1生长抑素干预组患者并发器官功能衰竭的发生率显著低于对照组 (45 %比 5 8% ,P<0 .0 5 ) ;2治疗后第 7日生长抑素治疗组 p Hi值较对照组显著增高 (7.392± 0 .0 5 8比 7.335± 0 .10 1,P=0 .0 0 7) ;3p Hi值与功能衰竭器官数目呈显著负相关 (r=0 .5 92 ,P<0 .0 0 1)。结论 :生长抑素可降低急性重症胰腺炎患者器官功能衰竭的发生率 ,其作用机制可能与提高 p Hi、改善患者组织供氧有关     

中度急性胰腺炎临床异质性分析

目的探讨中度急性胰腺炎的临床异质性及意义。方法回顾性分析收治的急性胰腺炎住院病例,根据2012年亚特兰大分类标准进行重新分型,选出中度、重度二组,并把中度急性胰腺炎细分为2个亚组(MSAP1组为仅具有局部和全身并发症,MSAP2组为发生了小于48h的一过性器官功能衰竭同时合并或不合并局部、全身并发症),以重度急性胰腺炎为参照,比较中度的及二个亚组及重度的临床资料。结果 2年间AP共363例,中度急性胰腺炎83例,占22.9%;重度急性胰腺炎16例,占4.4%;疾病严重程度指标中,中重度差异具有统计学意义,而MSAP1与MSAP2相比,MSAP1与SAP具有更多项目的统计学差异。结论中度急性胰腺炎具有独立的临床特征,且其发生器官衰竭的类型病情更接近于重症急性胰腺炎。     

重症胰腺炎并发多脏器系统功能衰竭的治疗

目的 提高对重症急性胰腺炎并发多脏器系统功能衰竭（MSOF）救治方法的认识。方法 回顾入住SICU的30例重症急性胰腺炎的临床处理和结果，并分析其中11例并发MSOF的治疗和死亡原因。结果 累及2个器官5例（45.5%)，无1例死亡。累及3个器官2例（18.2%)。死亡1例；累及4个器官4例（36.4%)，死亡3例（75%）。病死率为36.4%(4/11)，另≥3个器官衰竭病死率66.7%(2/3)。结论 在加强胰外脏器功能监测和支持的前提下，重视控制胰腺坏死组织的继发感染，方能减少MSOF的发生并降低死亡率。     

重症急性胰腺炎的救治

急性胰腺炎是常见的急腹症之一,而且常累及全身多个器官。多数急性胰腺炎为水肿型,无明显并发症,呈自限性病理生理过程,不需特殊监测和治疗,但急性胰腺炎中约有20％为重症,预后凶险,病死率高达30％～40％。重症急性胰腺炎是指急性胰腺炎伴有器官功能障碍,或胰腺出现坏死、脓肿,假性囊肿等局部并发症。多器官功能障碍综合征（MODS）和全身性感染是重症胰腺炎患者最突出的问题。严密的生命体征、器官功能监测和加强治疗是影响重症胰腺炎患者预后的关键。     

1例急性重症胰腺炎致MODS患者的护理

正重症急性胰腺炎(SAP)是一种比较常见的临床危重病,具有病情凶险、并发症多、致死率高的特点且易导致多器官功能障碍综合征(MODS)。MODS是指机体遭受严重感染、创伤、休克、大手术等损害24 h后,同时或序贯发生两个或两个以上器官或系统功能不全或衰竭的临床综合征,是临床常见的危重症,其发病急骤,病死率高,花费高,严重威胁人类健康和生命[1]。我科于2017年3月收治1例急性重症胰腺炎致MODS患者,经及时救治与护理,患者病情好转,顺利转     

急性重度有机磷农药中毒胃黏膜pH值监测的意义

目的：探讨胃黏膜内pH值（pHi）监测在急性重度有机磷农药中毒（ASOPP）中的应用及临床意义。方法：28例ASOPP患者在洗胃后立即经鼻插入TRIP－NGS导管测定pHi,以后每12小时监测1次;另以12例健康者为对照。结果：在ASOPP未并发急笥呼吸衰竭（ARF）时,患者的pHi就明显降低（P＜0.05）,而此时全身氧供指标－－动脉氧分压（PaO2)无明显改变（P＞0.05）;在ASOPP并发ARF时,患者的pHi比PaO2降低得更明显。结论：pHi监测对早期发现ASOPP患者局部组织缺氧及采取措施预防ARF与多脏器功能衰竭的发生具有重要临床指导意义。     

Role of immunological disorders in the pathophysiology of severe acute pancreatitis

Severe acute pancreatitis is a disease associated with high mortality, causes of which are multiple organ failure(MOF) in the early course and the development of bacterial infections in the later course. Inflammatory response leading to organ failure continues to be one of the major problem after acute pancreatitis. This review summarizes recent studies that demonstrate the critical role played by inflammatory mediators in acute pancreatitis. Immunological disorder, immune suppression, also plays a role at high risk of sepsis in the development of severe acute pancreatitis. We have to clarify the mechanism of immunological suppression in the development of bacterial infections in severe acute pancreatitis. It is important that the elucidation of key mediators in MOF and the mechanism of immune suppression in the development of bacterial infection could be improved by the prognosis of severe acute pancreatitis.     

Intramucosal pH and endotoxin and cytokine release in severe acute pancreatitis

It has been postulated that in severely ill patients splanchnic hypoperfusion may cause endotoxin release from the gut, and this leakage of endotoxin into the circulation can trigger the cascade of inflammatory cytokines. We tested this hypothesis in 9 patients with acute severe pancreatitis by monitoring gastric intramucosal pH (pHi) as measure of splanchnic hypoperfusion at 12-h intervals trying to correlate it to endotoxin and cytokine release. Only 3 of 59 samples, obtained from 3 patients contained circulating endotoxin. Thirteen of 15 plasma samples drawn at pHi <7.20 did not contain endotoxin. The pHi was significantly lower in patients who subsequently developed 3 or more organ failures (P = 0.0017, analysis of variance). Although endotoxemia was only occasionally found, most patients had measurable interleukin 1beta (IL-1beta), interleukin 6 (IL-6), interleukin 8 (IL-8), and interleukin 10 (IL-10) in their plasma. Concentrations of IL-6, IL-8, and IL-10 on admission correlated to degree of organ dysfunction as measured by the multiple organ system failure score (P = 0.035, r = 0.74; P = 0.010, r = 0.91; P = 0.021, r = 0.82, respectively). In conclusion, patients with acute, severe pancreatitis often have splanchnic hypoperfusion and produce a wide array of cytokines despite a rare occurrence of endotoxemia.     

重症急性胆管炎后多器官衰竭的危险因素分析

分析了２００例重症急性胆管炎（ＡＣＳＴ）及其中７０例并发多器官衰竭（ＭＯＦ）病例的临床资料，旨在研究重症急性胆管炎并发ＭＯＦ的危险因素。结果发现：早期休克、营养不良、肺部感染、败血症及长期胆道梗阻等病例的ＭＯＦ发生率明显增高。作者认为早期监护高危患者和综合治疗是降低ＭＯＦ病死率的关键。     

40例多器官衰竭时急性肾功能衰竭的临床分析

目的：探讨多器官衰竭（ＭＯＦ）时急性肾功能衰竭（ＡＲＦ）的更为有效的防治手段，防止和阻断其进一步发展，改善ＭＯＦ的预后。方法：对４０例ＭＯＦ合并ＡＲＦ的病例资料进行临床分析。结果：ＭＯＦ的主要原发病因是感染（７０．０％），其次是创伤（２２．５％），其它占７．５％；本组患者的病死率６５．０％，且随衰竭器官的数目增多而病死率升高。ＡＲＦ表现为少尿型８７．５％，非少尿型１２．５％。采用血液透析（ＨＤ）治疗２２例中存活１２例，死亡１０例，病死率５４．５％；非ＨＤ治疗１８例中存活２例，死亡１６例，病死率８８．９％，比较此两种治疗方法的疗效ＨＤ组明显高于非ＨＤ组（Ｐ＜０．０１）。结论：对于ＭＯＦ时ＡＲＦ的治疗，首先应针对各器官衰竭的治疗；积极有效地控制感染是抢救成功的关键；早期充分的血液净化是治疗的重要环节；辅助支持疗法，提高免疫功能，改善组织缺氧，禁止应用对肾脏有损害的药物，对改善本病的预后具有重要意义。     

Recent advances in the surgical management of necrotizing pancreatitis

PURPOSE OF REVIEW: To summarize advances and new concepts in the surgical management of necrotizing pancreatitis published within the past year with emphasis on the evolving importance of the recognition of abdominal compartment syndrome as a significant contributor to early development of organ failure. RECENT FINDINGS: Underdiagnosed and untreated, abdominal compartment syndrome is a potential contributing factor to the development of early organ failure in patients with severe acute pancreatitis and warrants routine measurement of intra-abdominal pressure in patients treated for severe pancreatitis. The current estimate of the prevalence of intra-abdominal hypertension in severe acute pancreatitis is about 40%, with about 10% overall developing abdominal compartment syndrome, associated with increased hospital mortality rates. Early surgical decompression without exploring the pancreas further seems to be the most effective treatment. Primary fascial closure of the abdominal wall following abdominal decompression can be attempted, but in most cases the prolonged inflammatory process in the abdomen and the risk of recurrent abdominal compartment syndrome favors use of gradual closure or delayed reconstruction of the abdominal wall. SUMMARY: Recent studies confirm the overall validity of the established surgical principles for necrotizing pancreatitis: delayed necrosectomy in patients with infected peripancreatic necrosis, mostly nonoperative management of sterile necrosis, and delayed cholecystectomy in severe gallstone-associated pancreatitis. The role of abdominal compartment syndrome as an important contributing factor to early development of multiple organ failure and the potential benefit of surgical decompression are gaining support from recent reports and should be carefully assessed in future studies.     

Significance of tissue pH in the prognosis of postoperative complications in heart surgery patients

Ischemia of the gastrointestinal mucosa is characterized by acidosis in the submucosal layer during the majority of interventions, which necessitates monitoring of tissue pH (pHi) of the abdominal organs during aortocoronary bypass surgery and the immediate postoperative period. The pHi was measured by gastrotonometry with a nasogastral tube (Trip catheter) and Tonocap-TC200 device (Datex Engstrom, Finland); pHi was measured in 17 patients in department of intensive care on days 1 or 2 after cardiosurgical interventions with at least 120-min artificial circulation and in 23 patients during the operation. Surgical treatment consisted in correction of acquired valvular diseases, myocardial revascularization (shunting operations), and combinations of these operations. The first stage of investigation revealed a relationship between decreased pHi level to the acid values and complicated course of the postoperative period. The second stage showed that postoperative complications occurred in 27.2% cases only in patients subjected to long artificial circulation bypass (more than 120 min). The frequency of complications were 2-fold more in the patients with tissue acidosis (pHi < 7.35) during surgery than in patients with normal and alkaline pHi values. The following complications occurred: acute pancreatitis, acute peptic ulcer, acute renal and polyorgan failure. Comparative analysis of pHi and other metabolic markers of arterial blood showed a correlation between these parameters, but pHi was more specific for the diagnosis of tissue ischemia. Hence, a low invasive highly specific method of gaseous gastrotonometry helps evaluate the blood supply to abdominal organs during and after cardiac surgery with artificial circulation and predict postoperative gastrointestinal and grave systemic complications (sepsis, acute renal failure, and polyorgan failure).     

Pre-operative tonometry is predictive for mortality and morbidity in high-risk surgical patients

OBJECTIVE: To determine whether a) pre-operative measurement of gastric intramucosal pHi is predictive for mortality and morbidity in high-risk surgical patients and b) peri-operative improvement of global oxygen delivery (DO2) with fluids and dopexamine leads to increased gastric pHi and c) either improved global perfusion or improved splanchnic perfusion is related to the prevention of multiple organ failure (MOF). DESIGN: Retrospective analysis of a double-blind, placebo-controlled, randomised study. SETTING: General intensive care units from 14 hospitals. PATIENTS: Two hundred eighty-six high-risk surgical patients. INTERVENTIONS: Swan-Ganz and tonometer catheter placement; patients were stabilised pre-operatively using fluids, blood and/or oxygen to preset goals before receiving placebo or two doses of dopexamine (0.5 or 2.0 microg.kg.min) peri-operatively. MEASUREMENTS AND RESULTS: Haemodynamic assessment (including DO2 and oxygen consumption (VO2)) was performed together with measurement of gastric mucosal pHi pre-operatively and directly, 2, 6, 12, 24 and 36 h post-operatively. Retrospectively, patients were divided pre-operatively into two sub-groups based on the optimal cut-off value for mortality of the first pHi measurement after induction of anaesthesia as calculated by a receiver operator characteristic (ROC) curve analysis --low pHi group (< 7.35) and normal pHi (> or =7.35). Mortality in the low pHi, was higher than in the normal pHi, group (16.8 vs 2.3%; p = 0.0001). In the normal pHi group dopexamine, which was given prior to the first pHi measurement, had no effect on pHi, while DO2 increased significantly. In this group MOF score and number of patients with MOF remained similar for the treatment sub-groups. In the low pHi group gastric pHi increased significantly during dopexamine infusion (p = 0.008), despite the lack of an increase in DO2 and VO2. In this group the MOF score and the number of patients developing MOF decreased significantly with the use of dopexamine (p = 0.04). In both groups bicarbonate levels remained similar for the treatment subgroups. CONCLUSIONS: In high-risk surgical patients pre-operative measurement of pHi was predictive for mortality. The peri-operative response of pHi to dopexamine seemed to be dependent on pre-operative gastric pHi.     

重症急性胆管炎多器官功能衰竭的临床分析

作者对200例重症急性胆管炎(ACST)及其中70例并发多器官功能衰竭(MOF)的临床过程和可能的发病因素进行了分析。结果发现:早期循环休克、营养不良、肺部感染、败血症及长期胆道梗阻等使MDF发生率明显增高(P<0.05)。认为早期监护高危病人和综合治疗是降低MOF死亡率的关键。