不同评分系统对重症急性胰腺炎预后评估的临床价值

目的 探讨评估重症急性胰腺炎(SAP)的不同方法对SAP预后的判断效果.方法 回顾性分析10年间收治168例SAP患者的临床资料.运用受试者工作特征曲线(ROC曲线)下面积,单因素和多因素分析评价序贯器官衰竭评分(SOFA)、急性生理和慢性健康评估(APACHE Ⅱ)及CT严重性指数(CTSI)对SAP预后结果的预测能力.结果 ROC曲线面积比较:SOFA,APACHEⅡ,CTSI的ROC曲线下面积分别为0.846,0.809和0.779;SOFA与CTSI评分比较,差异有统计学意义(Z=2.68,P<0.01);APACHEⅡ与SOFA,CTSI比较,差异无统计学意义(Z=1.079,P>0.05和Z=0.693,P>0.05).单因素分析显示,住院期最大SOFA计分、最大APACHE Ⅱ评分、最大CT计分指数、年龄、胰腺感染等与SAP预后相关;多因素分析表明,最大SOFA计分、最大APACHE Ⅱ评分、最大CT计分指数为SAP预后判别预测的独立相关因素.联合评价表明,三者阳性与二者阳性或一个阳性的SAP患者病死率比较,有统计学意义(P<0.05).结论 动态观测SAP患者住院期间的SOFA,APACHE Ⅱ和CTSI对SAP预后有较强的判别预测能力,联合三者建立的判别方程具有更佳的SAP预后判别效果.     

Comparative Evaluation of the BISAP Score with CT Severity Index in Predicting the Severity of Acute Pancreatitis

Early diagnosis of severe acute pancreatitis (SAP) is important for the successful management of patients. Most scoring systems are complex or involve multiple parameters, which makes it difficult to ascertain the severity of acute pancreatitis at an early stage. Our study aims to evaluate the bedside index for severity in acute pancreatitis (BISAP) in predicting the severity of pancreatitis and mortality in a rural population, where financial constraints pose a major problem during treatment. We studied 55 patients of acute pancreatitis who presented to our institution between October 2014 and August 2016. The BISAP score was calculated within 24 h of admission. During the hospital stay, the CT severity index (CTSI) was calculated, and patients closely monitored to detect presence of organ failure or mortality. The accuracy of the BISAP and CTSI scores in predicting severity and mortality was determined by plotting receiver operating characteristic (ROC) curves, and calculating the area under curve (AUC). Sixteen (29%) patients developed persistent organ failure and were classified as severe acute pancreatitis (SAP), and four (7%) died. No patient with a BISAP score of 0 or 1 developed severe pancreatitis. The area under curve (AUC) for BISAP score in predicting severity and mortality was 0.902 and 0.958, respectively, better than that of CTSI. BISAP scores of 0 or 1 have a very high negative predictive value, and hence accurate for predicting mild disease. These patients can safely avoid a CT scan and the costs associated with it.     

早期肠屏障功能保护在重症急性胰腺炎治疗中的重要性

目的 观察早期保护肠屏障功能对重症急性胰腺炎(SAP)患者的影响.方法 分析56例SAP患者的治疗方法和预后.随机数字表法将患者分为常规治疗组(A组)和肠屏障保护组(B组),比较两组患者不同时间的APACHEⅡ评分、Ranson评分、Marshall评分、CT严重指数(CTSI)、胃肠功能评分、尿乳果糖/甘露醇(L/M)比值、血浆内毒素和二胺氧化酶(DAO)、血清C反应蛋白(CRP)和肿瘤坏死因子α(TNF-α)、胰腺感染和多器官功能障碍综合征(MODS)发生率、住院病死率.结果 治疗后第7天,B组APACHEⅡ评分、胃肠功能评分、尿L/M比值、血浆内毒素和DAO、血清CRP和TNF-α较A组显著降低,差异有统计学意义(P<0.05).入院2周内,两组患者CTSI比较,差异无统计学意义(P>0.05);B组患者胰腺感染和MODS发生率明显低于A组,差异有统计学意义(P<0.05);两组住院病死率比较,差异无统计学意义(P>0.05).结论 早期保护肠屏障功能,能明显减轻SAP患者的全身炎症反应,降低胰腺感染和MODS发生率,从而改善其预后.

Abstract：

Objective To observe the influence of early intestinal barrier protection in patients with severe acute pancreatitis(SAP). Methods To analyze the therapeutic methods and prognosis of 56 patients with SAP. The patients were randomly divided into the conventional therapy group (A) and the intestinal barrier protection group (B). The APACHE Ⅱ score, Ranson score, Marshall score, CT severity index (CTSI), gastrointestinal functions score (GFS), the ratio of Lactulose to Mannitol (L/M), plasma Endotoxin and Diamine Oxidase (DAO), serum C-reactive protein (CRP) and TNF-α, incidence of pancreatic infection and multiorgan dysfunction syndrome (MODS), and the hospitalization mortality were compared between the two groups. Results On the 7th day after admission, the APACHE Ⅱ score, GFS, L/M, Endotoxin, DAO, CRP and TNF-α were significantly less in group B than in group A (P<0. 05). There was no significant difference in the CTSI (P>0. 05)between the two groups at 2nd week after admission. The incidence of pancreatic infection and MODS in group B were significantly lower than in group A (P<0. 05). The hospitalization mortality was not significantly different (P>0. 05) between the two groups. Conclusion Early intestinal barrier protection in SAP alleviated systemic inflammatory response, and reduced the incidences of pancreatic infection and MODS, thus improved the prognosis.     

Cholangitis score: a scoring system to predict severe cholangitis in gallstone pancreatitis

Abstract. Background/Purposes: Emergency biliary decompression and stone extraction are mandatory for patients with gallstone pancreatitis who have ampullary stone impaction or persistent stones and pus in the bile duct (severe cholangitis). The aim of this study was to devise a simple scoring system for the prediction of complicating severe cholangitis in gallstone pancreatitis. Methods: Clinical signs, laboratory data, and ultrasonography (US) findings at the time of admission, and the bile duct pathology at the time of bile duct exploration, were reviewed in 66 patients with gallstone pancreatitis. Variables which discriminated 26 patients with bile duct stones from 40 without were defined as predictive factors of bile duct stones. The receiver operating characteristic (ROC) curve was used to determine the optimal cutoff values of numerical variables. One point was allocated to each predictive factor, and the total score was defined as the cholangitis score (CS). Bile duct pathology identified at the time of bile duct exploration was graded into three categories: mild, moderate, and severe cholangitis. A threshold value of the CS, claimed to be predictive of severe cholangitis, was determined by using the ROC curve. Results: The scoring system consisted of four predictive factors: (1) pyrexia (temperature ≧38 °C), (2) elevated serum bilirubin (≧2.2 mg/dl), (3) dilated bile duct (≧11 mm maximum diameter on US), and (4) bile duct stones detected on US. The scoring system predicted severe cholangitis with 92% sensitivity and 98% specificity in patients with scores of three or four points. Conclusions: Patients with gallstone pancreatitis who meet three or four of the above predictive factors at the time of admission are likely to have severe cholangitis, and should be rapidly treated by biliary decompression and stone extraction. Received: July 13, 2001 / Accepted: November 16, 2001     

Long-term outcome of severe acute pancreatitis

BACKGROUND/PURPOSE: This study was undertaken to evaluate the post-discharge outcome of severe acute pancreatitis (SAP) and to clarify the prognostic factors for poor outcome. METHODS: In 45 patients, recurrence of acute pancreatitis (AP), transition to chronic pancreatitis (CP), and development of diabetes mellitus (DM) were evaluated. Relationships of the outcome with the findings on admission and the presence/absence of alcohol intake were analyzed. RESULTS: The mean follow-up period was 56 +/- 6 months. Recurrence of AP was noted in 19% of the patients. The recurrence rate was higher in patients with necrotizing pancreatitis than in those without this feature. C-reactive protein and white blood cell (WBC) count were higher in patients with recurrence of AP. Transition to CP was noted in 22% of patients. The transition rate was higher in those with alcoholic SAP than in those with biliary SAP. In patients with transition to CP, the WBC count, hematocrit, Ranson score, and Japanese severity score were higher, and base excess (BE) was lower, compared with these features in patients without this transition. Development of DM was noted in 39% of patients. Blood glucose and BE were higher in patients who developed DM than in those who did not. CONCLUSIONS: The degree of inflammation and pancreatic necrosis found on admission for SAP may be related to the recurrence of AP. Alcoholic SAP in which the disease is very severe may contribute to the transition to CP. Patients with impaired glucose tolerance readily develop DM after SAP.     

A modified gastrointestinal failure score for patients with severe acute pancreatitis

Purpose

No consensus has been reached to define gastrointestinal failure (GIF) associated with severe acute pancreatitis (SAP). Reintam and colleagues proposed a scoring system of GIF for critically ill patients, but its suitability for patients with SAP is questionable. The present study evaluates a modified GIF score we developed to assess the GIF of patients with SAP.

Methods

The subjects of this study were 52 patients with SAP treated between September 2010 and July 2011. We recorded the Reintam’s GIF score, our modified GIF score, the acute physiology and chronic health evaluation (APACHE) II score, the sequential organ failure assessment (SOFA) score, and other clinical values during the first 3 days after admission. The prognostic value of the modified GIF score, for evaluating the severity and outcomes of SAP, was also assessed.

Results

Compared with the Reintam’s GIF score, the modified GIF score seemed to be more valuable for predicting hospital mortality (the area under curve, AUC 0.915 vs. 0.850), multiple organ dysfunction syndrome (MODS) (AUC 0.829 vs. 0.766), and pancreatic infection (AUC 0.796 vs. 0.776). Moreover, combining the modified GIF score and the SOFA or APACHEII scores resulted in more accurate prediction of the prognosis of SAP than either score alone.

Conclusion

The modified GIF score is useful for assessing gastrointestinal system function, which may serve as an early prognostic tool to evaluate the severity and predict the outcomes of SAP.     

Early warning scores predict outcome in acute pancreatitis

The Early Warning Score (EWS) is a widely used general scoring system to monitor patient progress with a varying score of 0-20 in critically unwell patients. This study evaluated the EWS system compared with other established scoring systems in patients with acute pancreatitis. EWS scores were compared with APACHE scores, Imrie scores, computed tomography grading scores, and Ranson criteria for 110 admissions with acute pancreatitis. A favorable outcome was considered to be survival without intensive therapy unit admission or surgery. Nonsurvivors, necrosectomy, and critical care admission were considered adverse outcomes. EWS was the best predictor of adverse outcome in the first 24 hours of admission (receiver operating curve, 0.768). The most accurate predictor of mortality overall was EWS on day 3 of admission (receiver operating curve, 0.920). EWS correlated with duration of intensive therapy unit stay and number of ventilated days (P<0.05) and selected those who went on to develop pancreas-specific complications such as pseudocyst or ascites. EWS of 3 or above is an indicator of adverse outcome in patients with acute pancreatitis. EWS can accurately and reliably select both patients with severe acute pancreatitis and those at risk of local complications.     

4种评分系统评估院前急救患者病情及预后的价值的比较研究

目的:比较改良早期预警评分(MEWS)、全身炎症反应综合征评分(SIRS)、简单临床评分(SCS)、快速急诊内科评分(REMS)评估院前急救患者病情及预后的价值.方法:对我院实施院前急救的685例急诊患者分别进行MEWS评分、REMS评分、SCS评分和SIRS评分,追踪患者的预后,并以当次入院病死率为根据,比较4种评分系统不同分值段的病死率差异,通过ROC曲线下面积比较4种评分系统评估院前急救患者病情及预后的准确性.结果:存活与死亡患者的MEWS评分、REMS评分、SCS评分和SIRS评分比较差异均具有统计学意义(P＜0.05).MEWS评分、REMS评分、SCS评分和SIRS评分的分值越高,病死率越高,各分值段间病死率比较差异均具有统计学意义(x2=72.60、82.31、151.94、72.49,P均＜0.05);MEWS评分、REMS评分、SCS评分和SIRS评分的ROC曲线下面积分别为0.765、0.758、0.829和0.695,以SCS评分的ROC曲线下面积最大.结论:MEWS评分、REMS评分、SCS评分和SIRS评分均能对院前急诊患者的病死率进行预测,准确度SCS＞MEWS＞REMS＞SIRS,SCS评分更能准确地对院前急救患者进行早期预后评估.     

Outcome predictors and new score of critically ill cirrhotic patients with acute renal failure.

BACKGROUND: End-stage liver disease is often complicated by renal function disturbances. Cirrhotic patients with acute renal failure admitted to intensive care units (ICUs) have high mortality rates. This work seeks to identify specific predictors of hospital mortality in critically ill cirrhotic patients with acute renal failure. METHODS: A total of 111 patients with cirrhosis and acute renal failure were admitted to ICU from March 2003 to February 2005. Twenty-six demographic, clinical and laboratory variables were prospectively gathered as predictors of survival on the first day of ICU admission. RESULTS: The overall hospital mortality rate was 81.1%. The univariate analysis identified 11 of the 32 variables as prognostically valuable. The multiple logistic regression analysis (excluding five scoring systems) indicates that the mean arterial pressure (MAP), serum bilirubin, respiratory failure and sepsis on the first day in ICU are significantly related to prognosis. The best Youden index (sensitivity + specificity - 1) yields cutoff points of 80 MAP (in mmHg) and 80 serum bilirubin (in micromol/L) (or 4.7 mg/dL) and indicates acute respiratory failure and sepsis. A simple model for mortality is developed on the basis of these four readily available parameters on Day 1 of ICU admission. The new score (MBRS score: MAP + bilirubin + respiratory failure + sepsis) displays an excellent area under the receiver operating characteristic curve (0.898 +/- 0.031, P < 0.001). The mortality rate exceeds 90% when the MBRS (MAP + bilirubin + respiratory failure + sepsis) score is 2 or higher. CONCLUSION: The MBRS score is a straightforward, reproducible and easily adopted evaluative tool with good prognostic abilities, which generates objective data for patient families and physicians and supplements a clinical judgment of prognosis.     

Calcitonin precursors in the prediction of severity of acute pancreatitis on the day of admission

BACKGROUND: Calcitonin precursors are sensitive markers of inflammation and infection. The aim of this study was to evaluate the role of plasma calcitonin precursor levels on the day of admission in the prediction of severity of acute pancreatitis, and to compare this with the Acute Physiology And Chronic Health Evaluation (APACHE) II scoring system. METHODS: Plasma concentrations of calcitonin precursors were determined on admission in 69 patients with acute pancreatitis. APACHE II scores were calculated on admission. Attacks were classified as mild (n = 55) or severe (n = 14) according to the Atlanta criteria. Plasma calcitonin precursor levels were determined with a sensitive radioimmunoassay. RESULTS: On the day of hospital admission, plasma levels of calcitonin precursors were significantly greater in patients with a severe attack compared with levels in those with a mild attack of pancreatitis (median 64 versus 25 fmol/ml; P = 0.014), but the APACHE II scores were no different (median 9 versus 8; P = 0.2). The sensitivity, specificity, positive predictive and negative predictive values, and accuracy for the prediction of severe acute pancreatitis were 67, 89, 57, 93 and 85 per cent respectively for plasma calcitonin precursor levels higher than 48 fmol/ml, and 69, 45, 23, 86 and 50 per cent respectively for an APACHE II score greater than 7. Differences in the specificity and accuracy of the two prognostic indicators were significant (P < 0.001 and P = 0.001 respectively). A plasma calcitonin precursor concentration of more than 160 fmol/ml on admission was highly accurate (94 per cent) in predicting the development of septic complications and death. CONCLUSION: The assay of plasma calcitonin precursors on the day of admission to hospital has the potential to provide a more accurate prediction of the severity of acute pancreatitis than the APACHE II scoring system.     

Applying Ockham's razor to pancreatitis prognostication: a four-variable predictive model

OBJECTIVE: We sought to develop a simple yet accurate prognostic scoring system to determine the severity of acute pancreatitis at admission. SUMMARY BACKGROUND DATA: Because acute pancreatitis has a variable and frequently unpredictable course, identifying individuals at greatest risk for significant, life-threatening complications and stratifying their care appropriately remain a concern. Previous prognostic scoring systems predict severity reasonably well but are limited by time constraints, are unwieldy to use, or both. METHODS: Data from the international phase III trial of the platelet-activating factor receptor-antagonist Lexipafant were used to develop a 4-variable prognostic model. We then compared the model's ability to predict the severity of acute pancreatitis with the Ranson, Glasgow, and APACHE II systems. RESULTS: The model (BALI), which included BUN >or=25 mg/dL, Age >or=65 years, LDH >or=300 IU/L, and IL-6 >or=300 pg/mL, measured at admission, was similar to the Ranson, Glasgow, and APACHE II systems in its ability to identify increased mortality from acute pancreatitis. The receiver operating characteristic curve area for the BALI model was >or=0.82 +/- 0.03 (mean +/- SD) versus 0.75 +/- 0.04 (Ranson), 0.80 +/- 0.03 (Glasgow), and 0.79 +/- 0.03 (APACHE II). Furthermore, at a prevalence of 15%, the positive and negative predictive values for increased mortality were similar for all systems. CONCLUSION: The prognostic ability of the BALI 4-variable model was similar to the Ranson, Glasgow, and APACHE II systems but is unique in its simplicity and ability to accurately predict disease severity when used at admission or anytime during the first 48 hours of hospitalization.     

Efficacy of somatostatin and its analogues in the treatment of acute pancreatitis: clinical retrospective study

Acute pancreatitis is an acute inflammatory disease of the pancreas, with variable involvement of other regional tissues or remote organ systems. Acute pancreatitis is mild in 80% of cases; virtually all patients with this form of disease will survive, because it's associated with minimal organ dysfunction and uneventful recovery; the severe pancreatitis develops in 20% of cases and is associated with higher morbidity and mortality. It's most important to identify the severity of disease at the moment of hospital admission; many scoring systems have been developed to serve as early prognostic signs: Ranson's criteria, Imrie's criteria, Apache II score, Balthazar's TC score. Recently, new drugs have been proposed in the treatment of acute pancreatitis, as, for example, calcitonine, glucagon, systemic antioxidants, antagonists of the receptors of interleukines, antiproteases (aprotinin and gabexate-mesilate) and the inhibitors of pancreatic secretions (somatostatin and its analogues). However, many controversies still exist concerning the real efficacy of these drugs in the treatment of acute pancreatitis, particularly regarding the inhibitors of pancreatic secretions: recently, some studies showed that somatostatin is able to actually reduce the local complication of the disease and the development of severe forms of acute pancreatitis; on the other hand, other studies failed to show real advantages of somatostatin reducing morbidity and mortality for pancreatitis. The aim of present study is a retrospective analysis of patients affected by acute pancreatitis in order to evaluate efficacy of somatostatin and its analogues. All patients subdivided in two groups: group A, patients treated with conventional therapy plus somatostatin and/or octreotide (SS/LS), and group B, patients treated only with conventional therapy. Results seem to show that somatostatin does not positively affect morbidity and mortality in patients with acute pancreatitis. The Authors conclude that, at present; somatostatin cannot be considered surely effective in preventing complications and mortality in acute pancreatitis. Further studies are still necessary to verify the effectiveness of somatostatin and its analogues in the therapy of acute pancreatitis.     

Surgical Treatment for Severe Acute Pancreatitis: Extent and Surgical Control of Necrosis Determine Outcome

In patients operated on for severe acute pancreatitis (SAP), the factors determining outcome remain unclear. From 1986 to 1998 a total of 340 patients with a diagnosis of SAP and in need of operative treatment were admitted to the intensive care unit (ICU) of a university hospital and a secondary care hospital. The mean APACHE II score on the day of admission was 16.1 (range 8–35). All patients required operative therapy. Among the 340 patients, 270 (79.4%) had to be reoperated: 196 patients (72.6%) underwent operative revisions on demand, and 74 (27.4%) patients had preplanned reoperation. The overall mortality was 39.1% (133 patients). Septic organ failure in 126 patients (37.1%) and myocardial infarction or pulmonary embolism in 7 patients (2%) were the causes of death. The patient’s age (p <0.0002), APACHE II scores at admission (p <0.0001), presence or development of (single or multiple) organ failure (p <0.002), infection (p <0.02) and extent (p <0.04) of pancreatic necrosis, and surgical control of local necrosis (p <0.0001) significantly determined survival. SAP that requires surgical treatment is associated with high in-hospital mortality. Surgical control of local necrosis is the precondition for survival. Advanced age of the patient, high APACHE II score at admission, development of organ failure, and the extent and infection of pancreatic necrosis influence the outcome.     

重症急性胰腺炎早期液体治疗策略的探讨

目的探讨重症急性胰腺炎(SAP)早期两种不同液体治疗策略对患者预后的影响。方法回顾性分析我院2000年1月至2011年11月期间收治的符合入选标准且达到液体治疗目标的97例SAP患者,2000年1月至2004年12月期间收治的患者采用传统的液体治疗方法(简称传统治疗组,n=34),2005年1月至2011年11月期间收治的患者采取的早期目标指导的液体治疗策略(简称早期目标治疗组,n=63),比较2组间急性生理与慢性健康状况Ⅱ评分(APACHEⅡ)、器官功能不全评分(Marshall)、多器官功能障碍综合征(MODS)发生率、胰腺感染率和住院病死率的差异。结果与传统治疗组相比,早期目标治疗组患者液体治疗后第3天时的APACHEⅡ和Marshall评分较传统治疗组明显降低(APACHEⅡ评分:7.38±4.01比11.35±4.27,P=0.011;Marshall评分:4.13±2.06比6.82±3.15,P=0.016)。另外,早期目标治疗组患者入院后7 d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(MODS:46.0%比61.8%,P=0.139;胰腺感染率:31.7%比44.1%,P=0.226;住院病死率:15.8%比23.5%,P=0.355),但其差异均无统计学意义。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。     

急性胰腺炎患者外周血NGAL和胃饥饿素水平变化及其意义

目的:探讨中性粒细胞明胶酶相关脂质运载蛋白(NGAL)及胃饥饿素(ghrelin)在急性胰腺炎(AP)患者外周血中水平高低与患者病情的关系。方法:收集既往收治的199例AP患者资料,其中急性轻症胰腺炎(MAP)103例,急性重症胰腺炎(SAP)96例;治疗期间17例(8.54%)死亡,分别比较不同病情与不同治疗转归及患者间入院第1天NGAL、ghrelin水平和其他指标的差异。结果:SAP患者的NGAL、ghrelin、C反应蛋白(CRP)、白细胞(WBC)、血淀粉酶、降钙素原(PCT)、APACHE II评分、Balthazar CT评分、BISAP指数均明显高于MAP组患者(均P0.05);治疗期间死亡患者的以上指标也均明显高于存活患者(均P0.05);199例患者外周血中NGAL、ghrelin水平与BISAP指数呈明显正相关关系(r=0.579、0.482,均P0.05),且两者与BISAP指数的相关性优于血淀粉酶、WBC、PCT。结论:AP患者外周血中NGAL、ghrelin水平与病情密切相关,两者水平增高预示着患者预后的不良的风险增大。     

入院时APACHEⅡ评分对重症急性胰腺炎发生深部真菌感染的判断价值

目的评价入院时急性生理与慢性健康评估Ⅱ(APACHEⅡ)评分在重症急性胰腺炎(SAP)发生深部真菌感染(DFI)中的判断价值。方法回顾性分析2006年1月至2011年6月期间我院收治的132例SAP患者的临床资料,采用受试者操作特征曲线(ROC)评价APACHEⅡ评分预测DFI的价值。结果 132例SAP患者中39例发生DFI(29.5%),其中白色念珠菌感染36例(92.3%),合并热带念珠菌2例(5.1%),合并近平滑仿珠菌1例(2.6%);单部位感染27例(69.2%),多部位感染12例(30.8%)。39例发生DFI患者入院时APACHEⅡ评分为(17.1±3.8)分,而93例未发生DFI患者入院时APACHEⅡ评分为(9.7±2.1)分,前者明显高于后者(t=14.316,P=0.000)。APACHEⅡ评分对SAP患者发生DFI预测的ROC曲线下面积为0.745(P=0.000),95%CI为0.641～0.849。当截断值为15分时,预测效能最佳,其特异度为0.81,灵敏度为0.72,约登指数为0.53。结论入院时APACHEⅡ评分能较好地预测SAP患者DFI的发生,尤其当APACHEⅡ评分大于15分时,高度提示发生DFI的可能,必要时可行预防性抗真菌治疗。     

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??Objective:To analyse the clinic characteristics of acute renal failure (ARF) complicating severe actue pancreatitis(SAP),and study the methods of prevention and therapy of it. Methods:503 patients with SAP who were in hospital between Jan.1997 and Apr.2005 and 54 of whom were complicated with ARF were retrospectively analyzed to conclude the morbility and mortality from ARF complicating SAP,then analyze the impact factors of them respectively by linear regression (stepwise regression) methods. Results:In SAP patients,the morbility of ARF was 10.7%.The distinct impact factors of it were the patients'age,the duration of SIRS,severity grade(APACHE ??score,CT score),ARDS,MODS,ACS,infection and local complications and so on.18 of 54 patients with ARF were dead and the motality was 33??3%.Complicating ARDS and MODS simultaneously was the important reason of increasing motality??but whether complicating the infection around pancreas was not. Conclusion:ARF is the severe complication of SAP,early liquid resuscitation??function protection of vital organs and positive eduction are the important measures to prevent SAP from complicating ARF and improve the prognosis.     

重症急性胰腺炎感染期CD4+ T淋巴细胞内ATP含量的变化

目的:探讨CD4+T淋巴细胞内三磷酸腺苷(ATP)含量在重症急性胰腺炎(SAP)感染期的变化。方法:将南开医院收治的42例SAP患者(SAP组)及36名健康志愿者(对照组)纳入研究。SAP组入院后于1,4,7,14,21 d用ImmuKnowTM免疫细胞功能测定试剂盒检测CD4+T淋巴细胞内ATP值,对照组以相同的时间间隔做相同的检测。之后根据SAP组是否进入感染期分为感染组(18例)和非感染组(24例)。分析和比较3组ATP含量的变化,并用受试者工作特征(ROC)曲线分析ATP含量变化对判断SAP继发感染的价值。结果:对照组CD4+T淋巴细胞ATP含量保持稳定。两个SAP组的ATP含量变化趋势基本一致,入院后第1,4天两组的ATP含量明显高于对照组(P<0.05),第7天两组ATP含量明显降低,均于第14天降至最低水平,其中感染组下降程度明显大于非感染组(P<0.05),随后两组ATP含量开始回升,第21天非感染组ATP含量已基本接近对照组,但感染组仍低于对照组(P<0.05)。ROC曲线分析表明,当CD4+T细胞内ATP值降低(<151.55 ng/mL)时,SAP继发感染的机率明显增加;ATP含量的降低对判断SAP继发感染的敏感度为0.810,特异度为0.605。结论:CD4+T淋巴细胞内ATP含量可较准确地反映SAP患者的整体细胞免疫功能状况和继发感染的风险。     

Comparison of the severity of illness scoring systems for critically ill cirrhotic patients with renal failure

BACKGROUND: Mortality rates of cirrhotic patients with renal failure admitted to the medical intensive care unit (ICU) are high. End-stage liver disease is frequently complicated by disturbances of renal function. This investigation is aimed to compare the predicting ability of acute physiology, age, chronic health evaluation II and III (APACHE II and III), sequential organ failure assessment (SOFA), and Child-Pugh scoring systems, obtained on the first day of ICU admission, for hospital mortality in critically ill cirrhotic patients with renal failure. METHODS: Sixty-seven patients with liver cirrhosis and renal failure were admitted to ICU from April 2001-March 2002. Information considered necessary for computing the Child-Pugh, SOFA, APACHE II and APACHE III score on the first day of ICU admission was prospectively collected. RESULTS: The overall hospital mortality rate was 86.6%. Liver disease was most commonly attributed to hepatitis B viral infection. The development of renal failure was associated with a history of gastrointestinal bleeding. Goodness-of-fit was good for SOFA, APACHE II and APACHE III scores. The APACHE III and SOFA models reported good areas under receiver operating characteristic curve (0.878 +/- 0.050 and 0.868 +/- 0.051, respectively). CONCLUSION: Renal failure is common in critically ill patients with cirrhosis. The prognosis for cirrhotic patients with renal failure is poor. APACHE III and SOFA showed excellent discrimination power in this group of patients. They are superior to APACHE II and Child-Pugh scores in this homogenous group of patients.     

Scoring of human acute pancreatitis: state of the art

Background

Acute pancreatitis remains as one of the most difficult and challenging digestive disorder to predict in terms of clinical course and outcome. Every case has an individual course and therefore acute pancreatitis remains challenging and fascinating. Due to this variability, many different scoring systems have evolved during the last decades. Every scoring system has advantages and disadvantages. Not every scoring system is capable of assessing the clinical time course of the disease, some are only suitable for the time of initial presentation.

Aim

This paper will give an overview on the development of different widely used scoring systems and their performance in assessing severity and prognosis of acute pancreatitis.

Conclusion

Severity assessment means objective quantification of overall severity of illness. Early and reliable stratification of severity is required to decide best treatment of the individual patient, preparation for possible evolving complications or for referral to specialist centers. No single scoring system is able to cover the entire range of problems associated with treatment and assessment of acute pancreatitis. In our clinical experience, we recommend hematocrit upon admission, daily sequential organ failure assessment score and procalcitonin, C-reactive protein on day 3 and CT severity index beyond the first week. These scoring tools together with close clinical follow-up of the patient ultimately lead to an optimized treatment of this challenging disease.