连续性血液净化治疗在急性重症胰腺炎临床应用

重症急性胰腺炎是外科临床常见的急腹症，起病急、进展快，死亡率高，可达20％～30％，出现一个器官功能不全时死亡率〉36％．有多个脏器功能不全背的平均死亡率更高达47％。[第一段]     

重症急性胰腺炎血液稀释治疗犬的实验观察

本实验提示：患重症急性胰腺炎（ＳＡＰ）时，在外科手术的前提下，及早经胰腺局部动脉灌注血管扩张剂和抑酶剂，尤其是用低分子右旋糖酐作为扩容剂，比单纯的晶体扩容复苏更为重要，通过改变其血流，增加胰腺的灌注，从而防止ＳＡＰ早期局部缺血所至的继发性损伤。     

早期连续性血液净化治疗老年重症脓毒血症急性肾损伤效果及对患者死亡率的影响

目的:观察老年重症脓毒血症急性肾损伤(AKI)早期连续性血液净化治疗的临床效果.方法:临床资料采集收治的90例重症脓毒症合并AKI患者,按不同治疗方案分为两组,每组45例,对照组施予基础治疗,观察组在基础治疗上行连续性血液净化(CBP)治疗,比较两组炎性因子、肾功能及预后.结果:观察组治疗后C-反应蛋白(CRP)(27...     

重症急性胰腺炎27例分析

重症急性胰腺炎是一个全身性疾病 ,常引起多器官功能不全综合征(ＭＯＤＳ) ,现对我院收治的 2 7例重症急性胰腺炎进行临床分析 ,报告如下。1　临床资料1 1　一般资料　 2 7例中男 17例 ,占6 3% ,女 10例 ,占 37% ;年龄 2 5～ 74岁。发病原因 :存在胆道结石 2 0例 ,占 74 % ,胆囊炎 3例 ,占 11% ,其他原因 4例 ,占15 %。2 7例均有不同程度的腹痛、腹胀、恶心、呕吐及发热等症状 ,均有血、尿淀粉酶的升高。1 2　多器官受累表现　心血管并发症 :心电图表现为心肌缺血 5例、心律失常 3例、心肌酶明显升高 2例 ,共 10例 ,占37% ,并发休克者 11例 …     

重症急性胰腺炎血液稀释治疗犬的实验观察

本实验提示:患重症急性胰腺炎(SAP)时,在外科手术的前提下,及早经胰腺局部动脉灌注血管扩张剂和抑酶剂,尤其是用低分子右旋糖酐作为扩容剂,比单纯的晶体扩容复苏更为重要,通过改变其血流,增加胰腺的灌注,从而防止SAP早期局部缺血所至的继发性损伤.     

急性胰腺炎致多器官功能不全综合征临床分析

目的:探讨重症急性胰腺炎(SAP)致多器官功能不全综合征(MODS)的临床病理过程及发病机制。方法回顾性分析92例SAP及其中28例并发MODS者的临床资料。结果本组28例MODS的发生与重度胰腺坏死、早期循环休克及继发性胰腺感染等因素有关。死亡30例,死亡率32.61%。结论发生于胰腺炎病程不同时期,临床经过也不一致的MODS病例,却以显著的全身脓毒性反应为共同特征,SAP后MODS是由局部胰腺毒性病灶始动而波及全身各器官系统的炎症性病理过程。     

乌司他丁治疗重症急性胰腺炎疗效观察

近年来对重症胰腺炎(SAP)的治疗，绝大多数学者主张早期非手术治疗。目前，对SAP的非手术治疗仍属探索阶段，我们总结近年来78例非手术治疗SAP病例，其中30例使用乌司他丁治疗，取得了较好的疗效。现报道如下。     

连续性血液净化用于ICU重症脓毒血症的临床疗效及安全性评价

目的:对ICU重症脓毒血症患者实施连续性血液净化治疗的效果及方案的安全性进行探讨。方法:选取102例ICU重症脓毒血症患者进行分组比较,观察组共51例患者实施连续性血液净化治疗,对照组共51例患者实施常规方法治疗,就不同方案的应用效果展开比较,并探讨方案是否具有安全性。结果:治疗前,两组患者的肿瘤坏死因子、白细胞介素-6比较,差异无统计学意义(P>0.05)。治疗后,观察组的肿瘤坏死因子、白细胞介素-6均低于对照组,差异有统计学意义(P<0.05);对照组的治疗总有效率低于观察组,观察组12个月、24个月的死亡率均较对照组低,差异均有统计学意义(P<0.05)。结论:保证方案安全的基础上,应用连续性血液净化治疗ICU重症脓毒血症,可提升治疗效果,延长患者的生命周期。     

连续性血液净化治疗脓毒血症合并急性肾损伤应用价值分析

目的分析连续性血液净化治疗脓毒血症合并急性肾损伤应用价值。方法选取我院于2011-06-2013-12间收治的38例脓毒血症合并急性肾损伤患者,随机将其分成对照组与观察组,每组各19例。给予对照组常规治疗,观察组除常规治疗外给予连续性血液净化（CRRT）治疗。对两组患者治疗前后的生命体征与肾功电解质以及其预后进行观察。结果观察组患者的生命体征、酸碱平衡、肾功电解质及预后的改善程度均明显好于对照组,两组结果比较,具有显著差异（P〈0.05）。结论 CRRT对脓毒血症合并急性肾损伤的治疗可以显著改善患者酸碱平衡、肾功电解质及预后从而缓解病情。     

漂浮导管对重症急性胰腺炎继发脓毒血症患者临床治疗的价值研究

目的探讨分析漂浮导管技术对指导重症急性胰腺炎继发脓毒血症患者临床治疗的价值研究。方法选取2017年1月至2019年4月我院收治的重症急性胰腺炎继发脓毒血症患者60例,跟踪病情变化,其中病情好转患者40例（A组）,病情恶化患者20例（B组）。对比观察两组患者的治疗前后48 h的中心静脉压（CVP）、平均肺动脉压（MPAP）、肺毛细血管楔压（PCWP）、心率（HR）、心脏指数（CI）、外周血管阻力指数（SVRI）等指标的血流动力学变化,同时观察记录病情好转组治疗后1～6 d的血流动力学改变。结果相比于治疗前,A组患者治疗48 h后CVP、CI指标明显下降（P<0.05）,SVRI、HR、PCWP、MPAP指标明显升高（P<0.05）; B组患者治疗前后血流动力学指标差异均无统计学意义（P>0.05）。与对照值相比,A组患者治疗后1～3 d CI、CVP明显降低（P<0.05）,PCWP、SVRI明显升高（P<0.05）;治疗后4～6 d内SVRI明显降低（P<0.05）;治疗后6 d内MPAP和HR明显升高（P<0.05）。结论漂浮导管技术应用于重症急性胰腺炎继发脓毒血症患者,能够及时检测外周血管扩张和低血容量的问题,评估病情,在临床治疗的监测指导和预后评估有着重要价值     

Rapid hemodilution is associated with increased sepsis and mortality among patients with severe acute pancreatitis

Background Hemoconcentration may be an important factor that determines the progression of severe acute pancreatitis （SAP）. In addition, it has been proposed that biomarkers may be useful in predicting subsequent necrosis in SAP. However, it is still uncertain whether hemodilution in a short term can improve outcome. We aimed to investigate the effect of rapid hemodilution on the outcome of patients with SAP. Methods One hundred and fifteen patients were admitted prospectively according to the criteria within 24 hours of SAP onset. Patients were randomly assigned to either rapid hemodilution （hematocrit （HCT） 〈35%, n=56） or slow hemodilution （HCT 〉35%, n=-59） within 48 hours of onset. Balthazar CT scores were calculated on admission, day 7, and day 14, after onset of the disease. Time interval for sepsis presented, incidence of sepsis within 28 days and in-hospital survival rate were determined. Results The amount of fluid used in rapid hemodilution was significantly more than that used in slow hemodilution （P 〈0.05） on the admission day, the first day, and the second day. There were significant differences between the rapid and slow hemodilution group in terms of hematocrit, oxygenation index, pH values, APACHE II scores and organ dysfunction at different time during the first week. There were significant differences in the time interval to sepsis in rapid hemodilution （（7.4±1.9） days） compared with the slow hemodilution group （（10.2±2.3） days）, and the incidence of sepsis （78.6%） was higher in the rapid group compared to the slow （57.6%） in the first 28 days. The survival rate of the slow hemodilution group （84.7%） was better than the rapid hemodilution （66.1%. P 〈0.05）. Conclusions Rapid hemodilution can increase the incidence of sepsis within 28 days and in-hospital mortality. Hematocrit should be maintained between 30%-40% in the acute response stage.     

Rapid hemodilution is associated with increased sepsis and mortality among patients with severe acute pancreatitis

Background Hemoconcentration may be an important factor that determines the progression of severe acute pancreatitis (SAP). In addition, it has been proposed that biomarkers may be useful in predicting subsequent necrosis in SAP. However, it is still uncertain whether hemodilution in a short term can improve outcome. We aimed to investigate the effect of rapid hemodilution on the outcome of patients with SAP.Methods One hundred and fifteen patients were admitted prospectively according to the criteria within 24 hours of SAP onset. Patients were randomly assigned to either rapid hemodilution (hematocrit (HCT) <35%, n=56) or slow hemodilution (HCT 235%, n=59) within 48 hours of onset. Balthazar CT scores were calculated on admission, day 7, and day 14, after onset of the disease. Time interval for sepsis presented, incidence of sepsis within 28 days and in-hospital survival rate were determined.Results The amount of fluid used in rapid hemodilution was significantly more than that used in slow hemodilution (P <0.05) on the admission day, the first day, and the second day. There were significant differences between the rapid and slow hemodilution group in terms of hematocrit, oxygenation index, pH values, APACHE II scores and organ dysfunction at different time during the first week. There were significant differences in the time interval to sepsis in rapid hemodilution ((7.4 1.9) days) compared with the slow hemodilution group ((10.2 2.3) days), and the incidence of sepsis (78.6%) was higher in the rapid group compared to the slow (57.6%) in the first 28 days. The survival rate of the slow hemodilution group (84.7%) was better than the rapid hemodilution (66.1%. P<0.05).Conclusions Rapid hemodilution can increase the incidence of sepsis within 28 days and in-hospital mortality. Hematocrit should be maintained between 30%-40% in the acute response stage.     

Rapid hemodilution is associated with increased sepsis and mortality among patients with severe acute pancreatitis

Background Hemoconcentration may be an important factor that determines the progression of severe acute pancreatitis (SAP). In addition, it has been proposed that biomarkers may be useful in predicting subsequent necrosis in SAP. However, it is still uncertain whether hemodilution in a short term can improve outcome. We aimed to investigate the effect of rapid hemodilution on the outcome of patients with SAP.Methods One hundred and fifteen patients were admitted prospectively according to the criteria within 24 hours of SAP onset. Patients were randomly assigned to either rapid hemodilution (hematocrit (HCT) <35%, n=56) or slow hemodilution (HCT 235%, n=59) within 48 hours of onset. Balthazar CT scores were calculated on admission, day 7, and day 14, after onset of the disease. Time interval for sepsis presented, incidence of sepsis within 28 days and in-hospital survival rate were determined.Results The amount of fluid used in rapid hemodilution was significantly more than that used in slow hemodilution (P <0.05) on the admission day, the first day, and the second day. There were significant differences between the rapid and slow hemodilution group in terms of hematocrit, oxygenation index, pH values, APACHE II scores and organ dysfunction at different time during the first week. There were significant differences in the time interval to sepsis in rapid hemodilution ((7.4 1.9) days) compared with the slow hemodilution group ((10.2 2.3) days), and the incidence of sepsis (78.6%) was higher in the rapid group compared to the slow (57.6%) in the first 28 days. The survival rate of the slow hemodilution group (84.7%) was better than the rapid hemodilution (66.1%. P<0.05).Conclusions Rapid hemodilution can increase the incidence of sepsis within 28 days and in-hospital mortality. Hematocrit should be maintained between 30%-40% in the acute response stage.     

Continuous veno venous hemofiltration in treatment of acute necrotizing pancreatitis

Objective To investigate the effectiveness of using continuous veno venous hemofiltration (CVVH) in the treatment of acute necrotizing pancreatitis (ANP). Methods Thirteen ANP patients were involved in this study, including 4 females and 9 males, averaging 50.6±10.8 years old. CT scans upon admission revealed 33% necrosis involving the body of the pancreas in 2 patients, 67% necrosis in 3 patients and 100% necrosis in the other 8; the CT severity score was 8.9±2.1. CVVH was maintained for at least 72 hours and the AN69 hemofilter (1.2 m2) was changed every 24 hours. The ultrafiltration rate during CVVH was 2993.9±983.0 ml/h, the blood flow rate was 250-300 ml/min, and the substitute fluid was infused in a pre-diluted manner. Low molecular weight heparin was used as anticoagulant. Results CVVH was well tolerated in all the patients. Bloody abdominal cavity drainage fluid was observed in 2 patients, but no other side-effects related with CVVH were observed. Two patients died of systemic fungal infections and another died of intracranial fungi infection, resulting in an ICU mortality of 23.1%. Ten of the patients survived in the ICU, but one of them died for other reasons unrelated to the SAP before discharge. The APACHE Ⅱ score before CVVH was 15.2±6.5, but decreased significantly to 8.1±5.3, 7.5±4.9 and 8.0±5.2 at the 24th, 48th and 72nd hour after CVVH, respectively (P&lt;0.01). Serum concentration of IL-1β and TNFα decreased to the trough at the 6th hour after a new hemofilter was used and increased slowly to pre-CVVH levels 12 hours later.　After CVVH had ceased, the serum levels of two cytokines increased to their peaks at the 120th hour and decreased eventually at the 144th hour. The sieving coefficient (SC) of IL-1β and TNFα was 0.33±0.11 and 0.16±0.08. Conclusion CVVH offered therapeutic options for ANP and was well tolerated resulting in clearance of IL-1β and TNFα; CVVH at early stages of SAP may contribute to the improvement of outcome.     

急性胰腺炎患者血小板计数的变化及其临床意义

目的探讨急性胰腺炎（AP）患者血小板计数的变化与病情及预后的关系。方法对105例急性胰腺炎患者的临床资料进行回顾性分析,分为符合全身炎症反应综合征（SIRS）标准的SIRS组和非SIRS组,比较各组血小板计数、多脏器功能不全综合征的（MODS）的发生率、病死率。结果SIRS组的血小板计数明显降低,MODS发生率及病死率均明显高于非SIRS组（P〈0.01）。结论血小板计数能比较准确地反映危重病患者的病情及预后,对预测AP并发MODS有较高的价值。     

急性重症胰腺炎脏器损伤及病理学基础研究

目的 探讨血管内皮损伤在SAP并发MODS发病机制中的作用.方法 通过建立病因及发病机制与人类SAP相似的大鼠SAP模型,测定SAP组与SO组大鼠不同时间点肝肾功能及血清淀粉酶的变化,观察各器官的血管内皮病理损伤程度,并用流式细胞仪测定并比较不同时间点SAP组与SO组大鼠静脉血中血管脱落内皮细胞数量,动态观察SAP组大鼠血管内皮的损伤.结果 脱落血管内皮细胞数量与胰腺病理损伤及淀粉酶水平呈正相关.结论 急性重症胰腺炎时血浆胰蛋白酶对血管内皮的损伤是组织脏器损伤的病理基础之一.     

中性粒细胞弹性蛋白酶在重症急性胰腺炎并急性肺损伤发病中的表达和意义

目的探讨中性粒细胞弹性蛋白酶（NE）在重症急性胰腺炎并急性肺损伤（SAP-ALI）发病过程中的作用和意义。方法健康SD大鼠60只,随机分成3组：假手术组（n=18）、SAP-ALI组（n=22）、NE处理组（n=20）。ELISA法测定血清NE、TNF-α、IL-1β含量,RT-PCR法检测肺组织中NE的变化,Western blot检测肺组织中NE的表达,ELISA法检测肺泡灌洗液（BALF）和血清中的NE的含量变化,同时观察肺和胰腺组织湿/干质量比和病理形态学变化。结果 NE处理组肺组织、BALF和血清NE含量均较假手术组和SAP-ALI组大鼠明显增加（P〈0.05或P〈0.01）,血清TNF-α、IL-1β含量也明显增加（P〈0.05）。结论中性粒细胞的大量激活及其NE、TNF-α、IL-1β的过度释放参与了SAP-ALI的发病过程。     

Effect of Early Hemofiltration on Pro- and Anti-inflammatory Responses and Multiple Organ Failure in Severe Acute Pancreatitis

Severeacute pancreatitis (SAP )progressesrapidlywithacomplicatedoutcomeandhighmortali ty .Themultipleorgandysfunctionsyndrome(MODS)inducedbytheoverreleaseofcytokineswhichisthemaincauseofpatients’deathsintheear lystage[1] .Hemofiltration (HF)isoneoftheblo…     

乌司他丁治疗重症急性胰腺炎32 例

目的探讨乌司他丁治疗重症急性胰腺炎(SAP)的临床疗效。方法76例SAP患者随机分为2组,对照组44例给予常规非手术治疗,治疗组32例在常规治疗基础上加用乌司他丁10万U溶于5%葡萄糖250 ml中静脉滴注,每日2次,连用7~12 d。结果两组血淀粉酶恢复、胃肠减压量无显著差异(P>0.05),治疗组患者受损器官的功能恢复时间明显短于对照组(P<0.05)。结论乌司他丁配合常规方法治疗SAP在改善受损器官的功能及预防多器官功能不全综合征的发生方面有较好的作用。     

重症急性胰腺炎标准作业程序诊治流程的临床应用

目的 自拟重症急性胰腺炎（SAP）院内急救一体化标准作业程序（SOP）诊治流程,观察该SOP的临床应用效果。方法 组织上海市部分急诊重症监护病房（ICU）质量控制中心专家讨论,参阅国内外相关文献与SAP指南,并结合国内临床实际和海军军医大学（第二军医大学）长征医院"急诊-ICU"一体化建设经验,草拟SAP院内急救一体化SOP诊治流程。并将自拟的SOP方案应用于海军军医大学（第二军医大学）长征医院急救科2015年7月至2017年1月收治的42例符合SOP实施标准的SAP患者（优化组）,选择2014年1月至2015年6月收治的40例SAP患者作为常规组。比较两组患者的临床疗效,入院后72 h和1周时的白细胞计数、中性粒细胞比例、C-反应蛋白水平、降钙素原（PCT）水平、血淀粉酶水平、血糖水平、血乳酸水平、血清肌酐水平、氧合指数、改良CT严重指数（MCTSI）评分、腹腔内压力、尿中性粒细胞明胶酶相关脂质运载蛋白（NGAL）水平、急性生理和慢性健康评估Ⅱ（APACHE Ⅱ）评分等临床指标,以及相关并发症发生情况和生存情况。结果 拟定的SOP诊治流程主要参考2012年度国际SAP诊治标准,其主要变化在于患者由急诊外科医师首诊改为直接进入急诊绿色通道（抢救室）,且在综合救治方案中加入大剂量乌司他丁静脉推注、人血清白蛋白快速滴注（必要时呋噻米静脉推注）、规范化全腹芒硝外敷和生大黄灭菌溶液灌肠。优化组患者的总有效率优于常规组（P<0.05）,住院时间、自主排气时间、腹胀缓解时间、ICU停留时间、连续肾脏替代疗法治疗时间相比常规组均缩短（P均<0.05）。入院后72 h、1周时,两组患者的白细胞计数、中性粒细胞比例、C-反应蛋白水平、PCT水平、血糖水平、血乳酸水平、血清肌酐水平、氧合指数、MCTSI评分、腹腔内压力、尿NGAL水平、APACHE Ⅱ评分差异均有统计学意义（P均<0.05）,血淀粉酶水平仅在入院后72 h差异有统计学意义（P<0.01）。优化组患者急性肾衰竭、急性呼吸窘迫综合征、腹腔积液、腹腔间隔室综合征、胰腺假性囊肿和胰腺脓肿的发生率均低于常规组（P均<0.05）,生存时间长于常规组（P<0.05）,治疗2个月内的生存率高于常规组（P<0.05）。结论 拟定的院内急救一体化SOP可规范SAP诊治流程,提高SAP的救治有效率,降低病死率。