早期目标指导的容量治疗防治重症急性胰腺炎腹腔高压和多脏器功能不全的作用

目的 探讨早期目标指导的容量治疗中使用6%羟乙基淀粉130/0.4氯化钠注射液防治重症急性胰腺炎患者腹腔高压和多脏器功能不全的作用.方法 根据病例入选和排除标准,4个医学中心共有120例重症急性胰腺炎患者入选.所有患者就诊时距离初发症状时间均在72 h之内,年龄18～65岁.随机分为研究组(n=59)和对照组(n=61).两组患者均实施重症急性胰腺炎早期综合治疗方案.对照组的容量治疗使用乳酸林格溶液;研究组除使用乳酸林格溶液外,同时静脉输注6%羟乙摹淀粉130/0.4氯化钠注射液.入组时及入组后监测患者液体平衡、腹内压、肺、肝、肾功能及APACHE Ⅱ评分.结果 入组后第4天和第5天,研究组平均腹内压低于对照组(P<0.05);调整基线效应和多中心效应后,平均腹内压相对基线的下降幅度自第2天开始明显大于对照组(P<0.05);两组腹内压高峰值出现时间的分布无差异(P>0.05),但研究组腹内压高峰出现时间有前移趋势.研究组液体正平衡总量低于对照组(P=0.041);液体负平衡出现时间早于对照组(P=0.036).两组各个时间点的APACHE Ⅱ评分的差异均无统计学意义(P>0.05),但调整基线效应和多中心效应后,自第4天开始,研究组相对基线值下降的幅度大于对照组(P<0.05).相关性分析显示,APACHE Ⅱ评分与腹内压水平呈正相关.研究组的氧合指数大于对照组(P<0.05).结论 在重症急性胰腺炎患者早期治疗中应关注容量治疗对腹内压的影响,使用羟乙基淀粉130/0.4氯化钠注射液有助于减轻液体扣押、降低腹内压和APACHE Ⅱ评分、保护脏器功能.

Effects of early goal-directed fluid therapy on intra-abdominal hypertension and multiple organ dysfunction in patients with severe acute pancreatitis

Objective To observe the effects of early gual-directed fluid therapy with hydroxyethyl starch 130/0.4 on intra-abdominal hypertension (IAH), multiple organ dysfunction and fluid balance in severe acute pancreatitis (SAP) patients. Methods According to the criteria of selection and exclusion, 120 SAP patients within 72 hours after the symptom occurred from 4 study sites were recruited. They were given standard medication according to "the guideline of diagnosis and treatment of SAP in China" in SICU or PICU. The patients were randomly divided into two groups with crystalloid( control group) and colloid plus crystalioid resuscitation(research group). The objective of fluid therapy was to keep steady hemodynamics for 8 days. IAP was measured three times daily by means of urinary bladder transduction. Function of liver,renal and lung were detected daily. APACHE Ⅱ score and fluid balance were calculated daily. Results Total 120 cases were recruited into research group(n=59) and control group(n=61). The demography and baseline data were comparable, IAP was lower in research group than that in control group at day 4 and day 5 (P<0.05). There was no significant difference in APACHE Ⅱ scores between two groups pre- and after admission. The decline of daily IAP to baseline(△IAP) in research group was significantly higher than in research group from day 2 to day 8 (P<0.05), whilst the decline of daily APACHE Ⅱ score to baseline (△APACHE Ⅱ score) in research group were significantly higher from day 4 to day 8(P<0.05). Negative fluid balance emerged much earlier in the research group (P=0.036). Percentage of patients with negative fluid balance within 8 days was significantly higher in research group than that in control group(94.9% vs.62.3%). The amount of positive fluid balance was significantly lower in research group (P=0.039). IAP correlated significantly with APACHE Ⅱ score (r~2=0.322, P=0.000). PaO_2/FiO_2 was significantly higer in research group at day 4 and day 8. Conclusions It is very important to pay close attention to IAP in early fluid therapy of SAP patients. Early goal-directed fluid therapy with HES130/0.4 shortens the duration of positive fluid balance, decreases the amount of positive fluid balance, reduces APACHE Ⅱ score, relieves IAH, and improves PaO_2/FiO_2.