血液滤过治疗重症急性胰腺炎和暴发性胰腺炎的策略与疗效

目的 探讨血液滤过治疗重症急性胰腺炎(SAP)和暴发性胰腺炎(FAP)的策略与疗效.方法 1997年3月至2008年12月,上海瑞金医院外科ICU同一外科小组共收治130例SAP患者和81例FAP患者接受血液滤过治疗,比较两组患者的血液滤过指征、血液滤过参数、临床疗效和并发症发生情况.结果 所有患者均在发病72 h内接受高流量血液滤过或透析滤过.SAP患者接受短时血液滤过应用率(76.9%)显著高于FAP(38.3%)(P<0.05),而持续血液滤过的比例(23.1%)显著低于FAP(61.7%)(P<0.05);SAP和FAP患者的血液滤过治疗剂量分别为(53±6)ml·kg~(-1)·h~(-1)和(59±10)ml·kg~(-1)·h~(-1)(P<0.05);FAP的透析滤过应用率显著高于SAP(P<0.05).低分子肝素和普通肝素均可用于血液滤过的抗凝,但FAP患者所需剂量显著高于SAP患者(P<0.05).血液滤过改善SAP和FAP腹痛的时间分别为(9±6)h和(15±10)h;血液滤过结束后SAP和FAP患者的腹内压较血液滤过前均显著降低(P<0.05).SAP患者的28 d手术率(73.8%)显著低于FAP(87.7%)(P<0.05).SAP和FAP患者的住院治愈率分别为88.5%和67.9%.FAP的血液感染率和出血率显著高于SAP(P<0.05).结论 发病72 h内,适合非手术治疗的SAP和FAP患者接受短时和持续高流量血液滤过或透析滤过可显著提高生存率.

Strategy of treatment with high-volume hemofiltration on severe acute pancreatitis and fulminant acute pancreatitis

Objective To investigate strategy of treatment of hemofiltration on severe acute pancreatitis (SAP) and fulminant acute pancreatitis (FAP). Methods One hundred and thirty patients with SAP and eighty-one patients with FAP treated with hemofihration(HF) were prospectively observed from March 1997 to December 2008. Indications for HF, variables (time interval for hemofihration), mode,therapeutic dosage, blood rate, heparin dosage and components of hemofihration, therapeutic efficacy (time of disapearance of abdominal pain, intra-abdominal pressure and survival rate) and complications(incidence of bleeding and blood infection). Results All patients underwent high volume hemofiltration (HVHF)or hemodialysis-filtration (HDF)within 72 hours after onset of the disease. Dose of SAP and FAP was (53±6)ml·kg~(-1)·h-1 and (59±10) ml·kg~(-1)·h~(-1) (P<0.05), respectively. Rate of short veno-venous hemofiltration in SAP (76.9%) was higher than that of FAP (38.3%) (P<0.05) ; however, rate of continuous veno-venous hemofiltration (23.1%) was lower than that of FAP (37.0%) (P < 0.05). Rate of HDF was much higher in FAP than that of SAP.Low molecular weight heparin and heparin were both available to anticoagualte;but dosage required in patients with FAP was much higher than that of SAP(P <0.05). Time intervals for amelioration of abdominal pain in SAP and FAP were (9±6) h and (15±10) h,respectively, ltra-abdominal pressure was decreased significantly at the end of hemofiltratiou compared to prior to hemofihration in SAP and FAP (P< 0.05). Level of serum triglyceride decreased abruptly after adsorption(P<0.05). Rate of operation within 28 days in SAP(73.8%) was lower than FAP (87.7%).The in-hospital survival rates in SAP and FAP were 88. 5% and 67.9%, respectively. Amount of platelet decreased in patients with blood flow rate less than 240 ml/min was higher than that of more than 240 ml/min(P<0.05). And incidence of blood stream infection and bleeding increased significantly(P<0.05).Conclusions HVHF and HDF used in SAP and FAP patients underwent conservative treatment within 72 hours, respectively ,can increase survival rate significantly.