腹腔填塞在非创伤性腹腔大出血中的应用

目的:探讨腹腔填塞在非创伤性腹腔大出血患者中的应用价值.方法:收集2002年2月至2007年2月应用纱布填塞控制非创伤性腹腔大出血患者的资料.回顾性分析患者的生理学参数、手术指征及操作、输血输液量、ICU及住院时间、并发症及病死率.将实际病死率分别与计数死亡率和发病率的生理学和手术严重性评分(POSSUM)和Portsmouth计数病死率和发病率的生理学和手术严重性评分(P-POSSUM)预计病死率进行比较.结果:本组患者共26例,平均年龄(42.6±15.8)岁(18～72岁).与腹腔大出血相关的常见病因为坏死性胰腺炎(11例)、肠瘘(5例)和肿瘤(4例).24例(92.4%)患者单纯填塞获得止血,1例联合血管造影栓寨获得止血,1例止血失败.术中平均出血虽为1253.8 ml.经ICU复温复苏后生理学参数明显改善的有:体温、收缩压、心率、动脉血pH、碱剩余、血红蛋白、红细胞压积、凝血酶原时间及国际标准化比率.平均填塞时间(4.3±2.4)d.平均住ICU时间和住院时间分别为(40.5±41.5)d和(67.4±51.0)d.死亡7例(26.9%),实际病死率显著低于POSSUM(77.7%,P=0.001)和P-POSSUM(63.4%,P=0.025)预计病死率.最常见的并发症包括肺炎15例(57.7%)、菌血症13例(50.0%)和再出血7例(26.9%).结论:腹腔填塞是控制非创伤性腹腔大出血的有效手段,可阻断患者向以低体温、凝血障碍及酸中毒为特征的"致死三联征"发展,对经严格选择的患者使用该策略可降低病死率.

Application of abdominal packing in non-trauma patients with severe abdominal hemorrhage

Objective To assess the efficacy and safety of damage control surgery with abdominal packing in non-trauma patients with severe abdominal hemorrhage. Methods A retrospective review of consecutive non-trauma patients who underwent abdominal packing to control severe abdominal hemorrhage between February 2002 and February 2007 were performed. The demographics, physiological parameters, surgical indications and procedures, mortality, morbidity and volumes of resuscitation were retrieved. The observed mortality was compared to those calculated from the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) and Portsmouth Predictor Equation (P-POSSUM) scores. Results A total of 26 non-trauma patients were included in this study, with a mean age of (42.6 ± 15.8) years ( range, 18-72 years ). The most common etiologies associated with the severe hemorrhage was necrotizing pancreatitis (11 cases), intestinal fistula (5 cases) and tumor (4 cases). Of the patients, 24 cases (92.4%) achieved hemostasis by simple packing, 1 achieved hemostasis by using packing and angiographic embolizatiou, and the other one failed and died. The mean intra-operative blood loss during the initial procedure was 1253.8 ml. The physiological parameters which improved significantly after rewarming and resuscitation in ICU phase included: body temperature, systolic blood pressure, heart rate, arterial pH, base excess, hemoglobin, hematocrit, prothrombin time, and international normalized ratio. The mean duration of packing was 4.3 days. The mean length of SICU stay and hospital stay was 40.5 and 67.4 days, respectively. Mortality rate predicted by POSSUM and P-POSSUM was 77.7% and 63.4%, respectively. Seven patients (26.9% ) died after operation, brought an observed mortality rate significantly lower than predicted (P=0.001 and 0.025, respectively). The most common complications included pneumonia (57.7% ), bacteremia (50.0% ), and re-bleeding (26.9% ). Conclusions Damage control laparotomy with packing is an effective procedure in the management of severe non-trauma abdominal hemorrhage, it can prevent the aggravation of "lethal triad" characterized by hypothermia, coagulopathy and acidosis. Appropriate application of the technique in strictly selected patients can result in a lower mortality rate.