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急性胰腺炎(acute pancreatitis,AP)是一种发展迅速的急腹症,是常见的导致住院或死亡的消化系统疾病之一。大多数轻型AP病人经保守治疗后可完全康复。然而,约20%的AP病人可能会进展为重症急性胰腺炎(severe acute pancreatitis,SAP),并且会迅速且持续地进展为全身炎症反应综合征和多器官功能障碍综合征,预后不良,死亡率高达30%[1]。造成不良后果的主要原因在于没有有效的治疗策略来控制SAP期间激活的炎症级联反应和恢复免疫内环境的稳态[2]。研究[3]表明,SAP继发造成相关性腹水在其并发症的发病机制中发挥重要作用,腹水中包含大量肿瘤坏死因子、白细胞介素(IL)、内毒素等炎性介质。血必净作为中药制成的静脉注射制剂在国内广泛使用,已被证明可抑制过度炎症反应、防止氧化应激、中和内毒素、改善微循环等[4]。然而,关于应用腹腔穿刺引流联合血必净对SAP病人临床效果方面的研究仍然较少。本研究回顾性分析腹腔穿刺引流术联合血必净对SAP病人的治疗效果,旨在评估该治疗策略应用于SAP病人的临床价值。现作报道。
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选取2019年1月至2021年12月我院急诊医学科EICU收治的60例SAP病人,均根据2012年修订的亚特兰大急性胰腺炎分类,根据临床症状、体格检查、实验室检查及影像学检查诊断为SAP[5]。纳入标准:(1)持续性单个器官或多器官衰竭(>48 h)AP病人;(2)年龄≥18周岁;(3)经影像学检查腹腔内有大量积液。排除标准:(1)经影像学检查腹腔无积液或积液较少无法行腹腔穿刺术;(2)并发严重感染(如人类免疫缺陷病毒或人类巨细胞病毒)或自身免疫性疾病(如类风湿性关节炎或系统性红斑狼疮);(3)合并其他胃肠道炎症性疾病(如克罗恩病);(4)入院前1个月内接受过抗生素治疗;(5)孕妇或哺乳期妇女。将入组病人按随机数字表法分为对照组和观察组,各30例。2组病人性别、年龄、基础病、并发症差异均无统计学意义(P>0.05)(见表 1),具有可比性。本研究经蚌埠医学院第一附属医学院伦理委员会批准,根据赫尔辛基宣言进行。所有参与者或其监护人在入组前均获告知并自愿参与研究。
分组 n 男 女 年龄/岁 基础疾病 并发症 糖尿病 高脂血症 高血压 冠心病 肝损伤 肾损伤 肺损伤 凝血功能异常 观察组 30 13 17 54.23±16.12 4(13.33) 2(6.67) 5(16.67) 3(10.00) 2(6.67) 3(10.00) 4(13.33) 8(26.67) 对照组 30 14 16 55.07±15.63 5(16.67) 3(10.00) 4(13.33) 4(13.33) 3(10.00) 2(6.67) 5(16.67) 6(20.00) χ2 — 0.07 0.20* 0.27 0.07 P — >0.05 >0.05 >0.05 >0.05 *示t值 表 1 2组病人一般资料比较[n;百分率(%)]
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2组病人入组后均给予SAP常规治疗,禁食水、胃肠减压、芒硝外敷、抗生素应用、纠正电解质紊乱、抑制胰液分泌及胰酶活性药物及营养支持。对照组单纯行腹腔穿刺术,观察组行腹腔穿刺术联合应用血必净。
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比较2组病人入院时和入院第3、5、7天的白细胞(WBC)计数和C反应蛋白(CRP)、血清淀粉样蛋白(SAA)、肝素结合蛋白(HBP)水平及急性生理与慢性健康评分(APACHE Ⅱ)、序贯器官衰竭评分(SOFA)、CT严重程度指数(CTSI),并比较2组病人入住EICU时间和住院时间。
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采用t检验、χ2检验、方差分析和q检验。
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2组病人入院时相关指标差异均无统计学意义(P>0.05);入院第3天,2组WBC计数、CRP、SAA、HBP、APACHE Ⅱ评分、SOFA评分和CTSI评分均较入院时升高(P < 0.05),随后在第5、7天降低(P < 0.05),但观察组在第3天,除WBC计数与对照组差异无统计学意义(P>0.05)外,上述指标均低于对照组(P < 0.05~P < 0.01),第5、7天上述所有指标均低于对照组(P < 0.05~P < 0.01)(见表 2)。
分组 入院时 第3天 第5天 第7天 F P MS组内 WBC计数/(×109/L) 观察组 17.03±4.34 20.32±6.23* 16.45±5.79# 9.45±3.28*#▲ 24.60 < 0.01 25.483 对照组 17.35±4.78 22.67±5.45* 20.35±6.03* 14.57±4.28*#▲ 13.94 < 0.01 26.808 t 0.27 1.56 2.56 5.20 — — — P >0.05 >0.05 < 0.05 < 0.01 — — — CRP/(mg/L) 观察组 190.45±23.17 288.07±32.15* 173.67±26.93*# 92.42±21.45*#▲ 280.80 < 0.01 688.950 对照组 188.79±21.53 321.54±41.27* 256.32±42.21*# 143.53±25.78*#▲ 158.00 < 0.01 753.464 t 0.29 3.50 9.04 8.35 — — — P >0.05 < 0.01 < 0.01 < 0.01 — — — SAA/(mg/L) 观察组 543.67±63.24 743.42±67.92* 571.52±53.64*# 403.45±42.46*#▲ 175.80 < 0.01 846.577 对照组 547.32±61.77 795.62±72.64* 664.57±54.78*# 512.68±47.57*#▲ 137.20 < 0.01 965.123 t 0.23 2.88 6.65 9.38 — — — P >0.05 < 0.01 < 0.01 < 0.01 — — — HBP/(ng/mL) 观察组 56.23±6.43 64.07±7.03* 58.57±6.63# 41.75±5.05*#▲ 67.90 < 0.01 40.056 对照组 57.23±6.02 69.35±7.45* 63.54±7.13*# 50.57±5.52*#▲ 45.40 < 0.01 45.235 t 0.62 2.82 2.80 6.46 — — — P >0.05 < 0.01 < 0.01 < 0.01 — — — APACHEⅡ评分/分 观察组 13.72±3.71 15.43±4.08* 13.51±3.23# 10.27±2.74*#▲ 11.32 < 0.01 12.008 对照组 14.12±3.83 17.52±3.63* 15.36±3.51*# 13.44±3.08#▲ 7.91 < 0.01 10.573 t 0.41 2.11 2.19 4.13 — — — P >0.05 < 0.05 < 0.05 < 0.01 — — — SOFA评分/分 观察组 6.22±1.32 7.81±1.53* 6.41±1.17*# 4.72±0.79*#▲ 32.08 < 0.01 1.505 对照组 6.30±1.24 8.93±1.64* 7.58±1.21*# 6.10±1.06#▲ 30.48 < 0.01 1.004 t 0.31 2.75 3.87 5.64 — — — P >0.05 < 0.01 < 0.01 < 0.01 — — — CTSI评分/分 观察组 5.33±1.59 7.82±1.49* 6.72±1.33*# 5.71±1.35*#▲ 17.72 < 0.01 1.221 对照组 5.18±1.48 8.91±1.64* 7.79±1.47*# 6.88±1.63*#▲ 29.51 < 0.01 1.326 t 0.25 2.66 3.04 3.09 — — — P >0.05 < 0.05 < 0.01 < 0.01 — — — q检验:与入院时比较*P < 0.05;与入院第3天比较#P < 0.05;与入院第5天比较▲P < 0.05 表 2 2组病人治疗前后炎性指标和相关评分比较(ni=30;x±s)
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观察组EICU停留时间和住院时间均明显短于对照组(P < 0.01)(见表 3)。
分组 n EICU停留时间/d 住院时间/d 观察组 30 3.14±0.73 14.15±4.67 对照组 30 4.34±1.23 19.42±7.33 t — 4.60 3.32 P — < 0.01 < 0.01 表 3 2组病人EICU停留时间及住院时间比较(x±s)
血必净联合早期腹腔穿刺引流应用于重症急性胰腺炎病人的临床价值
Clinical application value of Xuebijing combined with early abdominal puncture and drainage in patients with severe acute pancreatitis
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摘要:
目的探讨血必净联合早期腹腔穿刺引流治疗重症急性胰腺炎(SAP)病人的临床效果。 方法选择SAP病人60例,随机分为对照组和观察组,各30例。2组病人均给予SAP常规治疗,对照组单纯行腹腔穿刺术,观察组行腹腔穿刺术联合应用血必净。比较2组病人入院时和入院第3、5、7天白细胞(WBC)计数、C反应蛋白(CRP)、血清淀粉样蛋白(SAA)、肝素结合蛋白(HBP)、急性生理与慢性健康评分(APACHE Ⅱ)、序贯器官衰竭评分(SOFA)、CT严重程度指数(CTSI),以及2组入住EICU时间和住院时间。 结果2组病人入院时WBC计数、CRP、SAA、HBP、APACHE Ⅱ评分、SOFA评分及CTSI评分差异均无统计学意义(P>0.05);入院第3天,2组上述指标均较入院时升高(P < 0.05),随后在第5、7天降低(P < 0.05),但观察组在第3天,除WBC计数与对照组差异无统计学意义(P>0.05)外,CRP、SAA、HBP、APACHE Ⅱ评分、SOFA评分和CTSI均低于对照组(P < 0.05~P < 0.01),第5、7天上述所有指标均低于对照组(P < 0.05~P < 0.01)。观察组EICU停留时间及住院时间均明显短于对照组(P < 0.01)。 结论SAP病人在早期应用腹腔穿刺引流术联合血必净有助于减轻病人炎症反应,改善预后,缩短病人住院时间。 Abstract:ObjectiveTo investigate the clinical effects of Xuebijing combined with early paracentesis and drainage in the treatment of patients with severe acute pancreatitis(SAP). MethodsSixty SAP patients were selected, and randomly divided into the control group and observation group(30 cases in each group).Both groups were given the conventional SAP treatment.The control group was treated with abdominal puncture alone, while the observation group was treated with abdominal puncture combined with Xuebijing.The white blood cell(WBC) count, C-reactive protein(CRP), serum amyloid protein(SAA), heparin-binding protein(HBP), acute physiology and chronic health score(APACHE Ⅱ), sequential organ failure score(SOFA) and CT severity index(CTSI) were compared between two groups at admission and on the third, fifth and seventh day after admission.The length of EICU stay and hospital stay in two groups were analyzed. ResultsThe differences of the WBC count, CRP, SAA, HBP, APACHE Ⅱ score, SOFA score and CTSI score between two groups were not statistically significant at admission(P>0.05).On the third day of admission, the above indexes of two groups increased compared with those on admission(P < 0.05), and then which decreased on the fifth and seventh day(P < 0.05).On the third day, the difference of the WBC count between two groups was not statistically significant(P>0.05), and the CRP, SAA, HBP, APACHE Ⅱ score, SOFA score and CTSI in observation group were lower than those in control group(P < 0.05 to P < 0.01).On the fifth and seventh day, all the above indexes in observation group were lower than those in control group(P < 0.05 to P < 0.01).The length of stay in EICU and hospital stay in observation group were significantly shorter than those in control group(P < 0.01). ConclusionsThe early application of paracentesis and drainage combined with Xuebijing in SAP patients can help reduce the inflammatory response, improve the prognosis, and shorten the hospitalization time of the patient. -
表 1 2组病人一般资料比较[n;百分率(%)]
分组 n 男 女 年龄/岁 基础疾病 并发症 糖尿病 高脂血症 高血压 冠心病 肝损伤 肾损伤 肺损伤 凝血功能异常 观察组 30 13 17 54.23±16.12 4(13.33) 2(6.67) 5(16.67) 3(10.00) 2(6.67) 3(10.00) 4(13.33) 8(26.67) 对照组 30 14 16 55.07±15.63 5(16.67) 3(10.00) 4(13.33) 4(13.33) 3(10.00) 2(6.67) 5(16.67) 6(20.00) χ2 — 0.07 0.20* 0.27 0.07 P — >0.05 >0.05 >0.05 >0.05 *示t值 表 2 2组病人治疗前后炎性指标和相关评分比较(ni=30;x±s)
分组 入院时 第3天 第5天 第7天 F P MS组内 WBC计数/(×109/L) 观察组 17.03±4.34 20.32±6.23* 16.45±5.79# 9.45±3.28*#▲ 24.60 < 0.01 25.483 对照组 17.35±4.78 22.67±5.45* 20.35±6.03* 14.57±4.28*#▲ 13.94 < 0.01 26.808 t 0.27 1.56 2.56 5.20 — — — P >0.05 >0.05 < 0.05 < 0.01 — — — CRP/(mg/L) 观察组 190.45±23.17 288.07±32.15* 173.67±26.93*# 92.42±21.45*#▲ 280.80 < 0.01 688.950 对照组 188.79±21.53 321.54±41.27* 256.32±42.21*# 143.53±25.78*#▲ 158.00 < 0.01 753.464 t 0.29 3.50 9.04 8.35 — — — P >0.05 < 0.01 < 0.01 < 0.01 — — — SAA/(mg/L) 观察组 543.67±63.24 743.42±67.92* 571.52±53.64*# 403.45±42.46*#▲ 175.80 < 0.01 846.577 对照组 547.32±61.77 795.62±72.64* 664.57±54.78*# 512.68±47.57*#▲ 137.20 < 0.01 965.123 t 0.23 2.88 6.65 9.38 — — — P >0.05 < 0.01 < 0.01 < 0.01 — — — HBP/(ng/mL) 观察组 56.23±6.43 64.07±7.03* 58.57±6.63# 41.75±5.05*#▲ 67.90 < 0.01 40.056 对照组 57.23±6.02 69.35±7.45* 63.54±7.13*# 50.57±5.52*#▲ 45.40 < 0.01 45.235 t 0.62 2.82 2.80 6.46 — — — P >0.05 < 0.01 < 0.01 < 0.01 — — — APACHEⅡ评分/分 观察组 13.72±3.71 15.43±4.08* 13.51±3.23# 10.27±2.74*#▲ 11.32 < 0.01 12.008 对照组 14.12±3.83 17.52±3.63* 15.36±3.51*# 13.44±3.08#▲ 7.91 < 0.01 10.573 t 0.41 2.11 2.19 4.13 — — — P >0.05 < 0.05 < 0.05 < 0.01 — — — SOFA评分/分 观察组 6.22±1.32 7.81±1.53* 6.41±1.17*# 4.72±0.79*#▲ 32.08 < 0.01 1.505 对照组 6.30±1.24 8.93±1.64* 7.58±1.21*# 6.10±1.06#▲ 30.48 < 0.01 1.004 t 0.31 2.75 3.87 5.64 — — — P >0.05 < 0.01 < 0.01 < 0.01 — — — CTSI评分/分 观察组 5.33±1.59 7.82±1.49* 6.72±1.33*# 5.71±1.35*#▲ 17.72 < 0.01 1.221 对照组 5.18±1.48 8.91±1.64* 7.79±1.47*# 6.88±1.63*#▲ 29.51 < 0.01 1.326 t 0.25 2.66 3.04 3.09 — — — P >0.05 < 0.05 < 0.01 < 0.01 — — — q检验:与入院时比较*P < 0.05;与入院第3天比较#P < 0.05;与入院第5天比较▲P < 0.05 表 3 2组病人EICU停留时间及住院时间比较(x±s)
分组 n EICU停留时间/d 住院时间/d 观察组 30 3.14±0.73 14.15±4.67 对照组 30 4.34±1.23 19.42±7.33 t — 4.60 3.32 P — < 0.01 < 0.01 -
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