| 摘要: |
| 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。 |
| 关键词: 重症急性胰腺炎 标准作业程序 细胞因子风暴 多器官功能障碍综合征 |
| DOI：10.16781/j.0258-879x.2018.04.0372 |
| 投稿时间：2018-01-24修订日期：2018-04-08 |
| 基金项目:上海市卫生局中医药科研课题（2010Y005A），上海市卫生计生系统重要薄弱学科建设项目（2016ZB0201），军队后勤重点课题（BWS14C018）. |
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| Standard operation procedure of diagnosis and treatment process for severe acute pancreatitis: clinical application |
| WEI Dong-po,JIANG Wei-wei,WANG Sheng-yun,HE Chao,LI Wen-fang* |
(Department of Emergency, Changzheng Hospital, Navy Medical University(Second Military Medical University), Shanghai 200003, China
*Corresponding author) |
| Abstract: |
| Objective To develop an integrated standard operation procedure (SOP) for in-hospital emergency care of severe acute pancreatitis (SAP), and to explore the clinical application value. Methods We designed an integrated SOP for in-hospital emergency care of SAP by consulting some experts from emergency intensive care unit (ICU) quality control centers in Shanghai, referencing relevant literature and SAP guidelines at home and abroad, and considering the clinical practice and the experience gained in the integration of "emergency-ICU" contraction at Changzheng Hospital of Navy Medical University (Second Military Medical University). Forty-two SAP patients meeting the SOP criteria, who were admitted to Department of Emergency of Changzheng Hospital of Navy Medical University (Second Military Medical University) between Jul. 2015 and Jan. 2017, were included and set as optimization group. Forty SAP patients, who were admitted to the Department of Emergency between Jan. 2014 and Jun. 2015, were set as routine group. Clinical data of the patients were compared between the two groups, including treatment efficiency, white blood cell count, neutrophil ratio, C-reactive protein level, procalcitonin level, blood amylase level, blood glucose level, blood lactic acid level, serum creatinine level, oxygenation index, modified CT severity index (MCTSI) score, intra-abdominal pressure, urinary neutrophil gelatinase-associated lipocalin (NGAL) level and acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score on 72 h and 1 week after admission, complications and survival. Results The proposed SOP mainly referred to the international standard for diagnosis and treatment of SAP in 2012. The updates were mainly in the emergency first visit and comprehensive treatment scheme. In the former, the emergency surgery doctor was changed to emergency green channel (resuscitation room). In the latter, several clinical protocols were added, such as intrarenous injection of a large dose of ulinastatin, rapid infusion of human albumin (intravenous injection of furosemidum when necessary), standardized full-thatch mirabilite external application and coloclysis of sterile solution of rheum officinale. Compared with the routine group, the total rate of treatment efficiency was significantly better, and hospital stay, exhaust recovery time, bloating relief time, ICU duration time, and continuous renal replacement therapy time were significantly shorter in the optimization group (all P<0.05). There were significant differences in the white blood cell count, neutrophil ratio, oxygenation index, MCTSI score and intra-abdominal pressure and the levels of C-reactive protein, procalcitonin, blood glucose, lactic acid, serum creatinine, urinary NGAL on 72 h and 1 week after admission between the two groups (all P<0.05). The levels of blood amylase were significantly different between the two groups on 72 h after admission (P<0.01). The incidences of acute renal failure, acute respiratory distress syndrome, ascites, abdominal compartment syndrome, pancreatic pseudocyst and pancreatic abscess were significantly lower in the optimization group than those in the routine group (all P<0.05). Compared with the routine group, the survival time was significantly longer and the survival rate within two months was significantly higher in optimization group (P<0.05). Conclusion The proposed in-hospital integrated emergency SOP can standardize the diagnosis and treatment process of SAP, improve the efficiency of treatment, and reduce mortality of patients. |
| Key words: severe acute pancreatitis standard operation procedure cytokine storm multiple organ dysfunction syndrome |
