重症急性胰腺炎标准作业程序诊治流程的临床应用  

Standard operation procedure of diagnosis and treatment process for severe acute pancreatitis: clinical application

作　　者：魏东坡 江伟伟[1] 王胜云[1] 何超[1] 李文放[1] 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)

机构地区：[1]海军军医大学(第二军医大学)长征医院急救科,上海200003

出　　处：《第二军医大学学报》2018年第4期372-379,共8页Academic Journal of Second Military Medical University

基　　金：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)~~

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(APACHEⅡ)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、APACHEⅡ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 hObjective 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 evaluationⅡ(APACHEⅡ)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 necess

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 

分 类 号：R459.7[医药卫生—急诊医学] R657.5[医药卫生—治疗学]