Mao En-qiang, Tang Yao-qing, Fei Jian, Qin Shuai, Wu Jun, Li Lei, Min Dong, Zhang Sheng-dao
Department of General Surgery, Shanghai Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200025, China.
Chin Med J (Engl). 2009 Jan 20;122(2):169-73.
Fluid therapy for severe acute pancreatitis (SAP) should not only resolve deficiency of blood volume, but also prevent fluid sequestration in acute response stage. Up to date, there has not a strategy for fluid therapy dedicated to SAP. So, this study was aimed to investigate the effects of fluid therapy treatment on prognosis of SAP.
Seventy-six patients were admitted prospectively according to the criteria within 72 hours of SAP onset. They were randomly assigned to a rapid fluid expansion group (Group I, n = 36) and a controlled fluid expansion group (Group II, n = 40). Hemodynamic disorders were either quickly (fluid infusion rate was 10 - 15 ml x kg(-1) x h(-1), Group I) or gradually improved (fluid infusion rate was 5 - 10 ml x kg(-1) x h(-1), Group II) through controlling the rate of fluid infusion. Parameters of fluid expansion, blood lactate concentration were obtained when meeting the criteria for fluid expansion. And APACHE II scores were obtained serially for 72 hours. Rate of mechanical ventilation, incidence of abdominal compartment syndrome (ACS), sepsis, and survival rate were obtained.
The two groups had statistically different (P < 0.05) time intervals to meet fluid expansion criteria (Group I, 13.5 +/- 6.6 hours; Group II, (24.0 +/- 5.4) hours). Blood lactate concentrations were both remarkably lower as compared to the level upon admission (P < 0.05) and reached the normal level in both groups upon treatment. It was only at day 1 that hematocrit was significantly lower in Group I (35.6% +/- 6.8%) than in Group II (38.5% +/- 5.4%) (P < 0.01). Amount of crystalloid and colloid in group I ((4028 +/- 1980) ml and (1336 +/- 816) ml) on admission day was more than those of group II ((2472 +/- 1871) ml and (970 +/- 633) ml). No significant difference was found in the total amount of fluids within four days of admission between the two groups (P > 0.05). Total amount of fluid sequestration within 4 days was higher in Group I ((5378 +/- 2751) ml) than in Group II ((4215 +/- 1998) ml, P < 0.05). APACHE II scores were higher in Group I on days 1, 2, and 3 (P < 0.05). Rate of mechanical ventilation was higher in group I (94.4%) than in group II (65%, P < 0.05). The incidences of abdominal compartment syndrome (ACS) and sepsis were significantly lower in Group II (P < 0.05). Survival rate was remarkably lower in Group I (69.4%) than in Group II (90%, P < 0.05).
Controlled fluid resuscitation offers better prognosis in patients with severe volume deficit within 72 hours of SAP onset.
重症急性胰腺炎（SAP）的液体治疗不仅应纠正血容量不足，还应防止急性反应期的液体潴留。迄今为止，尚无专门针对SAP的液体治疗策略。因此，本研究旨在探讨液体治疗对SAP预后的影响。
76例患者在SAP发病72小时内根据标准前瞻性入院。他们被随机分为快速液体复苏组（I组，n = 36）和控制性液体复苏组（II组，n = 40）。通过控制输液速度，血流动力学紊乱在I组（输液速度为10 - 15 ml·kg⁻¹·h⁻¹）中迅速得到改善，在II组（输液速度为5 - 10 ml·kg⁻¹·h⁻¹）中逐渐得到改善。达到液体复苏标准时，获取液体复苏参数、血乳酸浓度。并连续72小时获取急性生理与慢性健康状况评分系统II（APACHE II）评分。记录机械通气率、腹腔间隔室综合征（ACS）发生率、脓毒症发生率及生存率。
两组达到液体复苏标准的时间间隔有统计学差异（P < 0.05）（I组为13.5 ± 6.6小时；II组为（24.0 ± 5.4）小时）。与入院时相比，两组血乳酸浓度均显著降低（P < 0.05），且治疗后两组均达到正常水平。仅在第1天，I组的血细胞比容（35.6% ± 6.8%）显著低于II组（38.5% ± 5.4%）（P < 0.01）。入院当天I组的晶体液量（（4028 ± 1980）ml）和胶体液量（（1336 ± 816）ml）多于II组（（2472 ± 1871）ml和（970 ± 633）ml）。两组入院后4天内的总液量无显著差异（P > 0.05）。I组4天内的液体潴留总量（（5378 ± 2751）ml）高于II组（（4215 ± 1998）ml，P < 0.05）。I组在第1、2和3天的APACHE II评分较高（P < 0.05）。I组的机械通气率（94.4%）高于II组（65%，P < 0.05）。II组的腹腔间隔室综合征（ACS）和脓毒症发生率显著较低（P < 0.05）。I组的生存率（69.4%）显著低于II组（90%，P < 0.05）。
对于SAP发病72小时内存在严重容量不足的患者，控制性液体复苏可提供更好的预后。
