Aitken Emma L, Gough Vivienne, Jones Anna, Macdonald Angus
Department of Surgery, Monklands District General Hospital, Airdrie, North Lanarkshire, UK; Department of Anaesthetics and Intensive Care, Cardiff University, Cardiff, UK.
Department of Surgery, Monklands District General Hospital, Airdrie, North Lanarkshire, UK.
Surgery. 2014 May;155(5):910-8. doi: 10.1016/j.surg.2013.12.028. Epub 2013 Dec 28.
Intra-abdominal hypertension (IAH) is predictive of adverse outcome in critically ill patients; however, its role in acute pancreatitis is unclear, and prospective studies are lacking. We aimed to determine the overall incidence and predictive value of IAH on mortality in acute pancreatitis.
Transvesical IAP was measured on admission and every 4 hours within high-dependency unit/intensive care unit. Serum biochemistry and physiologic parameters permitted calculation of Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment, Imrie, and Ranson scores. The primary end point was 30-day mortality.
A total of 218 patients with acute pancreatitis were recruited; 30-day mortality was greater in patients with IAH (IAP ≥12 mmHg; 37%) than no IAH (2%; P < .001). A total of 14% of patients had IAH on admission; another 3% developed IAH in hospital. Mortality was greater in the latter group (37% vs 50%; P < .01). In the majority of cases IAH developed in line with other organ failure; however, there were several patients in whom the development of IAH appeared to be the sentinel event before rapid clinical decline. An IAP threshold of 9 mmHg had best predictive value for mortality (sensitivity 86%, specificity 87%; area under the ROC curve 0.91). This finding was comparable with other validated markers of severe pancreatitis (Imrie ≥3: sensitivity 51%, specificity 70%; Acute Physiology and Chronic Health Evaluation II: sensitivity 67%, specificity 96%; C-reactive protein >150: sensitivity 89%, specificity 83%).
IAP is a good predictor of mortality and organ failure in acute pancreatitis and compares favorably with other validated prognostic scores. Whether IAH is a phenomenon causative of organ failure or an epiphenomenon, occurring in conjunction with other organ dysfunction, remains unclear.
腹内高压（IAH）可预测危重症患者的不良预后；然而，其在急性胰腺炎中的作用尚不清楚，且缺乏前瞻性研究。我们旨在确定IAH在急性胰腺炎中的总体发生率及其对死亡率的预测价值。
入院时及在高依赖病房/重症监护病房内每4小时测量一次膀胱内腹内压（IAP）。血清生化指标和生理参数用于计算急性生理与慢性健康状况评分系统II（APACHE II）、序贯器官衰竭评估（SOFA）、Imrie评分和Ranson评分。主要终点为30天死亡率。
共纳入218例急性胰腺炎患者；IAH患者（IAP≥12 mmHg；37%）的30天死亡率高于无IAH患者（2%；P<0.001）。14%的患者入院时即有IAH；另有3%的患者在住院期间出现IAH。后一组患者的死亡率更高（37%对50%；P<0.01）。在大多数情况下，IAH与其他器官衰竭同时出现；然而，有几名患者在临床迅速恶化之前，IAH的出现似乎是首发事件。IAP阈值为9 mmHg时对死亡率的预测价值最佳（敏感性86%，特异性87%；ROC曲线下面积0.91）。这一发现与其他经过验证的重症胰腺炎标志物相当（Imrie≥3：敏感性51%，特异性70%；APACHE II：敏感性67%，特异性96%；C反应蛋白>150：敏感性89%，特异性83%）。
IAP是急性胰腺炎死亡率和器官衰竭的良好预测指标，与其他经过验证的预后评分相比具有优势。IAH是导致器官衰竭的现象还是与其他器官功能障碍同时出现的附带现象，仍不清楚。
