Karvellas C J, Abraldes J G, Zepeda-Gomez S, Moffat D C, Mirzanejad Y, Vazquez-Grande G, Esfahani E K, Kumar A
Division of Critical Care Medicine and Gastroenterology/Hepatology, University of Alberta, Edmonton, AB, Canada.
Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, AB, Canada.
Aliment Pharmacol Ther. 2016 Oct;44(7):755-66. doi: 10.1111/apt.13764. Epub 2016 Aug 10.
Cholangitis-associated septic shock carries significant mortality. There is uncertainty regarding the most appropriate time to achieve biliary decompression.
To determine whether the timing of biliary decompression and anti-microbial therapy affect the survival in cholangitis patients with septic shock.
Nested retrospective cohort study of all cholangitis-associated septic shock patients (hypotension requiring vasopressors) from an international, multi-centre database between 1996 and 2011.
Among 260 patients (mean age 69 years, 57% male), overall mortality was 37%. Compared to nonsurvivors (n = 96), survivors (n = 164) had lower mean admission Acute Physiology And Chronic Health Evaluation (APACHE) II (22 vs. 28, P < 0.001) and lower median serum lactate on admission (3.4 vs. 4.6 mmol/L, P < 0.001). Survivors were more likely to receive appropriate anti-microbial therapy earlier (median 2.6 vs. 6.8 h from shock, P < 0.001). Survivors were also more likely to undergo successful biliary decompression earlier (median 8.8 vs. 22 h, P < 0.001). After adjusting for co-variates, APACHE II (odds ratio, OR 1.21 per increment (1.11-1.32), time delay to appropriate anti-microbial therapy [OR 1.15 per hour (1.07-1.25)] and delayed biliary decompression >12 h [OR 3.40 (1.12-10.31)] were all significantly associated with increased mortality (P < 0.04 for all; c-statistic 0.896).
Patients with septic shock secondary to acute cholangitis have significant mortality. Endoscopic biliary decompression >12 h after the onset of shock and delayed receipt of appropriate anti-microbial therapy were both significantly associated with adverse hospital outcome. This might suggest that early initiation of anti-microbial therapy and urgent biliary decompression (within 12 h) could potentially improve outcomes in this high-risk patient population.
胆管炎相关性感染性休克死亡率颇高。对于实现胆道减压的最佳时机尚无定论。
确定胆道减压和抗菌治疗的时机是否会影响胆管炎合并感染性休克患者的生存率。
对1996年至2011年间来自一个国际多中心数据库的所有胆管炎相关性感染性休克患者（需血管升压药治疗的低血压患者）进行巢式回顾性队列研究。
在260例患者（平均年龄69岁，57%为男性）中，总体死亡率为37%。与非幸存者（n = 96）相比，幸存者（n = 164）入院时急性生理与慢性健康状况评估（APACHE）II评分均值较低（22对28，P < 0.001），入院时血清乳酸中位数较低（3.4对4.6 mmol/L，P < 0.001）。幸存者更有可能更早接受恰当的抗菌治疗（休克发生后中位数时间分别为2.6小时和6.8小时，P < 0.001）。幸存者也更有可能更早成功进行胆道减压（中位数时间分别为8.8小时和22小时，P < 0.001）。在对协变量进行校正后，APACHE II评分（比值比，OR每增加一个单位为1.21（1.11 - 1.32））、至恰当抗菌治疗的时间延迟[每小时OR为1.15（1.07 - 1.25）]以及胆道减压延迟>12小时[OR为3.40（1.12 - 10.31）]均与死亡率增加显著相关（所有P值均< 0.04；c统计量为0.896）。
急性胆管炎继发感染性休克患者死亡率颇高。休克发生12小时后进行内镜下胆道减压以及延迟接受恰当的抗菌治疗均与不良的医院结局显著相关。这可能表明早期启动抗菌治疗和紧急胆道减压（12小时内）可能会改善这一高危患者群体的预后。
