Clinical significance of changes in clinical indicators after early fluid resuscitation in patients with severe pancreatitis
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摘要: 目的 探讨重症急性胰腺炎患者早期液体复苏后，患者液体平衡情况、乳酸、白蛋白等指标变化对患者临床疗效及预后的意义。方法 分析2016年1月－2019年12月期间本院重症医学科收治的符合重症胰腺炎诊断标准的101例患者，其中男53例，女48例。根据入院前7 d液体复苏后患者乳酸变化趋势，将患者分为乳酸下降组、乳酸不降组。统计分析患者资料，比较入院前7 d乳酸下降组及不降组液体复苏量、尿量、血红蛋白、HCT、白蛋白、呼吸机及CRRT使用、病死率等是否存在差异。结果 乳酸不降组较乳酸下降组，入院后前7 d液体复苏量、液体正平衡量更高，呼吸机及持续肾脏替代治疗(CRRT)需求更高，28 d内存活率、小便量、入院第7天时血清HCT及白蛋白水平更低，差异有统计学意义(P< 0.05)。结论 重症急性胰腺炎患者入院液体复苏7 d后乳酸不下降、液体正平衡越大且白蛋白下降程度越大者，预后转归越差。早期液体复苏后患者乳酸变化趋势、液体正平衡量、尿量、白蛋白下降程度等，能够反映出患者实际病情严重程度及变化趋势。故这些指标可作为判断患者是否治疗有效的因素，也可作为疾病预后转归的预测因素。Abstract: Objective Objective To investigate the significance of fluid balance, lactic acid, albumin and other indicators in the clinical efficacy and prognosis of patients with severe acute pancreatitis after early fluid resuscination.Methods A total of 101 patients (53 males and 48 females) who met the diagnostic criteria for severe pancreatitis admitted to the intensive Care Department of our hospital from January 2016 to December 2019 were collected and analyzed. According to the trend of lactic acid change after fluid resuscitation 7 days after admission, patients were divided into lactic acid decreased group and non-group. The data of patients were statistically analyzed to compare whether there were differences in fluid resuscitation, urine volume, hemoglobin, HCT, albumin, ventilator and CRRT use, mortality and other clinical indicators between the lactic acid decreased group and the non-decreased group 7 days after admission.Results Compared with the lactic acid decreased group, the non-decreased group had higher fluid resuscitation and positive fluid balance in the first 7 days after admission, higher requirements for ventilator and continuous renal replacement therapy(CRRT), lower survival rate and urine volume within 28 days, and HCT and serum albumin levels on the 7th day of admission, with statistically significant differences(P< 0.05).Conclusion Patients with severe acute pancreatitis who received fluid resuscitation 7 days after admission and showed no decrease in lactic acid, higher positive fluid balance and lower albumin level had a poorer prognosis. After early fluid resuscitation, the trend of lactic acid, positive fluid balance, urine volume, and the degree of albumin decrease in patients can reflect the actual severity and progression of disease. Therefore, these indicators can be used to assess the clinical efficacy and predict the prognosis.
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Key words:
- severe acute pancreatitis /
- early fluid resuscination /
- lactic acid /
- fluid balance
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表 1 两组患者呼吸机及CRRT使用及转归等情况比较
例(%)，X±S 项目 乳酸不降组(13例) 乳酸下降组(88例) P 性别/例 >0.05 男 6 47 女 7 41 呼吸机(使用) 9(69.2) 7(8.0) < 0.05 CRRT(使用) 6(46.2) 13(14.8) < 0.05 转归(28 d内存活) 3(23.1) 85(96.6) < 0.05 年龄/岁 46.31±18.64 53.10±15.59 >0.05 住ICU天数/d 6.92±1.50 7.39±2.42 >0.05 
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表 2 两组患者液体复苏后血红蛋白、HCT、白蛋白等变化情况比较
X±S 项目 乳酸不降组(13例) 乳酸下降组(88例) P 血红蛋白/(g·L-1) 第1天 145.00±23.75 141.48±28.84 >0.05 第2天 134.46±22.20 124.63±26.43 >0.05 第3天 111.31±24.10 113.59±22.27 >0.05 第7天 98.69±19.95 108.26±21.65 >0.05 HCT/% 第1天 42.54±7.45 42.88±7.59 >0.05 第2天 36.46±9.82 39.45±7.63 >0.05 第3天 34.15±5.46 36.40±6.85 >0.05 第7天 30.62±4.13 35.22±7.50 < 0.05 白蛋白/(g·L-1) 第1天 39.25±6.68 37.99±6.66 >0.05 第2天 30.94±9.67 33.91±5.30 >0.05 第3天 31.06±2.28 32.88±3.64 >0.05 第7天 28.94±3.53 33.67±3.82 < 0.05
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表 3 两组患者液体复苏后乳酸、输液量、液体平衡等情况比较
mL，X±S 项目 乳酸不降组(13例) 乳酸下降组(88例) P Lac/(mmol·L-1) 第1天 3.98±1.96 3.26±1.67 >0.05 第2天 5.45±4.65 2.74±1.24 >0.05 第3天 7.28±6.22 2.51±0.96 < 0.05 输液量 第1天 4722.69±1620.93 3173.78±1560.71 < 0.05 第2天 3064.31±1838.99 3141.41±1454.80 >0.05 第3天 2614.38±450.88 2676.56±1169.52 >0.05 尿量 第1天 1550.00±975.00 2008.86±964.84 >0.05 第2天 1600.00±695.95 2193.64±1026.45 < 0.05 第3天 1728.85±796.98 2270.68±900.24 < 0.05 液体正平衡 第1天 2980(1086，3924) 524(-646，1588) < 0.05 第2天 484(-176.5，1009.5) 181.5(-682.5，839.75) >0.05 第3天 250(-282，953) -112(-712.5，387.5) >0.05
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表 4 入院后第1、2、3、7天Lac水平来预测转归(死亡)
指标 AUC 标准误 P 95%CI 敏感度 特异度 Lac第1天 0.713 0.065 0.013 0.586~0.840 1.000 0.386 Lac第2天 0.783 0.072 0.001 0.641~0.925 0.615 0.875 Lac第3天 0.704 0.109 0.0180 0.490~0.918 0.538 1.000 Lac第7天 0.851 0.087 0 0.680~1.000 0.769 1.000
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