Expert consensus on prevention and blocking of severe acute pancreatitis in emergency department
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摘要: 急性胰腺炎是急诊科常见的严重消化系统疾病之一，近年来急诊科收治的急性胰腺炎患者有增无减。急诊科早期积极有效地处理可以减轻胰腺炎带来的器官功能损害，改善患者预后。目前急性胰腺炎的严重程度分型需要在发病后48 h才能确定，这种诊断时间上的“滞后性”，无法为急诊科急性胰腺炎分级诊疗提供帮助。该共识通过文献整理、专家讨论，根据患者的基础病情、来急诊时全身和胰腺局部表现等，提出“疑似重症急性胰腺炎(SSAP)”的概念，为急性胰腺炎的早期规范化处理提出了病理生理学依据，为预防与阻断重症急性胰腺炎的发生提供了基础。本共识总结既往研究，从高危患者筛选到细胞因子测定，联合多项重症患者通用评分和胰腺炎专项评分，使急性胰腺炎患者在急诊科得到充分评估，并提出一系列包括液体复苏、器官支持、中医中药等SSAP阻断方案，促进急性胰腺炎患者早期康复。Abstract: Acute pancreatitis is one of the common serious digestive system diseases in emergency department, recently, the number of acute pancreatitis patients admitted to emergency department is increasing.Early active and effective management in emergency department can reduce organ function damage caused by pancreatitis and improve the prognosis of patients.At present, the severity of acute pancreatitis can only be determined 48 hours after the onset of the disease.This "lag" in diagnosis time cannot provide help for the graded diagnosis and treatment of acute pancreatitis in the emergency department.Through literature review and expert discussion, the concept of "suspicious severe acute pancreatitis(SSAP)" was proposed according to patients' basic conditions, systemic and local pancreatic manifestations when they came to the emergency department, so as to provide a pathophysiological theory for the early standardized management of acute pancreatitis, and to provide a basis for the prevention and blocking of severe acute pancreatitis.Consensus summarizes the previous studies, from screening high-risk patients to the determination of cytokines, combined a number of patients with severe general special score, score and pancreatitis make full assessment of the patients with acute pancreatitis in the emergency department, and put forward a series include: liquid recovery, organ support, such as Chinese medicine SSAP blocking scheme, promote early rehabilitation of acute pancreatitis.
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Key words:
- suspicious severe acute pancreatitis /
- early recogmition /
- prevention /
- treatment
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表 2 中国急性胰腺炎分类诊断及预后
分类诊断 特征 预后 MAP 具备急性胰腺炎表现和生化变化，不伴有局部或全身并发症 通常在1~2周内就可恢复，病死率极低 MSAP 具备急性胰腺炎表现和生化变化，伴有一过性器官功能衰竭(48 h内可以恢复)和(或)局部并发症 早期病死率低，如坏死组织合并感染，则病死率增高 SAP 具备急性胰腺炎表现和生化变化，伴有持续(>48 h)器官功能衰竭 病死率高，如合并感染则病死率极高 
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表 3 急性胰腺炎病情判断评分系统
评分系统 评分名称 Glasgow昏迷评分 急重症通用评分 急性生理与慢性健康评分Ⅱ(APACHEⅡ) 序贯器官衰竭评分(SOFA) JSS Ranson评分 改良Marshall评分 胰腺炎专项评分 简化急性生理评分(SAPSⅡ) BISAP 胰腺炎活动度评分系统(pancreatitis activity scoring system，PASS)
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表 4 BISAP评分标准
评分指标 评分/分 血BUN>8.9 mmol/L 1 精神异常 1 存在SIRS 1 年龄>60岁 1 影像学检查显示胸腔积液 1 注：评分1~2分为低危患者，≥3分为高危患者。
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表 5 CTSI评分标准
项目 评分标准 评分/分 A级：胰腺正常 0 B级：胰腺局限性渗出肿大 1 急性胰腺炎分级 C级：胰腺实质异常伴有轻度胰腺周围炎症改变 2 D级：1处胰周积液、蜂窝织炎，通常位于肾前间隙 3 E级：≥2处区域胰周积液，或胰腺内、胰周炎症内积气 4 胰腺无坏死 0 胰腺坏死程度 胰腺坏死＜30% 2 胰腺坏死30%~50% 4 胰腺坏死>50% 6 注：CTSI评分=急性胰腺炎分级+胰腺坏死程度评分；Ⅰ级：0~3分, Ⅱ级：4~6分, Ⅲ级：7~10分；CTSI>4分为重症。
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表 6 血气分析对急性胰腺炎严重程度的判断
项目 变化 分级 含义 PaCO2 下降 Ⅰ级 轻度肺损伤，代偿期 PaO2 下降 Ⅱ级 肺损伤 碱剩余、HCO3- 下降 Ⅲ级 组织灌注下降 乳酸 升高 Ⅳ级 组织缺氧
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