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重症急性胰腺炎合并急性呼吸窘迫综合征经鼻高流量氧疗治疗失败的相关危险因素分析
作者:陆洋  沈浩亮  刘向新  崔晓莉  黄莉莉  王逸平 
单位:南通大学附属医院 重症医学科, 江苏 南通 226001
关键词:重症急性胰腺炎 急性呼吸窘迫综合征 经鼻高流量氧疗 危险因素 
分类号:R459.6
出版年·卷·期(页码):2018·37·第六期(951-956)
摘要:

目的:研究重症急性胰腺炎(SAP)合并急性呼吸窘迫综合征(ARDS)患者经鼻高流量氧疗(HFNC)治疗失败的相关危险因素,以期提高SAP合并ARDS患者初始呼吸支持的成功率。方法:回顾性分析2016年1月至2017年12月南通大学附属医院重症医学科接受HFNC治疗的SAP合并ARDS患者病历资料。根据HFNC治疗后是否需行机械通气(包括有创通气及无创通气)将患者分为治疗失败组与治疗成功组,比较两组患者一般情况、发病时间、腹内压、急性生理学与慢性健康状况评分系统Ⅱ(APACHE Ⅱ)评分、序贯器官功能衰竭评分(SOFA)、24 h液体输入量、血钙、总胆红素、血淀粉酶、降钙素原、改良CT严重评分、Murray肺损伤评分、HFNC治疗参数、HFNC治疗1 h的呼吸情况及血气分析结果、24 h是否接受腹腔引流和血液净化(CBP)治疗等。结果:共纳入84例患者,治疗失败组36例,治疗成功组48例。两组年龄、性别、BMI、发病时间、初始HFNC治疗参数(氧流量)比较,差异均无统计学意义(P>0.05)。单因素分析显示,治疗失败组腹内压(P=0.034)、APACHE Ⅱ评分(P=0.026)、SOFA评分(P=0.043)均高于治疗成功组,24 h液体输入量(P=0.037)也多于治疗成功组。多因素分析显示腹内压(OR=1.618,95%CI 1.070~2.446,P=0.023)、APACHE Ⅱ评分(OR=1.950,95%CI 1.269~2.996,P=0.012)、SOFA评分(OR=1.748,95%CI 1.156~2.296,P=0.032)、24 h液体输入量(OR=1.852,95%CI 1.349~2.896,P=0.023)为HFNC治疗失败的独立危险因素。结论:对SAP合并ARDS患者应监测腹内压,动态评估APACHE Ⅱ评分和SOFA评分,避免24 h液体输入量过多,接受HFNC治疗后无改善时应及时给予机械通气。

Objective:To investigate the risk factors of high flow nasal cannula oxygen therapy (HFNC) failure on severe acute pancreatitis (SAP) patients complicated with acute respiratory distress syndrome (ARDS) in order to improve the initial respiratory supporting effect. Methods:The data of SAP patients complicated with ARDS who were admitted to intensive care unit and treated with HFNC therapy in Affiliated Hospital of Nantong University from January 2016 to December 2017 were retrospectively analyzed. The patients were divided into failure group and success group according to whether need mechanical ventilation (including invasive ventilation or non-invasive ventilation) after HFNC. The clinical characteristics were reviewed and compared between the two groups which included baseline characteristics, the onset of disease, intra-abdominal pressure, APACHE Ⅱ, SOFA score, 24 h fluid intake, serum calcium, total bilirubin, serum amylase, procalcitonin, modified CT severity index, Murray's acute lung injury score, parameter of HFNC, breathing signs and blood-gas analysis after 1 hour treatment, whether abdominal drainage and blood purification was applied in 24 h. Results:Total of 84 patients were enrolled in this study, HFNC failure group had 36 patients and HFNC success group had 48 patients. No differences were found between the groups in age, sex, BMI, onset time, initial parameter of HFNC. Univariate analyses showed that intra-abdominal pressure (P=0.034), APACHEⅡscore (P=0.026), SOFA score (P=0.043) in the failure group were higher than those in the success group and 24 h liquid input (P=0.037) in the failure group was more than that in the success group. Multivariate analysis indicated that intra-abdominal pressure (OR=1.618, 95% CI 1.070~2.446, P=0.023), APACHEⅡ score (OR=1.950, 95% CI 1.269~2.996, P=0.012), SOFA score (OR=1.748, 95% CI 1.156~2.296, P=0.032) and 24 h fluid input (OR=1.852, 95% CI 1.349~2.896, P=0.023) were independent risk factors of HFNC failure. Conclusions:SAP patients complicated with ARDS should be closely monitored on intra-abdominal pressure, dynamic assessment of APACHEⅡ score and SOFA score and avoid excessive fluid input in 24 h. Mechanical ventilation should be given in time when HFNC fails.

参考文献:

[1] ELDER A S,SACCONE G T,DIXON D L.Lung injury in acute pancreatitis:mechanisms underlying augmented secondary injury[J].Pancreatology,2012,12(1):49-56.
[2] 中华医学会呼吸病学分会呼吸危重症医学学组.急性呼吸窘迫综合征患者机械通气指南(试行)[J].中华医学杂志,2016,96(6):404-424.
[3] FRAT J P,THILLE A W,MERCAT A,et al.High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure[J].New Engl J Med,2015,372(23):2185.
[4] BELLANI G,LAFFEY J G,PHAM T,et al.Noninvasive ventilation of patients with acute respiratory distress syndrome.insights from the LUNG SAFE Study[J].Am J Respir Crit Care Med,2017,195(1):67-77.
[5] 中华医学会外科学分会胰腺外科学组.急性胰腺炎诊治指南(2014)[J].中国实用外科杂志,2015,35(1):4-7.
[6] RANIERI V M,RUBENFELD G D,THOMPSON B T,et al.Acute respiratory distress syndrome:the Berlin Definition[J].Jama,2012,307(23):2526.
[7] ZHOU M T.Acute lung injury and ARDS in acute pancreatitis:Mechanisms and potential intervention[J].World J Gastroentero,2010,16(17):2094.
[8] DING L,ZHAN Q Y,LUO Z J,et al.Non-invasive positive pressure ventilation in patients with acute respiratory distress syndrome:a prospective cohort study[J].Chin J Critical Care,2009,21(10):613-616.
[9] TASAKA S.Noninvasive positive pressure ventilation for acute respiratory distress syndrome[J].Jpn J Chest Dis,2016,75(6):607-614.
[10] RAO M,MUNTA K.The role of noninvasive ventilation in mild to moderate acute respiratory distress syndrome[J].Indian J Crit Care Med,2015,19(12):751-752.
[11] ZHAO X,HUANG W,LI J,et al.Noninvasive positive-pressure ventilation in acute respiratory distress syndrome in patients with acute pancreatitis:a retrospective cohort study[J].Pancreas,2016,45(1):58.
[12] FISCHER H S,BOHLIN K,BÜHRER C,et al.Nasal high-frequency oscillation ventilation in neonates:a survey in five European countries[J].Eur J Pediatr,2015,174(4):465-471.
[13] JABER S,CHANQUES G,SEBBANE M,et al.Noninvasive positive pressure ventilation in patients with respiratory failure due to severe acute pancreatitis[J].Respiration,2006,73(2):166-172.
[14] PARKE R L,ECCLESTON M L,MCGUINNESS S P.The effects of flow on airway pressure during nasal high-flow oxygen therapy[J].Resp Care,2011,56(8):1151.
[15] LEE J H,REHDER K J,WILLIFORD L,et al.Use of high flow nasal cannula in critically ill infants,children,and adults:a critical review of the literature[J].Intens Care Med,2013,39(2):247.
[16] DYSART K,MILLER T L,WOLFSON M R,et al.Research in high flow therapy:mechanisms of action[J].Resp Med,2009,103(10):1400-1405.
[17] GROVES N,TOBIN A.High flow nasal oxygen generates positive airway pressure in adult volunteers[J].Aust Crit Care,2007,20(4):126-131.
[18] KANG B J,KOH Y,LIM C M,et al.Failure of high-flow nasal cannula therapy may delay intubation and increase mortality[J].Intens Care Med,2015,41(4):623.
[19] ROCA O,MESSIKA J,CARALT B,et al.Predicting success of high flow nasal cannula in pneumonia patients with hypoxemic respiratory failure:the utility of the ROX index[J].J Crit Care,2016,35:200.
[20] GODINJAK A,IGLICA A,RAMA A,et al.Predictive value of SAPS Ⅱ and APACHE Ⅱ scoring systems for patient outcome in a medical intensive care unit[J].Acta Med Acad,2016,45(2):97-103.
[21] FERREIRA F L,BOTA D P,BROSS A,et al.Serial evaluation of the SOFA score to predict outcome in critically ill patients[J].JAMA,2001,286(14):1754.
[22] BOYD J H,FORBES J,NAKADA T A,et al.Fluid resuscitation in septic shock:a positive fluid balance and elevated central venous pressure are associated with increased mortality[J].Crit Care Med,2011,39(2):259-265.
[23] YE S,LI Q,YUAN S,et al.Restrictive fluid resuscitation leads to better oxygenation than non-restrictive fluid resuscitation in piglets with pulmonary or extrapulmonary acute respiratory distress syndrome[J].Med Sci Monitor,2015,21:2008.

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