重症胰腺炎合并脓毒症的影响因素分析

谢朝云; 张萍; 王民开

doi:10.3969/j.issn.1001-5256.2021.04.030

重症胰腺炎合并脓毒症的影响因素分析

DOI: 10.3969/j.issn.1001-5256.2021.04.030

谢朝云^1a, ,,
张萍²,
王民开^1b

1a.
贵州医科大学第三附属医院急诊科，贵州都匀 558000
1b.
贵州医科大学第三附属医院普通外科，贵州都匀 558000
2.
黔南州人民医院住院处，贵州都匀 558000

基金项目:

贵州省科技厅联合项目 (黔科合LH字〔2014〕7162号);

贵州省黔南州社会发展科技项目 (黔南科合社字〔2018〕7号)

利益冲突声明：本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突。

作者贡献声明：谢朝云、张萍等负责课题设计，资料分析，撰写论文；谢朝云、张萍、王民开等参与收集数据，修改论文；谢朝云等负责拟定写作思路，指导撰写文章并最后定稿。

详细信息

作者简介:
谢朝云(1968—)，男，主任医师，从事感染性疾病防治研究

通信作者:
谢朝云，xcu2009@163.com

中图分类号: R576
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出版历程
- 收稿日期: 2020-09-12
- 录用日期: 2020-11-09
- 出版日期: 2021-04-20

Influencing factors for severe acute pancreatitis with sepsis

1a.
Emergency Department, The Third Affiliated Hospital of Guizhou Medical University, Duyun, Guizhou 558000, China
1b.
Department of General Surgery, The Third Affiliated Hospital of Guizhou Medical University, Duyun, Guizhou 558000, China
2.
Inpatient Department of Qiannan People's Hospital, Duyun, Guizhou 558000, China

摘要

摘要: 目的分析重症胰腺炎(SAP)合并脓毒症的相关因素。方法回顾性分析2007年1月—2020年3月收治的178例SAP患者的临床资料，根据是否并发脓毒症分为脓毒症组(n=56)与非脓毒症组(n=122)。计量资料两组间比较采用t检验，计数资料两组间比较采用χ²检验。多因素分析采用logistic回归分析。结果 SAP患者脓毒血症的发生率为31.46%。单因素分析显示，APACHEⅡ评分、血糖、血钙、血清总胆固醇、血清甘油三酯、血尿素氮、血清肌酐、血清白蛋白，以及入住ICU、低氧血症、深静脉置管、机械通气、手术方式、血液净化、留置导尿、胰腺坏死范围在脓毒症和非脓毒症患者间差异均有统计学意义(P值均 < 0.05)。多因素分析结果显示，APACHEⅡ评分(OR＝6.748，95%CI: 2.191~20.788)、低氧血症(OR＝3.383，95%CI: 1.112~10.293)、血糖(OR＝5.288，95%CI: 1.176~23.781)、胰腺坏死范围(OR＝5.523，95%CI: 1.575~19.360)、血清肌酐(OR＝5.012，95%CI: 1.345~18.762)等5个因素是SAP并发脓毒症的独立危险因素(P值均 < 0.05)，腹腔镜清除病灶坏死组织(OR＝0.250，95%CI: 0.066~0.951)为SAP并发脓毒症的独立保护因素(P < 0.05)。结论控制血糖，保护肺肾等重器官功能，采用微创手术方式清除病灶坏死组织，注意重症、胰腺坏死程度高患者的救治是减少SAP并发脓毒症的重要措施。
- 胰腺炎 /
- 脓毒症 /
- 影响因素分析
Abstract: Objective To investigate related factors for severe acute pancreatitis (SAP) with sepsis. Methods A retrospective analysis was performed for the clinical data of 178 SAP patients who were admitted from January 2007 to March 2020, and according to the presence or absence of sepsis, they were divided into sepsis group with 56 patients and non-sepsis group with 122 patients. The t-test was used for comparison of continuous data between the two groups, and the chi-square test was used for comparison of categorical data between the two groups. A logistic regression model was used for multivariate analyses. Results The incidence rate of sepsis was 31.46% in SAP patients. The univariate analysis showed that there were significant differences between the patients without sepsis and those with sepsis in APACHEⅡ score, blood glucose, blood calcium, serum total cholesterol, serum triglyceride, blood urea nitrogen, serum creatinine, serum albumin, admission to the intensive care unit, hypoxemia, deep venous catheterization, mechanical ventilation, surgical procedure, blood purification, indwelling urinary catheterization, and extent of pancreatic necrosis (all P < 0.05). The multivariate analysis showed that APACHEⅡ score (odds ratio [OR]=6.748, 95% confidence interval [CI]: 2.191-20.788, P < 0.05), hypoxemia (OR=3.383, 95% CI: 1.112-10.293, P < 0.05), blood glucose (OR=5.288, 95%CI: 1.176-23.781, P < 0.05), extent of pancreatic necrosis (OR=5.523, 95%CI: 1.575-19.360, P < 0.05), and serum creatinine (OR=5.012, 95%CI: 1.345-18.762, P < 0.05) were independent risk factors for infectious SAP with sepsis, while laparoscopic removal of focal necrotic tissue (OR=0.250, 95%CI: 0.066-0.951, P < 0.05) was an independent protective factor against SAP with sepsis. Conclusion There are several important measures to reduce SAP with sepsis, including blood glucose control, protection of the functions of important organs such as lungs and kidneys, application of minimally invasive surgery to remove focal necrotic tissue, and emphasis on the treatment of critically ill patients with a high degree of pancreatic necrosis.
- Pancreatitis /
- Sepsis /
- Root Cause Analysis

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表 1 SAP合并脓毒症患者的菌种构成比

病原菌	株数(n=61)	构成比(%)
革兰阳性菌	14	22.95
表皮葡萄球菌	8	13.11
溶血葡萄球菌	4	6.56
粪肠球菌	2	3.28
革兰阴性菌	39	63.93
肺炎克雷伯菌	11	18.03
鲍曼不动杆菌	9	14.75
铜绿假单胞菌	9	14.75
大肠埃希菌	7	11.48
嗜麦芽窄食假单胞菌	2	3.28
阴沟肠杆菌	1	1.64
真菌	8	13.11
白色假丝酵母菌	5	8.20
光滑假丝酵母菌	2	3.28
热带假丝酵母菌	1	1.64

下载: 导出CSV

表 2 SAP并发脓毒症的单因素分析

因素	非脓毒症(n=122)	脓毒症(n=56)	统计值	P值
年龄(岁)	48.95±15.14	51.29±13.92	t=1.011	0.314
男/女(例)	70/52	36/20	χ²=0.761	0.383
APACHEⅡ评分(分)	24.35±5.86	27.71±5.56	t=3.683	< 0.001
入住ICU(例)	41	31	χ²=7.538	0.006
低氧血症(例)	36	31	χ²=10.926	0.001
深静脉置管(例)	82	46	χ²=4.235	0.040
机械通气(例)	44	30	χ²=4.842	0.028
血糖(mmol/L)	11.37±3.80	13.13±4.34	t=2.596	0.011
预防性使用抗生素(例)	51	21	χ²=0.295	0.587
手术方式(例)			χ²=8.249	0.004
腹腔镜	43	8
开腹	79	48
血液净化(例)	83	29	χ²=4.343	0.037
留置导尿(例)	34	34	χ²=17.539	< 0.001
胰腺坏死范围(例)			χ²=13.386	0.001
>50%	9	12
30%~50%	39	25
< 30%	74	19
血钙(mmol/L)	2.26±0.32	2.14±0.33	t=-2.144	0.034
血清总胆固醇(mmol/L)	6.13±2.26	7.03±2.20	t=2.498	0.014
血清甘油三酯(mmol/L)	2.02±1.12	2.59±1.23	t=2.946	0.004
血尿素氮(mmol/L)	7.13±2.52	9.05±4.56	t=2.951	0.004
血清肌酐(μmol/L)	116.46±46.78	147.87±67.31	t=3.160	0.002
血清白蛋白(g/L)	36.08±7.95	32.62±10.22	t=-2.246	0.027

下载: 导出CSV

表 3 SAP并发脓毒症的多因素分析

变量	B	SE	Wald	P值	OR	95%CI
APACHEⅡ评分(分)	1.909	0.574	11.063	0.001	6.748	2.191~20.788
入住ICU	0.994	0.652	2.321	0.128	2.701	0.752~9.700
低氧血症	1.219	0.568	4.607	0.032	3.383	1.112~10.293
深静脉置管	0.577	0.677	0.728	0.394	1.781	0.473~6.710
机械通气	0.750	0.560	1.794	0.180	2.118	0.706~6.350
血糖(mmol/L)	1.665	0.767	4.714	0.030	5.288	1.176~23.781
手术方式(腹腔镜)	-1.387	0.682	4.133	0.042	0.250	0.066~0.951
血液净化	-0.185	0.554	0.112	0.738	0.831	0.280~2.463
留置导尿	0.636	0.559	1.293	0.256	1.889	0.631~5.651
胰腺坏死范围	1.709	0.640	7.130	0.008	5.523	1.575~19.360
血钙(mmol/L)	-0.964	0.586	2.710	0.100	0.381	0.121~1.202
血清总胆固醇(mmol/L)	0.498	0.593	0.703	0.402	1.645	0.514~5.263
血清甘油三酯(mmol/L)	0.740	0.840	0.777	0.378	2.097	0.404~10.880
血尿素氮(mmol/L)	1.066	0.630	2.862	0.091	2.903	0.845~9.977
血清肌酐(μmol/L)	1.612	0.671	5.771	0.016	5.012	1.345~18.672
血清白蛋白(g/L)	-0.719	0.705	1.041	0.308	0.487	0.122~1.939

下载: 导出CSV

参考文献(22)

[1]	van DIJK SM, HALLENSLEBEN N, van SANTVOORT HC, et al. Acute pancreatitis: Recent advances through randomised trials[J]. Gut, 2017, 66(11): 2024-2032. DOI: 10.1136/gutjnl-2016-313595
[2]	FORSMARK CE, VEGE SS, WILCOX CM. Acute pancreatitis[J]. N Engl J Med, 2016, 375(20): 1972-1981. DOI: 10.1056/NEJMra1505202
[3]	YOKOE M, TAKADA T, MAYUMI T, et al. Japanese guidelines for the management of acute pancreatitis: Japanese Guidelines 2015[J]. J Hepatobiliary Pancreat Sci, 2015, 22(6): 405-432. DOI: 10.1002/jhbp.259
[4]	SAGANA R, HYZY RC. Achieving zero central line-associated bloodstream infection rates in your intensive care unit[J]. Crit Care Clin, 2013, 29(1): 1-9. DOI: 10.1016/j.ccc.2012.10.003
[5]	HU TY, CHEN XE, JIN HL, et al. The microbial distribution and antimicrobial resistance of nosocomial bloodstream infections in a tertiary hospital[J]. Chin J Nosocomiol, 2018, 28(8): 1139-1143, 1178. (in Chinese) https://www.cnki.com.cn/Article/CJFDTOTAL-ZHYY201808005.htm 胡田雨, 陈雪娥, 金浩龙, 等. 某三甲综合医院医院获得性血流感染病原菌分布及耐药性分析[J]. 中华医院感染学杂志, 2018, 28(8): 1139-1143, 1178. https://www.cnki.com.cn/Article/CJFDTOTAL-ZHYY201808005.htm
[6]	Pancreatic Surgery Group, Branch of External Sciences, Chinese Medical Association. Guidelines for diagnosis and treatment of acute pancreatitis (2014)[J]. Chin J Pract Surg, 2015, 35(1): 4-7. (in Chinese) https://www.cnki.com.cn/Article/CJFDTOTAL-SYNK201307012.htm 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. https://www.cnki.com.cn/Article/CJFDTOTAL-SYNK201307012.htm
[7]	Ministry of Health of the People's Republic of China. Diagnostic criteria for nosocomial infections (proposed)[J]. Natl Med J China, 2001, 81(5): 314-320. (in Chinese) DOI: 10.3760/j:issn:0376-2491.2001.05.027 中华人民共和国卫生部. 医院感染诊断标准(试行)[J]. 中华医学杂志, 2001, 81(5): 314-320. DOI: 10.3760/j:issn:0376-2491.2001.05.027
[8]	LUO LY, XIONG C, CHEN XQ. Predictive value of early measurement of serum procalcitonin and C-reactive protein for infectious pancreatic necrosis[J]. J Clin Hepatol, 2018, 34(2): 346-349. (in Chinese) DOI: 10.3969/j.issn.1001-5256.2018.02.025 罗丽娅, 熊灿, 陈晓琴. 早期血清降钙素原和C反应蛋白检测对感染性胰腺坏死的预测价值[J]. 临床肝胆病杂志, 2018, 34(2): 346-349. DOI: 10.3969/j.issn.1001-5256.2018.02.025
[9]	CHEN DY, WANG XG, LI XJ, et al. Effect of alprostadil injection combined with gabetil in the treatment of acute severe pancreatitis and its effect on serum inflammatory factors[J]. Clin J Med Offic, 2020, 48(12): 1467-1468. (in Chinese) https://kns.cnki.net/KCMS/detail/detail.aspx?dbcode=CJFD&filename=JYGZ202012030 陈德育, 王新刚, 李新健, 等. 前列地尔注射液联合加贝酯治疗急性重症胰腺炎疗效及对血清炎性因子水平影响[J]. 临床军医杂志, 2020, 48(12): 1467-1468. https://kns.cnki.net/KCMS/detail/detail.aspx?dbcode=CJFD&filename=JYGZ202012030
[10]	CHEN SY, CHEN MH, SUN LJ, et al. The analysis of pathogen species distribution and drug resistance in blood culture of serious acute pancreatitis patients[J]. Chin J Nosocomiol, 2018, 22(7): 1109-1113, 1178. (in Chinese) https://www.cnki.com.cn/Article/CJFDTOTAL-ZSZD201807001.htm 陈莎燕, 陈明慧, 孙兰菊, 等. 重症急性胰腺炎患者血液病原菌感染特征分析[J]. 中华医院感染学杂志, 2018, 22(7): 1109-1113, 1178. https://www.cnki.com.cn/Article/CJFDTOTAL-ZSZD201807001.htm
[11]	LIAO QF, KANG M, ZHANG WL, et al. Analysis of pathogenic bacteria spectrum and antimicrobial susceptibility in 685 patients with severe acute pancreatitis[J]. Sichuan Med J, 2018, 39(9): 1031-1035. (in Chinese) https://www.cnki.com.cn/Article/CJFDTOTAL-SCYX201809018.htm 廖全凤, 康梅, 张为利, 等. 685例重症急性胰腺炎患者中血流感染病原菌谱及抗菌药物敏感性分析[J]. 四川医学, 2018, 39(9): 1031-1035. https://www.cnki.com.cn/Article/CJFDTOTAL-SCYX201809018.htm
[12]	HUA Z, SU Y, HUANG X, et al. Analysis of risk factors related to gastrointestinal fistula in patients with severe acute pancreatitis: A retrospective study of 344 cases in a single Chinese center[J]. BMC Gastroenterol, 2017, 17(1): 29. DOI: 10.1186/s12876-017-0587-8
[13]	CHEN BX, LI HZ, WANG YL, et al. Clinical characteristics and risk factors of secondary pancreatic infection in patients with severe acute pancreatitis[J]. Chin J Nosocomiol, 2019, 29(7): 1069-1071, 1075. (in Chinese) https://www.cnki.com.cn/Article/CJFDTOTAL-ZHYY201907028.htm 陈炳勋, 李汉智, 王云龙, 等. 重症急性胰腺炎继发胰腺感染患者的临床特征和影响因素分析[J]. 中华医院感染学杂志, 2019, 29(7): 1069-1071, 1075. https://www.cnki.com.cn/Article/CJFDTOTAL-ZHYY201907028.htm
[14]	SHEN Y, ZHANG X, WANG H, et al. Relationship between intensive insulin therapy and prognosis of severe acute pancreatitis[J]. J Nantong Univ(Med Sci), 2018, 38 (2): 143-145. (in Chinese) https://www.cnki.com.cn/Article/CJFDTOTAL-NTYX201802020.htm 沈艳, 张霞, 王辉, 等. 强化胰岛素治疗与重症急性胰腺炎预后的关系[J]. 南通大学学报(医学版), 2018, 38(2): 143-145. https://www.cnki.com.cn/Article/CJFDTOTAL-NTYX201802020.htm
[15]	XIE CY, WEI B, XIONG Y, et al. Nested case control study on the relationship between stress hyperglycemia and ventilator-associated pneumonia with bloodstream infection[J]. Chin J Endocrinol Metab, 2020, 36(12): 1022-1026. (in Chinese) DOI: 10.3760/cma.j.cn311282-20200119-00032 谢朝云, 韦波, 熊芸, 等. 应激性高血糖与呼吸机相关性肺炎伴血流感染关联性巢式病例对照研究[J]. 中华内分泌代谢杂志, 2020, 36(12): 1022-1026. DOI: 10.3760/cma.j.cn311282-20200119-00032
[16]	ZHOU LL, ZHU DH, SU Z. Effects of peritoneal dialysis on serum creatinine, urea nitrogen, albumin, hemoglobin and homocysteine in elderly patients with end-stage renal disease[J]. Chin J Gerontol, 2020, 40(11): 2369-2371. (in Chinese) DOI: 10.3969/j.issn.1005-9202.2020.11.039 周玲玲, 朱冬红, 苏震. 腹膜透析对老年终末期肾脏病患者血肌酐、尿素氮、白蛋白、血红蛋白及同型半胱氨酸的影响[J]. 中国老年学杂志, 2020, 40(11): 2369-2371. DOI: 10.3969/j.issn.1005-9202.2020.11.039
[17]	NOEL P, PATEL K, DURGAMPUDI C, et al. Peripancreatic fat necrosis worsens acute pancreatitis independent of pancreatic necrosis via unsaturated fatty acids increased in human pancreatic necrosis collections[J]. Gut, 2016, 65(1): 100-111. DOI: 10.1136/gutjnl-2014-308043
[18]	DENG YY, SHAMOON M, HE Y, et al. Cathelicidin-related antimicrobial peptide modulates the severity of acute pancreatitis in mice[J]. Mol Med Rep, 2016, 13(5): 3881-3885. DOI: 10.3892/mmr.2016.5008
[19]	TENNER S, BAILLIE J, DEWITT J, et al. American College of Gastroenterology guideline: Management of acute pancreatitis[J]. Am J Gastroenterol, 2013, 108(9): 1400-1415, 1416. DOI: 10.1038/ajg.2013.218
[20]	LI ZY, FENG QX, LIU JJ, et al. Risk factors for the need of surgical necrosectomy after percutaneous catheter drainage in the management of acute pancreatitis with infected necrosis[J]. J Abdominal Surg, 2019, 32(4): 257-260. (in Chinese) DOI: 10.3969/j.issn.1003-5591.2019.04.004 李政焰, 冯全新, 刘静静, 等. 急性胰腺炎合并感染性坏死经皮置管引流后开腹手术干预的危险因素分析[J]. 腹部外科, 2019, 32(4): 257-260. DOI: 10.3969/j.issn.1003-5591.2019.04.004
[21]	KE L, LI J, HU P, et al. Percutaneous catheter drainage in infected pancreatitis necrosis: A Systematic review[J]. Indian J Surg, 2016, 78(3): 221-228. DOI: 10.1007/s12262-016-1495-9
[22]	CHENG GY. Clinical value of CT imaging in diagnosis of acute pancreatitis[J]. J Mathematical Med, 2020, 33(1): 46-47. (in Chinese) https://www.cnki.com.cn/Article/CJFDTOTAL-SLYY202001021.htm 程国义. 急性胰腺炎应用CT影像诊断的临床价值分析[J]. 数理医药学杂志, 2020, 33(1): 46-47. https://www.cnki.com.cn/Article/CJFDTOTAL-SLYY202001021.htm