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早期胸腔穿刺引流对重症急性胰腺炎急性肺损伤的影响
DOI: 10.3969/j.issn.1001-5256.2023.07.018
伦理学声明：本研究方案于2018年2月经由中国人民解放军西部战区总医院医院伦理委员会审批，批号：A20180252004，所有患者均签署知情同意书。
利益冲突声明：本文不存在任何利益冲突。
作者贡献声明：汤礼军、王旭阳负责课题设计；王张鹏、景光旭负责收集数据；王旭阳、王张鹏负责资料筛查，统计分析，撰写论文；吴俊、黄竹协助论文修改；汤礼军、孙红玉负责论文指导和审阅。
Effect of early thoracic paracentesis drainage on acute lung injury in severe acute pancreatitis
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摘要:
目的 探讨重症急性胰腺炎(SAP)伴发的少、中量胸腔积液早期穿刺引流对SAP患者急性肺损伤的影响。 方法 回顾性分析中国人民解放军西部战区总医院2015年1月-2021年12月收治的107例SAP患者临床资料, 根据入院后前3天是否进行胸腔穿刺置管引流, 分为胸腔穿刺置管引流组(TPD组, 51例)和非胸腔穿刺置管引流组(N-TPD组, 56例)。分别比较入院后第5天、第10天两组相应时间节点实验室指标及临床结局。正态分布或近似正态分布的计量资料两组间比较采用成组t检验, 非正态分布的计量资料两组间比较采用Mann-Whitney U检验, 计数资料两组间比较采用χ2检验。 结果 TPD组重症监护病房住院时间、总住院时间、住院费用明显少于N-TPD组(P值均 < 0.05);而TPD组与N-TPD组患者病死率(9.8% vs 14.3%, χ2=0.502, P=0.478)、脓毒症发生率(29.4% vs 44.6%, χ2=2.645, P=0.104)比较差异无统计学意义。TPD组急性呼吸窘迫综合征(ARDS)发生率明显降低(χ2=6.038, P=0.043), 且中度ARDS发生率显著低于N-TPD组, 差异有统计学意义(7.8% vs 21.4%, χ2=3.874, P=0.049)。TPD组患者机械通气使用率明显低于N-TPD组(35.3% vs 57.2%, χ2=6.735, P=0.034), 且有创机械通气患者, TPD组明显低于N-TPD组(9.8% vs 26.8%, χ2=5.065, P=0.024)。TPD组肺部感染发生率显著低于N-TPD组(23.5% vs 42.9%, χ2=4.466, P=0.035), TPD组全身炎症反应综合征持续时间缩短[(11.2±5.0) d vs (16.8±4.7) d, t=5.949, P < 0.001]。在入院后第5、10天, TPD组患者实验室指标(超敏C反应蛋白、IL-1、IL-6、IL-8和TNF-α、动脉血气氧分压、氧饱和度、氧合指数)、呼吸衰竭发生率均显著优于N-TPD组(P值均 < 0.05)。入院后第10天, TPD组APACHE Ⅱ评分、改良Mashall评分均显著优于N-TPD组(P值均 < 0.05)。 结论 对于SAP伴发少、中量胸腔积液患者, 早期进行胸腔穿刺引流, 可有效改善患者的急性肺损伤, 减轻全身炎症反应, 缩短住院时间, 减少住院费用。 Abstract:Objective To investigate the effect of early thoracic paracentesis drainage for pleural effusion with a small or moderate volume on acute lung injury in patients with severe acute pancreatitis (SAP). Methods A retrospective analysis was performed for the clinical data of 107 patients with SAP who were admitted to The General Hospital of Western Theater Command from January 2015 to December 2021, and according to whether thoracic paracentesis drainage was performed within the first three days after admission, the patients were divided into thoracic paracentesis drainage group (TPD group with 51 patients) and non-thoracic paracentesis drainage group (N-TPD group with 56 patients).The two groups were compared in terms of laboratory markers and clinical outcome on days 5 and 10 after admission.The independent-samples t test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups; the chi-square test was used for comparison of categorical data between two groups. Results Compared with the N-TPD group, the TPD group had a significantly shorter length of stay in the intensive care unit, a significantly shorter length of hospital stay, and significantly lower hospital costs (all P < 0.05), while there were no significant differences between the TPD group and the N-TPD group in mortality rate (9.8% vs 14.3%, χ2=0.502, P=0.478) and the incidence rate of sepsis (29.4% vs 44.6%, χ2=2.645, P=0.104).The TPD group had a significant reduction in the incidence rate of acute respiratory distress syndrome (ARDS)(χ2=6.038, P=0.043), as well as a significantly lower incidence rate of moderate ARDS than the N-TPD group (7.8% vs 21.4%, χ2=3.874, P=0.049).Compared with the N-TPD group, the TPD group had a significantly lower rate of use of mechanical ventilation (35.3% vs 57.2%, χ2=6.735, P=0.034) and a significantly lower proportion of patients receiving invasive mechanical ventilation (9.8% vs 26.8%, χ2=5.065, P=0.024).Compared with the N-TPD group, the TPD group had a significantly lower incidence rate of pulmonary infection (23.5% vs 42.9%, χ2=4.466, P=0.035) and a significantly shorter duration of systemic inflammatory response syndrome (11.2±5.0 days vs 16.8±4.7 days, t=5.949, P < 0.001).Compared with the N-TPD group, the TPD group had significantly better laboratory markers (high-sensitivity C-reactive protein, interleukin-1, interleukin-6, interleukin-8, tumor necrosis factor-α, arterial partial pressure of oxygen, oxygen saturation, and oxygenation index) and incidence rate of respiratory failure on days 5 and 10 after admission (all P < 0.05).On day 10 after admission, the TPD group had significantly better APACHE Ⅱ score and modified Mashall score than the N-TPD group (both P < 0.05). Conclusion For SAP patients with a small or moderate volume of pleural effusion, early thoracic paracentesis drainage can effectively improve acute lung injury, alleviate systemic inflammatory response, shorten the length of hospital stay, and reduce hospital costs. -
Key words:
- Pancreatitis /
- Pleural Effusion /
- Drainage /
- Acute Lung Injury /
- Systemic Inflammatory Response Syndrome
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表 1 两组患者基线资料比较
Table 1. Baseline patient characteristics between two groups
项目 TPD组(n=51) N-TPD组(n=56) 统计值 P值 年龄(岁) 52.3±14.0 51.2±11.3 t=0.417 0.678 性别[例(%)] χ2=0.117 0.846 男 29(56.9) 30(53.6) 女 22(43.1) 26(46.4) 病因[例(%)] χ2=0.140 0.932 胆源型 22(43.1) 25(44.6) 高脂血症型 19(37.3) 19(33.9) 其他 10(19.6) 12(21.4) 炎症指标 WBC(×109/L) 16.4±3.8 16.5±4.2 t=0.065 0.948 N%(%) 89.8±4.7 88.6±3.9 t=1.432 0.155 HS-CRP(mg/L) 235.9±52.6 241.3±47.5 t=0.550 0.583 血沉(mm/h) 55.3±20.7 52.1±21.6 t=0.592 0.439 PCT(ng/mL) 1.8(0.9~4.7) 2.3(1.0~4.2) Z=0.873 0.383 细胞因子(pg/mL) IL-1 15.1±6.6 15.9±5.6 t=0.645 0.515 IL-6 187.2±62.3 205.3±56.4 t=1.580 0.117 IL-8 79.9±63.9 89.4±59.9 t=0.791 0.431 TNF-α 22.9±3.6 21.7±5.1 t=1.378 0.171 血气指标 PaO2(mmHg) 68.2±8.3 69.8±8.1 t=1.042 0.300 PaCO2(mmHg) 36.3±4.2 36.2±5.4 t=0.077 0.939 氧饱和度(%) 87.6±3.7 86.8±4.0 t=1.127 0.262 OI 200.4±29.3 202.3±29.7 t=0.327 0.744 乳酸(mmol/L) 2.4±1.7 2.2±1.1 t=0.587 0.558 pH 7.38±0.58 7.37±0.59 t=0.628 0.532 RR(次/min) 29.9±3.6 30.1±3.7 t=0.164 0.870 APACHⅡ评分(分) 16.7±3.2 16.6±3.5 t=0.117 0.907 改良MarshaⅡ评分(分) 4.2±1.2 4.1±1.4 t=0.344 0.731 
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表 2 2组患者临床结局比较
Table 2. Clinical outcomes between two groups
项目 TPD组(n=51) N-TPD组(n=56) 统计值 P值 疾病特异病死率[例(%)] 5(9.8) 8(14.3) χ2=0.502 0.478 ARDS[例(%)] χ2=6.038 0.043 无 35(68.6) 26(46.4) 轻度 12(23.5) 18(32.1) 中度 4(7.8) 12(21.4) 机械通气[例(%)] χ2=6.735 0.034 无 33(64.7) 24(42.9) 无创通气 13(25.5) 17(30.4) 有创通气 5(9.8) 15(26.8) 肺部感染发生率[例(%)] 12(23.5) 24(42.9) χ2=4.466 0.035 脓毒症发生率[例(%)] 15(29.4) 25(44.6) χ2=2.645 0.104 机械通持续时间(d) 7.2±2.4 9.5±4.2 t=2.155 0.036 氧疗持续时间(d) 16.6±2.7 20.5±4.8 t=5.100 ＜0.001 SRIS持续时间(d) 11.2±5.0 16.8±4.7 t=5.949 ＜0.001 ICU住院时间(d) 9.2±4.6 11.7±6.1 t=2.384 0.019 总住院时间(d) 30.1±9.7 37.3±10.3 t=3.280 0.001 总费用(元) 72 247±27 314 85 735±34 186 t=2.207 0.029
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表 3 入院后约5天和约10天两组实验室指标及临床评估比较
Table 3. Laboratory and clinical parameters between two groups 5 days and 10 days after admission
项目 入院后约5天 入院后约10天 TPD组
(n=51)N-TPD组
(n=56)统计值 P值 TPD组
(n=51)N-TPD组
(n=56)统计值 P值 炎症指标 WBC(×109/L) 15.7±2.9 16.3±4.1 t=0.873 0.384 12.6±6.1 14.8±5.4 t=2.046 0.040 N% 85.3±7.3 86.5±4.1 t=1.403 0.164 77.3±9.5 82.1±7.7 t=2.906 0.004 HS-CRP(mg/L) 173.8±51.1 225.4±54.8 t=5.018 ＜0.001 119.5±64.7 159.2±84.2 t=2.715 0.008 PCT(ng/mL) 3.9(2.4~7.3) 4.7(2.7~13.3) Z=0.986 0.324 1.5(0.5~4.1) 3.2(1.4~11.7) Z=2.532 0.011 细胞因子(pg/mL) IL-1 11.1±4.2 14.7±5.0 t=4.076 ＜0.001 10.7±7.0 14.5±6.5 t=2.889 0.005 IL-6 82.2±38.5 105.7±43.7 t=2.942 0.004 52.5±54.6 76.4±54.6 t=2.268 0.025 IL-8 40.1±24.2 64.0±26.2 t=4.884 ＜0.001 31.5±28.1 46.4±29.8 t=2.625 0.009 TNF-α 15.0±5.5 19.2±5.9 t=3.749 ＜0.001 14.0±6.2 17.1±6.4 t=2.533 0.010 血气指标 PaO2(mmHg) 84.9±10.2 80.8±9.7 t=2.104 0.038 89.9±9.3 84.84±11.4 t=2.509 0.014 PaCO2(mmHg) 38.3±3.7 37.2±3.8 t=1.505 0.135 37.6±2.7 37.1±2.9 t=1.006 0.317 氧饱和度(%) 95.1±2.3 90.5±4.2 t=6.967 ＜0.001 95.2±4.8 92.3±5.8 t=2.491 0.014 OI 269.1±47.8 246.3±49.5 t=2.421 0.017 299.0±47.7 270.9±51.4 t=2.918 0.004 乳酸(mmol/L) 1.4±0.7 1.5±0.6 t=0.311 0.756 1.3±0.5 1.4±0.7 t=0.985 0.327 pH 7.40±0.04 7.40±0.05 t=1.010 0.315 7.39±0.03 7.38±0.04 t=0.714 0.477 RR(次/min) 22.7±4.2 27.6±4.4 t=5.892 ＜0.001 19.6±4.3 23.5±5.8 t=3.933 ＜0.001 呼吸衰竭[例(%)] χ2=4.813 0.028 χ2=13.445 ＜0.001 无 22(43.1) 13(23.2) 38(74.5) 22(39.2) 有 29(59.6) 43(76.8) 13(25.5) 34(60.7) APACHEⅡ评分(分) 9.9±3.3 12.1±3.4 t=3.315 0.001 改良Marshall评分(分) 2.1±1.2 2.9±1.6 t=2.950 0.004
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