SAPwithARF

重症急性胰腺炎合并肾功能衰竭术后出血的高危因素分析和治疗,Analyzing the risk factors of post-operation bleeding in SAP patients with ARF,重症急性胰腺炎急性期诱发的MODS是导致死亡的主要原因，其中以合并急性肾功能衰竭最为常见。早期预防ARF发生，避免治疗过程中的肾功能损害对重症急性胰腺炎的预后影响意义重大。,目的,通过对ICU中SAP伴ARF患者的起病特征和入科后的治疗项目进行比较，发现引起肾功能衰竭的高危因素并早期进行预防，指导今后的治疗，减低死亡率。,方法,收集20082010年SICU收治的SAP病人60人，其中伴ARF病人m人，按预后分为生存组a和死亡组b.非肾衰组n-m人。 外科干预c人，术后出血d人，a/b，m/n-m肾功能损害按RIFLE分级Risk 1.5*SCr 尿量354 上升44.2 尿量1mEnd stage ARF3m,比较项目,一般情况（性别，年龄，APACHE-II）病因分析（胆源性，酒精性，高脂血症等）基础肝肾功能，电解质（入院第一个24h尿量，SCr，BUN，Na+，K+）入院常规（T，HR，BP，WBC，Hct，pH，PaCO2，PaO2，BE）脏器衰竭数目和次序机械通气（持续时间）CRRT（距发病时间，次数）ACS发生率（IAP）+ 肾脏灌注压（MAP-2IAP），血管活性药物应用时间清创手术（时间发病2周内/后，次数）并发症（术后出血，感染，消化道瘘）,肾衰组Logistic多因素回归分析,可能因素 术后出血（早期/迟发）/死亡 r P值1.年龄60y2.性别男/女3.ACS（IAP25cmH2O）有/无4.CRRT有/无5.血管活性药物应用有/无6.手术时机（第一次）早期2W,可能结果与讨论,早期危险因素：SIRS+感染+低血压=septic shock，其他（药物，造影剂）？术后出血的相关因素最终死亡原因（呼吸衰竭，ARF，MODS）CRRT （去除炎症因子，调节体液平衡，稳定内环境/清除肌酐，高钾）+ 手术时机保持肾脏灌注压,OBJECTIVE: Acute renal failure (ARF) is one of the most common causes of death in patients with severe acute pancreatitis (SAP). Here, we aimed to investigate the risk factors of ARF in patients with SAP, assess the prognosis of patients with SAP and ARF, and seek potential measures to prevent ARF.METHOD: A cross-sectional study was performed to analyze the data from patients with SAP. Both univariate and multivariate logistic regression analyses were performed, including 15 indices such as age, history of renal disease, Acute Physiology and Chronic Health Evaluation II scores, hypoxemia, abdominal compartment syndrome (ACS), and others. Univariate analysis was also used to compare the prognosis between the groups of patients with SAP with and without ARF.RESULTS: There was a significant difference in age, history of renal disease, Acute Physiology and Chronic Health Evaluation II scores, hypoxemia, and ACS between the groups with and without ARF. Patients with SAP and ARF had significantly longer average length of stay and intensive care unit length of stay and higher infection rate of the pancreas and mortality rate.CONCLUSION: The significant risk factors for ARF in patients with SAP include history of renal disease, hypoxemia, and ACS. Measures that can prevent ARF include homeostasis maintenance, adequate perfusion of the kidneys, adequate oxygenation, and abdominal decompression to avoid ACS.既往肾脏病史，低血容量，ACS稳定内环境，保持肾灌注和氧合，手术减压,BACKGROUND: Acute renal failure (ARF) complicating severe acute pancreatitis (SAP) carries a high mortality. Clinically useful scores to define patients who will develop this complication are lacking. We try to determine the incidence of ARF and variables predicting the appearance and severity of the episodes. MATERIAL AND METHOD: Retrospective study of all SAP patients admitted in an intensive care unit between 1991 and 1998 (n = 154). RESULTS: ARF incidence was 42%. Haemodynamic instability, APACHE II and Ranson score were related to ARF development. 62.2% of severe ARF patients had multiple organ failure (MOF). Mortality was 71.2% compared to 6.8% in patients without ARF (39.9% in mild ARF and 94.6% in severe ARF). Etiology relates to mortality (prerenal 46.4%, after severe hypotensive episode 71.4%, in MOF 93.3%; p 血透,AbstractOBJECTIVE: To investigate the risk factors affecting the mortality of severe acute pancreatitis (SAP).METHODS: The clinical data of 141 patients with SAP treated from January 2001 to October 2005 were analyzed retrospectively. All the patients were divided into 2 groups, the death group and the survival group. Fifteen potential factors influencing the prognosis of SAP were analyzed with Logistic regression analysis.RESULTS: Thirty-four cases (24.1%) among the 141 patients died. There were significant differences between the two groups in age, body mass index, length of stay, APACHE II score, multiple organ dysfunction syndrome (MODS) and abdominal compartment syndrome (ACS) (P 0.05). Multiple-factor Logistic regression analysis indicated that the MODS (OR = 67. 358, P 0.01), APACHE II score (OR =9.716, P 0.01) and ACS (OR = 5.775, P 0.05) were the independent risk factors affecting the prognosis of SAP during its early stage, whereas pancreatic infection (OR = 9.652, P 0.01), MODS (OR = 5.212, P 0.05) and celiac hemorrhage (OR = 4.707, P 0.05) were the independent risk factors during the advanced stage of SAP.CONCLUSIONS: MODS,especially respiratory dysfunction and renal dysfunction,is the main cause of early mortality for SAP, whereas infection, multiple organ dysfunction and celiac hemorrhage may impact the later mortality. Therefore early prevention and correct management on the risk factors play critical roles in reducing the mortality of SAP.,The outcome of acute renal failure in the intensive care unit according to RIFLE: model application, sensitivity, and predictability.Abosaif NY, Tolba YA, Heap M, Russell J, El Nahas AM.Sheffield Kidney Institute and Intensive Care Unit, Northern General Hospital, University of Sheffield, UK. AbstractBACKGROUND: The definition, classification, and choice of management of acute renal failure (ARF) in the setting of the intensive care unit (ICU) remain subjects of debate. To improve our approach to ARF in the ICU setting, we retrospectively applied the new classification of ARF put forward by the Acute Dialysis Quality Initiative group, RIFLE (acronym indicating Risk of renal failure, Injury to the kidney, Failure of kidney function, Loss of kidney function, and End-stage renal failure), to evaluate its sensitivity and specificity to predict renal and patient outcomes.METHODS: RIFLE classification was applied to 183 patients with ARF admitted to the ICU (2002 to 2003) at the Northern General Hospital, Sheffield, UK. Patients were divided into 4 groups according to percentage of decrease in glomerular filtration rate from baseline. The risk group included 60 patients; injury group, 56 patients; failure group, 43 patients; and control group, 24 patients. Demographic, biochemical, hematologic, clinical, and long-term health status were studied and compared in the 4 groups. An attempt was made to evaluate, by means of logistic regression analysis and receiver operator characteristic curve analysis, the predictive value of RIFLE classification for mortality in the ICU.RESULTS: The failure group showed the worst parameters with regard to Acute Physiology and Chronic Health Evaluation (APACHE) II score, pH, lowest and highest mean arterial pressures, and Glasgow Coma Scale (P 0.001). Mortality rate in the ICU (1 month) was significantly greater in the failure group compared with all groups (32 of 43 patients 74.4%; P 0.001) and, again, 6-month mortality rate (37 of 43 patients 86%; P 0.001). Receiver operator characteristic curve analysis showed that Simplified Acute Physiology Score (SAPS) II was more sensitive than APACHE II score for prediction of patient death in the risk and injury groups compared with the failure and control groups (risk group: SAPS II, 0.8 +/- 0.06; P 0.001; APACHE II, 0.63 +/- 0.07; P = 0.14; injury group: SAPS II, 0.76 +/- 0.08; P 3 and APACHE II 8), the CT-scan (Balthazar score D and E and CTSI 4), the presence of the organ and system dysfunctions assessed by Tran and Cuesta criteria and the presence of the abdominal compartment syndrome (abdominal pressure 25 mm Hg). 8 dialyzed cases (28.5%) were operated on: 2 cholecystostomy, 2 cholecystectomy+choledocho-lithotomy+T tube drainage, 4 exploring laparotomy + drainage. RESULTS: The following severity factors were identified: 1. the association of the ARF with other system and organ dysfunctions, the highest mortality rate being provided by the following associations: ARF + more than 3 organ and system dysfunctions and ARF + ARDS in assisted ventilated patients; 2. the abdominal compartment syndrome with abdominal pressure 25 mm Hg; 3. severe sepsis and altered biological status of the patients. We registered a general mortality rate of 53.57% (15 deaths) and a postoperative mortality rate of 75% (6 deaths from 8 operated patients). CONCLUSIONS: 1. Summing up the pathologic changes proper to the acute pancreatitis (enzymes and mediators releasing) with sepsis and abdominal compartment syndrome worsens the humoral and metabolic syndrome of the ARF. 2. The simultaneous presence of other organ and system dysfunctions makes the ARF in SAP one of the most severe forms. 3. ARF with anuria + ARDS in assisted ventilated patients and ARF + more than 3 associated organ and system dysfunctions are the clinical forms with the highest mortality rate. 4. The abdominal compartment syndrome is an important severity factor of the ARF because of its direct impact against the kidney and the organ and system dysfunctions which produces and worsens.,The onset of severe acute pancreatitis (SAP) is clinically harmful as it may rapidly progress from a local pancreatic inflammation into proemial systemic inflammatory reactions. Patients with SAP have a high mortality, with most cases of death resulting from complications involving the failure of organs other than the pancreas. The distinctive feature of SAP is that once it starts, it may aggrevate the clinical condition of the patient continuously, so that the levels of injury to the other organs surpass the severity of the pancreatic lesion, even causing multiple organ failure and, ulitmately, death. In clinical practice, the main complications in terms of organ dysfunctions are shock, acute respiratory failure, acute renal failure, among others. The acute renal injury caused by SAP is not only able to aggravate the state of pancreatitis, but it also develops into renal failure and elevates patients mortality. Studies have found that the injury due to massive inflammatory mediators, microcirculation changes and apoptosis, among others, may play important roles in the pathogenic mechanism of acute renal injury.瀑布效应（SIRS）,Despite the progress in intensive care treatment the ongoing systemic inflammatory response syndrome (SIRS) in patients with severe pancreatitis (SP) and renal failure (RF) is associated with high mortality. The aim of this lecture is to outline the knowledge drawn from literature and personal experience and to re-evaluate the management strategy of SP patients whose clinical course is complicated with impairment of the renal function. INCIDENCE, RISK FACTORS AND OUTCOME: Impaired renal function can be observed in 14-43% of patients with SP mostly in combination with other organ system failure. SIRS is the main culprit in the pathologic process. Extent of necrosis does not correlate with derangement of the renal function, however, infection is a serious risk