重症急性胰腺炎的预后评估1

null 重症急性胰腺炎的评估： APACHE Ⅱ，Balthazar CT, Mashall MODS score 重症急性胰腺炎的评估： APACHE Ⅱ，Balthazar CT, Mashall MODS score俞文桥 概述 1.诊断：发病一周以内，在住院48h 后经积极治疗仍表现为持续的器官衰竭（OF） 2.病情重，进展快。 3.累及全身多系统，致机体病理、生理及器官功能不全和衰竭。 概述 1.诊断标准：发病一周以内，在住院48h 后经积极治疗仍表现为持续的器官衰竭（OF） 2.病情重，进展快。 3.累及全身多系统，致机体病理、生理及器官功能不全和衰竭。 评估系统 评估系统 生理（APACHEⅡ） 严重程度 如何评估？ 病理（BalthazarCT） 预后情况 功能（Mashall） Acute Physiology and Chronic Health Evaluation Ⅱ(APACHE Ⅱ) Acute Physiology and Chronic Health Evaluation Ⅱ(APACHE Ⅱ) APACHE Ⅱ评分系统是APACHE系统的简化修正版（从34个变量缩减到12个） 12个变量都能通过量化来衡量 每个变量的诊断范围广，便于检测，且大都数医院都能检测 12个变量中涉及的系统较广，评分全面 null感染的全过程归纳为: Glasgow Coma ScaleGlasgow Coma Scale重症胰腺炎 重症胰腺炎 何时为最有价值评分时间？ 何时为最有价值评分时间？最佳评分时间： 在发病24小时内，急诊室或ICU各种干 预之前 在进入ICU24小时后测评，则至少偏差5分 进入ICU后每天或隔天评分，可了解病情变化及治疗效果 Willam A. Knaus.MD,Elizabeth A.Draper,MS,Douglas P.Wagner,PhD et al. APACHE Ⅱ:A severity of disease classifcation system.Critical Care Medicine.1985,13:818-829. Balthazar CT胰腺炎的严重程度 （胰腺肿胀、胰周渗出 假性囊肿和脓肿）胰腺坏死程度 (轮廓、大小、密度) 评测严重指数评估预后及治疗效果CT评分系统CT评分系统CT评分系统CT评分系统 The severity index=Grade score+Necrosis score, and it grades in three categores as follow: ①: 0-3 ②:4-6 ③:7-9 1. Balthazar,MD. Ranson,B.M.,B.Ch. David P.Naidich,M.D.et al. Acute Pancreatitis:Prognostic Value of CT.Radiology,1985;156:767-772. 2. Balthazar,MD.Robinson,MD.Megibow,MD.et al. Acute Pancreatitis:Value of CT in Establishing Prognosis.Radiology 1990:174:331-336. null CT severity index assigns points to patients according to their grade of acutepancreatitis (grade A 0, grade B 1, grade C = 2, grade D = 3, grade E 4) and the absence or presence of necrosis (no necrosis 0, necrosis of one-third of the pancreas 2, necrosis of one-half 4, necrosis of more than one-half 6). Black bars mortality, gray bars = morbidity (complications). Note that almost all patients with a high severity index (a severity index of 7-10) develop complications, and 17% die. null grade A : CT scan of normal pancreas in patient with clinical pancreatitis grade B : Diffuse enlargement of the pancreas without peripancreatic inflammatory changes grade C : Enlarged pancreas associated with haziness and increased density of peripancreatic grade D : (a) CT scan of the fluid collection in left anterior pararenal spacegrade D : (a) CT scan of the fluid collection in left anterior pararenal spacenullgrade E :CT scan showing large fluid collections in the lesser sac and double anterior pararenal space in patient以何时CT评估为准？以何时CT评估为准？以发病入院后首次CT结果来评估SAP严重程度指数 Balthazar等所有88位病人中，75%在入院后2天内完成首次CT，88%在4天内，95%在7天内完成。 3-7天复查一次，以评估病情的变化及相应治疗的效果 Mashall MODS scoreMashall MODS score 回顾分析Medline数据库中1969-1993年所有关于研究MODS各种变量，分析总结某个主要变量与其相关系统的关系，并用此变量来量化相关器官的功能。 Mashall,John C.MD, Cook,Deborah J.MD, Christou,Nicolas V.MD.et al. Multiple Organ Dysfunction Score: A reliable descriptor of a complex clinical outcome. Crit Care Med. 1995 Oct;23(10):1638-52 主要变量及其反映的相关器官主要变量及其反映的相关器官 Respiratory system -----PO2 /FIO2 ratio. renal system ----------serum creatinine concentration hepatic system ---serum bilirubin concentration hematologic system ---platelet count central nervous system ---Glasgow Coma Scale cardiovascular ---pressure-adjusted heart rate （PAR=CVP × HR） MAP Mashall,John C.MD, Cook,Deborah J.MD, Christou,Nicolas V.MD.et al. Multiple Organ Dysfunction Score: A reliable descriptor of a complex clinical outcome. Crit Care Med. 1995 Oct;23(10):1638-52Mashall MODS Score SystemMashall MODS Score System Mashall,John C.MD, Cook,Deborah J.MD, Christou,Nicolas V.MD.et al. Multiple Organ Dysfunction Score: A reliable descriptor of a complex clinical outcome. Crit Care Med. 1995 Oct;23(10):1638-52nullnullnullnull Mashall MODS不仅可用来患者预后的评估，还可用以治疗过程中临床病情的评估以及治疗效果的评估Mashall,John C.MD, Cook,Deborah J.MD, Christou,Nicolas V.MD.et al. Multiple Organ Dysfunction Score: A reliable descriptor of a complex clinical outcome. Crit Care Med. 1995 Oct;23(10):1638-52nullMashall 分数与病人的死亡率密切相关 首次Mashall评分能对患者的预后进行评估 Mashall 分数能反映患者ICU住院过程中各器官功能不全的发展变化，因此连续的Mashall评分更能反映出治疗的效果及其真正的预后　　　　　　　　　　　　　Mashall,John C.MD, Cook,Deborah J.MD, Christou,Nicolas V.MD.et al. Multiple Organ Dysfunction Score: A reliable descriptor of a complex clinical outcome. Crit Care Med. 1995 Oct;23(10):1638-52 Mashall MODS 评分与ICU病人死亡率 score mortality 9-12 25% 13-16 50% 17-20 75% 20-24 100% Mashall MODS 评分与ICU病人死亡率 score mortality 9-12 25% 13-16 50% 17-20 75% 20-24 100%Mashall,John C.MD, Cook,Deborah J.MD, Christou,Nicolas V.MD.et al. Multiple Organ Dysfunction Score: A reliable descriptor of a complex clinical outcome. Crit Care Med. 1995 Oct;23(10):1638-52对三大评估系统的几点感受对三大评估系统的几点感受1.侧重点不一样: APACHE Ⅱ，Mashall MODS score主要是对整个系统脏器生理及功能的评估 Balthazar CT主要针对胰腺炎局部炎症严重程度及并发症(脓肿、渗出液、假性囊肿) 2.有各自局限性： APACHE Ⅱ，Mashall MODS score均没有肠道系统的评估 Balthazar CT，局部的变化反映整体的预后？ 3.综合评估是否有另外的评估点？是否有另外的评估点？ 1.对肠道功能的评估 肠鸣音？腹腔压力？腹围？大便次 数及量？ null肠道功能 评估肠道通透性 检测肠粘膜PH 测定肠菌群监测二胺氧化酶 测定肠道动力转运 时间测定肠道粘膜 病理细菌易位乳果糖/甘露醇 比值null肠道通透性检测： 1.糖分子探针如尿乳果糖与甘露醇比值(L/M)。 2.内毒素检测：ELISA>55.34EU/L 3.血浆二胺氧化酶(DAO)活性 肠缺血指标： 尿24小时肠型脂肪酸结合蛋白(IFABP)含量测定 （ELISA>17ng） 细菌易位： 血、腹水培养 null2.CRP 反应炎症程度的最重要及最敏感的指标。 入院后24-48小时，CRP的高低可评估胰 腺炎的严重程度，特别是其量超过150 mg/L时。 Günay Gürleyik1, Seyfi Emir1, Gamze Kiliçoglu2，et al. Computed Tomography Severity Index, APACHE II Score, and Serum CRP Concentration for Predicting the Severity of Acute Pancreatitis. JOP. J Pancreas (Online) 2005; 6(5):562-567. Günay Gürleyik1, Seyfi Emir1, Gamze Kiliçoglu2，et al. Computed Tomography Severity Index, APACHE II Score, and Serum CRP Concentration for Predicting the Severity of Acute Pancreatitis. JOP. J Pancreas (Online) 2005; 6(5):562-567.nullTsunao Imamura, Shigeki Tanaka, Hitoshi Yoshida,et al. Significance of measurement of high-sensitivity C-reactive protein in acute pancreatitis. J Gastroenterol 2002; 37:935–938.null3.胸水？？？ Carlos Ocampo, Walter Silva, Hugo Zandalazini，et al. Pleural effusion is superior to multiple factor scoring system in predicting acute pancreatitis outcome. ACTA GASTROENTEROL LATINOAM - MARZO 2008;VOL 38:Nº1其他其他P. Mentula, M.-L. Ky¨anp¨a¨a, E. Kemppainen，et al. Early prediction of organ failure by combined markers in patients with acute pancreatitis. British Journal of Surgery 2005; 92: 68–75null 谢 谢