Study On Prediction Of Acute Septic Shock Post-operation Of Endoscopic Lithotripsy For Upper Tract Stone

The objective of the paper is studying acute septic shock following endoscopic lithotripsy for upper tract stone, and find the change of early indicators.The methods are establishing a animal model of renal pelvic high pressure with infection. The animal model will imitate the clinical pathogenesis of septic shock after endoscopic lithotripsy for upper urinary tract calculi. We analyzed the indicators of the animal model, and find the the change of early indicators. And the other hand, we retrospective the clinical data about septic shock post operation of endoscopic lithotripsy for upper urinary tract stones. To combine the data of animal model, we want to find the change of early indicators.The animal models of renal pelvic high pressure with infection and clinical data about septic shock post operation of endoscopic lithotripsy for upper urinary tract stones showed the white blood cell and neutrophil were sharp declined two hours after operation. With times going, the animal model showed the WBC and neutrophil were ascending gradually from four hours post-operation. And the clinical data showed the amount of mean leukocyte and neutrophil were obviously ascended twelve hours comparing with pre-operation. The animal model showed the lower WBC or netrophil was, the more obviously MAP decreased with higher mobidity was, when higher concertration of E.coil were injected in to renal pevis. We concluded the WBC and neutophil are the objective early warning indicators of acute septic shock following endoscopic lithotripsy for upper tract stones. Once the WBC and neutrophil were sharp declined during or post-operation, we need high alerting the occurring of acute septic shock post-operation. The decrease levels of WBC or neutrophil is positively related to the severity of acute septic shock followed by renal pelvic high pressure with infection.Part one:Establishing a animal model and study on prediction of acute septic shock following renal pelvic high pressure with infectionObjective:To establish a animal model of acute septic shock following renal pelvic high pressure with infection, and find the change of early indicators.Methods:New Zealand rabbits were divided into5groups as control group (A) and experiment groups(B, C, D, E). Group A was injected saline to renal pelvis by2ml/kg. Groups B, C, D and E were injected E.coli1.5×108cfu/ml,3.0×108cfu/ml,6.0×108cfu/ml,9.0×108cfu/ml, respectively. Mean arterial pressure(MAP), rectal temperature were recorded and white blood cell as well as neutrophil level were counted by flow cytometry and the plasma level of endotoxin, TNFα,ILβ,C-response protein weren determined by ELISA before and after the operation. Pathological biopsy of related organs was performed and mortality differences between control group and experiment ones were analyzed. All results were statistically analyzed by t test and one-way ANOVA.Results:There was no obvious difference of MAP between pre-operation and post-operation in A, B and C groups. But MAP was obvious declined one hour after operation in D and E groups. The rectal temperature were ascended gradually post-operation in A, B, C, D groups. But the temperature was declined two hours post-operation in E group compared with pre-operation, and then it was asecending gradually.The mortality of12h after operation for group D was16.7%(1/6), for group E was37.5%(3/8), while the mortality of3days after operation for group D and E were50%(3/6) and62.5%(5/8)respectively。For other3groups, All rabbits were alive3days after operation.Pathological biopsy showed diffuse hemorrhage in lung, liver, operative kidney and cardiac muscle. And there are diffuse and serious inflammatory infiltration in lung, liver and operative kidney. The results confirmed the rabbits died for multiple organ dysfunction.The endotoxin and TNFa levels were ascended two hours after operation and then declined gradually in every experiment groups but not control group. Neither of IL1β or CRP level had obvious change in each groups.The white blood cell and neutrophil were sharp declined two hours after operation in group B, C, D, E but not group A. And the mean amount of WBC and neutrophil of D and E groups were less than3×109/L and2×109/L, respectively two hours after operation. The WBC and neutrophil were ascending gradually from four hours post-operation in all experiment groups. The results showed the lower WBC or netrophil was, the more obviously MAP decreased with higher mortality was, when higher concertration of E.coil were injected into renal pevis.Conclusions:We successfully established a stable model of acute septic shock following endoscopic lithotripsy for upper tract stone when the renal pelvis were injected E.coli6.0×108cfu/ml or9.0×108cfu/ml by2ml/kg. To certain extend, measuring endotoxin and TNF-a was helpful. Amount of Leukocyte and neutrophil were always sharply declined in patients in two hours after operation which are a perfect earlier indicator for urosepsis. The decrease levels of WBC and neutrophil are positively related to the severity of acute septic shock. Part two:Retrospective analysis and Study on prediction of acute septic shock following endoscopic lithotripsy for upper tract stonesObjective:To investigate clinical charicteristics and early indicators of acute septic shock after endoscopic lithotripsy for upper urinary tract calculi.Methods:A clinical data was retrospective analyzed collected10cases of septic shock after endoscopic lithotripsy including uroscopic lithotripsy and percutaneous nephrolithotripsy for upper urinary tract calculi from January2005to October2011. There are2345cases who accepted endoscopic lithotripsy including1802cases for uroscopic lithotripsy and543cases for percutaneous nephrolithotripsy. The age of ten cases ranged from30to58years old with average45.3years old. We collected the data of ten patients'blood pressure, heart rate, blood routine, high-sensitivity c-reactive protein(CRP), etc. SIRS was diagnosed in patients who met two or more of the following four criteria:1. body temperature lower than36℃or higher than38℃;2. heart rate greater than90beats/min;3. respiratory rate greater than20breaths/min or PaCO2less than4.3kPa; and4. white blood cell count (WBC) greater than12×109/L or less than4×109/L or immature neutrophil more than10%. Septic shock criteria:SIRS plus systolic pressure<90mmHg(1mmHg=0.133kPa) or diastolic pressure<40mmHg. When the patients were diagnosed as acute septic shock, they were accepted anti-shock therapy and adjust the antibiotics by the result of urine and blood culture. Results:The mean arterial pressure (MAP) did not change obviously two hours post-operation comparing with pre-operation, while the MAP obviously decreased six hours post-operation comparing with pre-operation (P<0.05). Heart rate were ascended two hours post-operation (P<0.05). Amount of mean leukocyte and neutrophil were less than3×109/L and2×109/L respectively in2hours after operation. And the amount of mean leukocyte and neutrophil were obvious declined comparing with pre-operation (P<0.001). But the amount of mean leukocyte and neutrophil were obviously ascended twelve hours comparing with pre-operation (P<0.05). The amount of mean hemoglobin was declined two or twelve hours post-operation comparing with pre-operation as well as platelet (P<0.05). CRP was no obviously ascended six hours post-operation camparing with pre-operation, but it was obvious ascended twelve hours post-operation (P<0.001). All the cases were accepted anti-shock and antibiotics.Eight cases were fully recovered after7-14days after operation, respectively.1patient with multiple organ dysfunction syndrome (MODS) was discharged42days post operation. And1patient died19hours post operation.Conclusions:Septic shock is one of serious complications after endoscopic lithotripsy for upper urinary tract calculi. The patients were diagnosised as urosepsis according to the clinical manifestation in six hours post-operation. CRP had no obvious change in6hours post-operation. Amount of Leukocyte was always less than3×109/L in patients in2hours after operation which is an earlier indicator for urosepsis. The key to the successful treatment is early diagnosis and proper treatmeat for urosepsis.