| ObjectiveSevere acute pancreatitis(SAP)is a medical emergency commonly seen in emergency clinics and critical care medicine units.Acute abdominal pain,abdominal distension,high grade fever,circulatory or kidney failure are the main clinical manifestations of SAP.The course of disease is often acute and progresses rapidly,leading to the occurrence of septic shock and/or multiple organ dysfunction syndrome(MODS),in which the mortality rate could be as high as 30-50%.Experts from Shanghai City Emergency ICU Quality Control Center affiliated to the emergency department of Changzheng Hospital drew up an integrated standard operating procedure(SOP)for the recovery of SAP patients in emergency ICU within the hospital.A single center study was conducted to examine the clinical effects of SOP by comparing clinical cases before the application of the integrated SOP and those afterwards,in order to further improve the design of SOP and to discuss its rationality and promotability.Materials and MethodsTaking together more than twenty years of clinical experience in treating severe acute pancreatitis in the Emergency Department of Shanghai Changzheng Hospital,combining with references to the latest medical literature and guidelines(especially the 2012 Atlanta classification),we delegated quality control experts from Shanghai Emergency ICU Quality Control Center to coordinate with specialists from emergency department,pancreatic surgery department,infectious department,infection control office,ultrasound-guided intervention department in Changzheng Hospital to design an in-hospital integrated SOP for the recovery of SAP patients in emergency ICU.The design of the integrated SOP was completed in June 2015 after repeated discussions and considerations and was fully implemented in July 2015.The study subjects were patients selected from 42 cases who met the diagnostic criteria of SAP at Changzheng Hospital between July 2015 and January 2017.All patients were assigned to the study group according to the SOP treatment procedure,including 29 males and 13 females,with an average age of(44.56±14.66)year-old.The controls were patients selected from 40 cases who met the diagnostic criteria of SAP between January 2014 and June 2015,including 27 males and 13 females,with an average age of(42.28±12.86)year-old.The etiology of SAP,basic vital signs,blood amylase level,white blood cell count and classification,C-reactive protein(CRP),procalcitonin(PCT),blood lactate level,arterial blood gas analysis,creatinine,urine NGAL and other indicators(worst value noted within 24 hours of admission),upper abdominal CT,APACHE-II score(worst value noted within 24 hours of admission)and abdominal pressure(bladder pressure)were recorded.The changes of APACHE-II score,body temperature,white blood cell count,neutrophil percentage,CRP,PCT,blood amylase level,blood glucose and upper abdominal CT within 72 hours and after 1 week of admission were compared between the two groups.Also,the lactate changes were compared between the two groups to study damage in microcirculation,the changes in oxygen saturation index were compared to examine damage in lung,the changes in creatinine and urine NGAL levels were compared to understand renal injuries;the changes in abdominal pressure were compared between the two groups to study the incidence of abdominal septal syndrome and gastrointestinal dysfunction;the MCTSI score was compared between the two group to understand the severity of pancreatic injury;the hospitalization duration,ICU stay,fatality rate and incidence of complications were compared between the two groups,in order to evaluate the overall clinical effects.ResultsFrom the perspective of practicality in clinical applications,there was no statistically significant difference between the two groups in terms of gender,age and APACHE-II score(P>0.05);from an etiological perspective,among 82 cases of SAP patients,38 cases(46.34%)were caused by severe trauma,25 cases(30.48%)were of biliary origin,13 cases(15.85%)were due to hyperlipidemia,6 cases(7.3%)were due to unknown causes.Among 13 cases of SAP due to hyperlipidemia,there were 10 cases(76.92%)from the study group and only 3 cases(23.08%)from the control group.The treatment efficacy rate,hospitalization duration(days)and ICU stay(days)for the study and control group were 92.86% and 72.5%(P=0.03),42.88±11.37 and 50.45±11.416(P<0.01),17.55±6.39 and 26.55±7.59(P<0.01),respectively.Compared to before treatment,the body temperature,white blood cell count,neutrophil percentage,C-reactive protein(CRP),procalcitonin(PCT),blood amylase,blood glucose,lactate of the control group and study group after 72 hours of admission were 37.80±0.56 and 37.43±0.51(P<0.01),15.83±1.51 and 14.36±1.15(P<0.01),87.93±7.31 and 83.91±5.51(P<0.01),137.33±5.49 and 133.71±4.75(P<0.01),12.65±4.04 and 10.02±1.93(P<0.01),521.73±52.44 and 459.45±43.01(P<0.01),14.36±2.26 and 12.08±1.34(P<0.01),3.80±0.74 and 3.03±0.51(P<0.01),respectively;the body temperature,white blood cell count,neutrophil percentage,C-reactive protein(CRP),procalcitonin(PCT),blood amylase,blood glucose,lactate of the control group and study group after 1 week of admission were 37.57±0.57 and 37.11±0.39(P<0.01),15.44±0.86 and 12.25±0.91(P<0.01),83.81±5.42 and 78.40±3.43(P<0.01),131.61±6.96 and 104.81±12.72(P<0.01),9.07±1.47 and 5.26±1.52(P<0.01),93.45±11.75 and 93.46±14.90(P=0.09),10.46±1.36 and 7.82±0.95(P<0.01),2.09±0.96 and 1.25±1.05(P<0.01),respectively;the oxygen saturation index of the control and study group after 72 hours and 1 week of admission were 264.93±30.65 and 286.19±21.00(P<0.01),263.45±43.66 and 296.90±33.92(P<0.01),respectively;the creative of control group and study group after 72 hours and 1 week of admission were 378.53±89.09 and 291.43±87.58(P<0.01),183.23±70.52 and 113.76±51.47(P<0.01),respectively;the urine NGAL of control group and study group after 72 hours and 1 week of admission were 315.78±66.97 and 199.60±32.62(P<0.01),107.70±18.34 and 93.33±13.23(P<0.01),respectively.The MCTSI score of control group and study group after 72 hours and 1 week of admission were 8.05±1.13,7.38±0.80(P<0.01)and 7.43±0.71,4.94±1.10(P<0.01)respectively.The abdominal pressure of the control group and the study group after 72 hours and 1 week of admission were 14.78±3.04,11.76±4.07(P<0.01)and 9.73±2.56,6.95±1.83(P<0.01)respectively;the autonomous flatulence time,relief of abdominal distension time of the control group and the study group were 4.69±1.80 and 6.73±2.16(P<0.01),5.74±2.49 and 7.505±2.90(P<0.01)respectively.The incidence of complications(ARF,ARDS,ascites and pleural effusion,abdominal septal syndrome,pseudocysts and pancreatic abscess)in study group and control group were 4.76% and 20%(P<0.01),7.14% and 22.5%(P<0.01),7.14% and 20%(P=0.03),4.76% and 17.5%(P=0.02),7.14 and 25%(P<0.01),4.76 and 25%(P<0.01)respectively.Conclusion1.This design of integrated standard operating procedure for severe acute pancreatitis in emergency ICU is able to optimize the emergency protocol of severe acute pancreatitis,to facilitate the full process of quality control and informative settings,and to improve efficiency of emergency treatments.It is basically in accordance with the multiple disciplinary teams(MDTs)consensus of diagnosis and treatment for acute pancreatitis,which is the first in our country.2.The main cause of severe acute pancreatitis in our center was severe trauma.It should also be noted that SAP due to hyperlipidemia is growing in proportion.3.The integrated SOP for recovery of severe acute pancreatitis places emphasis on early fluid resuscitation,shortening of shock corrective period and minimization of complications.Comprehensive treatment measures include large doses of Ulinastatin to inhibit inflammatory responses and to reduce occurrence of inflammatory factors/cytokine storm.Rapid infusion of human albumin,or if necessary,combined with subsequent intravenous furosemide treatment can improve colloid osmotic pressure,reduce tissue edema and prevent occurrence of acute respiratory distress syndrome.External application of mirabilite on whole abdomen can reduce tissue exudation and edema,lower abdominal pressure and prevent abdominal septal syndrome.Rhubarb sterile solution can reduce oxygen radicals,improve gut microbiota ecology,minimize intestinal inflammatory response,promote gastrointestinal functional repair,and alleviate abdominal septal syndrome.Therefore,SOP can shorten the duration of shock resuscitation,reduce incidence of complications,improve efficiency of treatment and reduce patients' mortality rate. |
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