摘要
目的:制定重症急性胰腺炎(SAP)中西医结合治疗试行指南。方法:以循证医学证据为基础,通过查阅大量文献报道,采用系统综述的方法,参阅国内外多项指南内容,广泛征求专家意见和建议,初步制定出《重症急性胰腺炎中西医结合诊治常规》(草案)。指南中的推荐意见依据2001年国际感染论坛(ISF)提出的Delphi分级标准,推荐级别分为A～E,其中A级最高。结果:SAP是临床上常见的一类急腹症,病程通常分为三期。早期的重症监护治疗对SAP患者是至关重要的,而快速恰当的液体复苏又能预防循环并发症的发生。蛋白酶抑制剂如加贝酯,胰酶抑制剂如善得定,抗炎剂如昔帕泛等,尽管早期研究发现有效,但随后的大样本随机研究证实其效果不理想,不推荐常规使用。预防性抗生素应用可能在预防感染方面有效,但是否给予意见不一。如果给予,则疗程不应超过14d。SAP患者的营养支持是必需的,若肠道功能恢复,则优先选择肠内营养,肠内营养中经鼻空肠置管是可行的。胆道结石引起的SAP,有胆管炎、黄疸或胆总管扩张时,应紧急行ERCP治疗。当患者有脓毒症症状时,细针穿刺抽吸物培养是可靠的鉴别无菌性胰腺坏死和感染性胰腺坏死的方法。感染性胰腺坏死合并有脓毒症症状和体征时,是外科干预的指征,包括手术清除坏死组织和影像引导下引流。坏死组织清除的术式选择及术后的处理取决于患者病情和医师经验。中医治疗在降低SAP病死率、缩短病程方面是被实践证实了的有效手段。结论:该指南是以循证医学为指导制定的,随新的证据不断形成则应不断更新。
Objective To draft the practical guidelines for management of severe acute pancreatitis （SAP） by integrated traditional Chinese and western medicine Methods Established evidence- based data, a systematic review of literature was undertaken, the published guidelines were referred and expert opinions solicited. The recommendations were categorized into five grades from A to E, with A being the highest, according to the modified Delphi criteria, which were adopted by the International Sepsis Forum held in 2001. Results SAP is a critical abdominal disease which usually has three clinical phases. It is essential to manage the patients in a high dependency unit or intensive therapy unit with full monitoring and various systems support in the early phase. Adequate prompt fluid resuscitation is crucial in the prevention of systemic complications. Despite initial encouraging results, antiproteases such as gabexate, antisecretory agents such as octreotide, and anti - inflammatory agents such as lexipafant have all proved disappointing in large randomised studies and won＇ t be recommended to be used routinely. Antibiotic prophylaxis may be beneficial in the potential to prevent infection but there remains no consensus view on the value of antibiotic prophylaxis. Should antibiotic prophylaxis be used, it should be given for a maximum couse of 14 days is essential. Nutritional support is required in patients with SAP. The enteral route should be used if tolerated and the nasogastric route for feeding is feasible. Urgent therapeutic ERCP should be performed in patients with gallstone - associated SAP, when there is cholangitis, jaundice, or a di- lated common bile duct. Fine - needle aspiration for bacteriology should be performed to differentiate between sterile and infected pancreatic necrosis in patients with sepsis syndrome. Infected pancreatic necrosis in patients with clinical signs and symptoms of sepsis is an indication for intervention including surgery and radiological drainage. The choice of surgical technique for necrosectomy, and subsequent postoperative management depends on individual features and available expertise. The traditional Chinese medicine therapy has proved to be a valuable approach in reducing the mortality rate and shortening the clinical course. Conclusion The present guideline is drafted from evidence- based recommendations and should be updated when appropriate consideration of changes in the evidence base will be applied.
出处
《中国中西医结合外科杂志》
CAS
2007年第3期232-237,共6页
Chinese Journal of Surgery of Integrated Traditional and Western Medicine
关键词
重症急性胰腺炎
中西医结合
诊治
指南
SAP, integrated traditional Chinese and western medicine, diagnosis and treatment, practical guidline
