新斯的明對急性胰腺炎合并腹內高壓治療價值的臨床研究
發(fā)布時間：2018-08-25 15:29
【摘要】：背景:急性胰腺炎(acute pancreatitis,AP)是一個世界范圍內高死亡率的疾病,尤其重癥急性胰腺炎的死亡率達36%-50%。急性胰腺炎發(fā)病過程中可出現多種并發(fā)癥,其中腹內高壓(IAH)或腹腔間隔室綜合征(ACS)為急性胰腺炎的一種特殊并發(fā)癥,預后差、病死率高。目前認為IAH是ACS的前奏,IAH向ACS的演變速度在不同SAP患者中差異較大,IAH期可以看成是病情演變成為ACS的重要“窗口期”和轉折點,也是非手術治療的重要時期。而急性胰腺炎發(fā)病過程中,胰液滲出導致的麻痹性腸梗阻是引發(fā)腹內壓增高的重要原因之一,所以積極治療麻痹性腸梗阻導致的腹內高壓可以明顯緩解急性胰腺炎患者癥狀。新斯的明作為抗膽堿酯酶藥,通過與乙酰膽堿在膽堿能傳遞位點競爭性地與膽堿酯酶結合,阻遏乙酰膽堿的水解,增強膽堿能作用而提高興奮性副交感活性,使患者機體表現為毒蕈堿樣(M樣)作用,從而恢復病人的腸蠕動。當急性胰腺炎患者胃腸道M受體興奮時能夠增強胃腸道蠕動,可促使患者肛門排氣、排便,所以藥物新斯的明對于改善急性胰腺炎患者麻痹性腸梗阻,降低急性胰腺炎患者腹內壓可能具有一定效果。目前國內尚無新斯的明治療AP合并IAH的前瞻性臨床對照研究,具有創(chuàng)新性與實用性。目的:1.探討新斯的明改善急性胰腺炎導致的麻痹性腸梗阻,降低患者腹腔內壓力的治療價值。2.明確新斯的明對降低急性胰腺炎患者器官衰竭及改善預后的治療價值。方法:本臨床隨機對照試驗于2015年8月1日至2016年2月29日在南昌大學第一附屬醫(yī)院消化內科展開,本研究獲得醫(yī)院倫理委員會的批準,并在NIH注冊,注冊號為:NCT02543658。患者參與實驗之前均簽署知情同意書。根據亞特蘭大急性胰腺炎診斷標準,即臨床符合以下3項中的2項可診斷為急性胰腺炎:與急性胰腺炎符合的腹痛;血淀粉酶和(或)脂肪酶至少3倍正常上限;增強CT/MRI或腹部超聲呈急性胰腺炎改變。期間共483例病人診斷為急性胰腺炎,其中輕癥急性胰腺炎患者229例,中度重癥急性胰腺炎患者187例,重癥急性胰腺炎患者67例。腹內高壓(iah)診斷標準:每4-6小時測量一次腹內壓,連續(xù)3次平均腹內壓≥12mmhg。符合急性胰腺炎合并腹內高壓入組條件的患者有33例,根據隨機分組,分為實驗組(a組)、對照組(b組)。對照組為常規(guī)治療組;實驗組在常規(guī)治療基礎上給予肌肉注射新斯的明。結果:本研究的33位患者中男性24人(72.7%),女性9人(27.3%),其中重癥急性胰腺炎患者25人(75.7%),中度重癥急性胰腺炎患者8人(24.3%),無輕癥患者�；颊卟煌瑫r間點測得的糞便量之間統(tǒng)計學上具有差異(f=19.410,p=0.000)。實驗組及對照組糞便量均呈上升趨勢,實驗組高于對照組(f=8.509,p=0.007)。用藥后第1、2、3天實驗組的糞便量高于對照組(p?0.05),其余各時間點實驗組與對照組無顯著差異(p?0.05),實驗組與對照組之間存在交互作用(f=3.756,p=0.006)�；颊卟煌瑫r間點所測得的腹內壓之間統(tǒng)計學上有差異(f=35.820,p=0.000)。實驗組及對照組腹內壓均呈逐漸下降趨勢,實驗組與對照組統(tǒng)計學上無明顯差異(f=2.566,p=0.119)。第3天實驗組的腹內壓低于對照組(p=0.036),其余各時間點實驗組及對照組統(tǒng)計學上無差異(p?0.05),實驗組與對照組之間不存在交互作用(f=1.250,p=0.282);測量實驗組及對照組患者治療前腹內壓及治療后24h,48h,72h腹內壓下降百分比、72h內達標率(降到12mmhg以下),發(fā)現24h實驗組下降率較對照組高,差異具有統(tǒng)計學意義(f=5.270,p=0.029),其余各時間點無統(tǒng)計學差異(p?0.05)。兩組患者達到腹內壓ii級的患者共15例,其中實驗組7例,對照組8例,治療后實驗組患者24h,48h,72h腹內壓下降百分比、72h內達標率及降到i級(15mmhg)的時間均優(yōu)于對照組,差異有統(tǒng)計學意義(p?0.05)。實驗組第5天腹內壓恢復至正�；颊邤蹬c對照組相比明顯增加,差異具有統(tǒng)計學意義(p=0.038),其余各時間點無統(tǒng)計學意義(p?0.05);兩組之間器官衰竭持續(xù)時間統(tǒng)計學上無明顯差異(p=0.465)。兩組患者在重癥監(jiān)護時間、總住院時間及預后上的差異無統(tǒng)計學意義(p?0.05)。結論:(1)新斯的明可以改善急性胰腺炎患者麻痹性腸梗阻癥狀;(2)新斯的明可以降低腹內壓ii級以上急性胰腺炎患者的腹內壓;(3)本研究進行過程中未發(fā)生藥物新斯的明的安全不良事件;(4)新斯的明降低腹內壓i級急性胰腺炎患者的腹內壓較常規(guī)治療無明顯優(yōu)勢;(5)本研究中新斯的明對于改善急性胰腺炎患者的器官衰竭持續(xù)時間、重癥監(jiān)護時間、總住院時間及預后的作用有限;(6)由于本研究樣本量較小,實驗結果存在一定偏差,尚需擴大樣本量加以論證。
[Abstract]:BACKGROUND: Acute pancreatitis (AP) is a worldwide disease with high mortality, especially severe acute pancreatitis (SAP) with a mortality rate of 36% - 50%. Several complications may occur during the onset of acute pancreatitis, of which intraabdominal hypertension (IAH) or abdominal compartment syndrome (ACS) is a special complication of acute pancreatitis. At present, IAH is considered to be the prelude of ACS. The rate of evolution of IAH to ACS varies greatly among different SAP patients. IAH can be regarded as an important "window" and turning point for the development of ACS, and also an important period for non-surgical treatment. Neostigmine, as an anti-cholinesterase drug, is enhanced by competitive binding with acetylcholine at the cholinergic transmission site to inhibit the hydrolysis of acetylcholine. Cholinergic enhances excitatory parasympathetic activity and restores the intestinal peristalsis of patients with acute pancreatitis. When M receptors in the gastrointestinal tract are excited, the gastrointestinal peristalsis of patients with acute pancreatitis can be enhanced, and the anal exhaust and defecation of patients can be promoted. Therefore, neostigmine can improve the patients with acute pancreatitis. There is no prospective clinical controlled study of neostigmine in the treatment of AP complicated with IAH in China, which is innovative and practical. Objective: 1. To explore the effect of neostigmine on the improvement of paralytic intestinal obstruction caused by acute pancreatitis and the reduction of intraperitoneal pressure in patients with acute pancreatitis. Methods: A randomized controlled trial was conducted in the Department of Gastroenterology, First Affiliated Hospital of Nanchang University from August 1, 2015 to February 29, 2016. The study was approved by the Hospital Ethics Committee and registered in NIH with the registration number N:N. According to the diagnostic criteria of Atlanta acute pancreatitis, two of the following three items can be diagnosed as acute pancreatitis: abdominal pain consistent with acute pancreatitis; blood amylase and/or lipase at least three times the normal upper limit; enhanced CT/MRI or abdominal ultrasound showing acute pancreatitis A total of 483 patients were diagnosed as acute pancreatitis, including 229 patients with mild acute pancreatitis, 187 patients with moderate severe acute pancreatitis and 67 patients with severe acute pancreatitis. 33 patients were randomly divided into experimental group (group a) and control group (group b). The control group was treated with routine therapy, and the experimental group was given neostigmine intramuscularly on the basis of routine therapy. Results: Among the 33 patients in this study, 24 (72.7%) were male and 9 (27.3%) were female, including 25 (75.3%) with severe acute pancreatitis. There were statistically significant differences (f = 19.410, P = 0.000) in the amount of feces measured at different time points. The amount of feces in the experimental group and the control group showed an upward trend. The amount of feces in the experimental group was higher than that in the control group (f = 8.509, P = 0.007). The amount of feces in the experimental group was higher than that in the control group on the first, second and third days after treatment. There was no significant difference between the experimental group and the control group at the other time points (p? 0.05). there was interaction between the experimental group and the control group (f = 3.756, P = 0.006). the intraabdominal pressure of the patients at different time points was statistically different (f = 35.820, P = 0.000). the intraabdominal pressure of the experimental group and the control group showed a gradual downward trend, and the experimental group and the control group showed a gradual downward trend. The intraabdominal pressure of the experimental group was lower than that of the control group on the third day (p = 0.036), and there was no significant difference between the experimental group and the control group at other time points (p? 0.05). There was no interaction between the experimental group and the control group (f = 1.250, P = 0.282). 24 hours, 48 hours, 72 hours of intra-abdominal pressure decreased percentage, within 72 hours of the standard rate (down to 12 mmHg below), found that 24 hours of the experimental group than the control group, the decline rate was statistically significant (f = 5.270, P = 0.029), the rest of the time point no statistical difference (p? 0.05). Two groups of patients reached intra-abdominal pressure level II patients in 15 cases, including 7 cases in the experimental group, 8 cases in the control group, after treatment. The decrease percentage of intra-abdominal pressure at 24, 48 and 72 hours, the time of reaching the standard within 72 hours and the time of lowering to grade I (15mmhg) in the experimental group were all better than those in the control group (p?0.05). The number of patients whose intra-abdominal pressure returned to normal on the fifth day in the experimental group was significantly higher than that in the control group (p=0.038), and there was no statistical significance at the other time points. There was no significant difference in the duration of organ failure between the two groups (p = 0.465). there was no significant difference in the duration of intensive care, total hospitalization and prognosis between the two groups (p? 0.05). conclusion: (1) neostigmine can improve the symptoms of paralytic intestinal obstruction in patients with acute pancreatitis; (2) neostigmine can reduce intraabdominal pressure I Intra-abdominal pressure in patients with grade I or above acute pancreatitis; (3) Neostigmine did not occur during the study; (4) Neostigmine had no significant advantage in reducing intra-abdominal pressure in patients with grade I acute pancreatitis as compared with conventional treatment; (5) Neostigmine was shown to improve the persistence of organ failure in patients with acute pancreatitis. Time, intensive care time, total hospitalization time and prognosis are limited. (6) Because the sample size of this study is small, there are some deviations in the experimental results, it is necessary to expand the sample size to demonstrate.
【學位授予單位】：南昌大學
【學位級別】：碩士
【學位授予年份】：2016
【分類號】：R576
本文編號：2203324
[Abstract]:BACKGROUND: Acute pancreatitis (AP) is a worldwide disease with high mortality, especially severe acute pancreatitis (SAP) with a mortality rate of 36% - 50%. Several complications may occur during the onset of acute pancreatitis, of which intraabdominal hypertension (IAH) or abdominal compartment syndrome (ACS) is a special complication of acute pancreatitis. At present, IAH is considered to be the prelude of ACS. The rate of evolution of IAH to ACS varies greatly among different SAP patients. IAH can be regarded as an important "window" and turning point for the development of ACS, and also an important period for non-surgical treatment. Neostigmine, as an anti-cholinesterase drug, is enhanced by competitive binding with acetylcholine at the cholinergic transmission site to inhibit the hydrolysis of acetylcholine. Cholinergic enhances excitatory parasympathetic activity and restores the intestinal peristalsis of patients with acute pancreatitis. When M receptors in the gastrointestinal tract are excited, the gastrointestinal peristalsis of patients with acute pancreatitis can be enhanced, and the anal exhaust and defecation of patients can be promoted. Therefore, neostigmine can improve the patients with acute pancreatitis. There is no prospective clinical controlled study of neostigmine in the treatment of AP complicated with IAH in China, which is innovative and practical. Objective: 1. To explore the effect of neostigmine on the improvement of paralytic intestinal obstruction caused by acute pancreatitis and the reduction of intraperitoneal pressure in patients with acute pancreatitis. Methods: A randomized controlled trial was conducted in the Department of Gastroenterology, First Affiliated Hospital of Nanchang University from August 1, 2015 to February 29, 2016. The study was approved by the Hospital Ethics Committee and registered in NIH with the registration number N:N. According to the diagnostic criteria of Atlanta acute pancreatitis, two of the following three items can be diagnosed as acute pancreatitis: abdominal pain consistent with acute pancreatitis; blood amylase and/or lipase at least three times the normal upper limit; enhanced CT/MRI or abdominal ultrasound showing acute pancreatitis A total of 483 patients were diagnosed as acute pancreatitis, including 229 patients with mild acute pancreatitis, 187 patients with moderate severe acute pancreatitis and 67 patients with severe acute pancreatitis. 33 patients were randomly divided into experimental group (group a) and control group (group b). The control group was treated with routine therapy, and the experimental group was given neostigmine intramuscularly on the basis of routine therapy. Results: Among the 33 patients in this study, 24 (72.7%) were male and 9 (27.3%) were female, including 25 (75.3%) with severe acute pancreatitis. There were statistically significant differences (f = 19.410, P = 0.000) in the amount of feces measured at different time points. The amount of feces in the experimental group and the control group showed an upward trend. The amount of feces in the experimental group was higher than that in the control group (f = 8.509, P = 0.007). The amount of feces in the experimental group was higher than that in the control group on the first, second and third days after treatment. There was no significant difference between the experimental group and the control group at the other time points (p? 0.05). there was interaction between the experimental group and the control group (f = 3.756, P = 0.006). the intraabdominal pressure of the patients at different time points was statistically different (f = 35.820, P = 0.000). the intraabdominal pressure of the experimental group and the control group showed a gradual downward trend, and the experimental group and the control group showed a gradual downward trend. The intraabdominal pressure of the experimental group was lower than that of the control group on the third day (p = 0.036), and there was no significant difference between the experimental group and the control group at other time points (p? 0.05). There was no interaction between the experimental group and the control group (f = 1.250, P = 0.282). 24 hours, 48 hours, 72 hours of intra-abdominal pressure decreased percentage, within 72 hours of the standard rate (down to 12 mmHg below), found that 24 hours of the experimental group than the control group, the decline rate was statistically significant (f = 5.270, P = 0.029), the rest of the time point no statistical difference (p? 0.05). Two groups of patients reached intra-abdominal pressure level II patients in 15 cases, including 7 cases in the experimental group, 8 cases in the control group, after treatment. The decrease percentage of intra-abdominal pressure at 24, 48 and 72 hours, the time of reaching the standard within 72 hours and the time of lowering to grade I (15mmhg) in the experimental group were all better than those in the control group (p?0.05). The number of patients whose intra-abdominal pressure returned to normal on the fifth day in the experimental group was significantly higher than that in the control group (p=0.038), and there was no statistical significance at the other time points. There was no significant difference in the duration of organ failure between the two groups (p = 0.465). there was no significant difference in the duration of intensive care, total hospitalization and prognosis between the two groups (p? 0.05). conclusion: (1) neostigmine can improve the symptoms of paralytic intestinal obstruction in patients with acute pancreatitis; (2) neostigmine can reduce intraabdominal pressure I Intra-abdominal pressure in patients with grade I or above acute pancreatitis; (3) Neostigmine did not occur during the study; (4) Neostigmine had no significant advantage in reducing intra-abdominal pressure in patients with grade I acute pancreatitis as compared with conventional treatment; (5) Neostigmine was shown to improve the persistence of organ failure in patients with acute pancreatitis. Time, intensive care time, total hospitalization time and prognosis are limited. (6) Because the sample size of this study is small, there are some deviations in the experimental results, it is necessary to expand the sample size to demonstrate.
【學位授予單位】：南昌大學
【學位級別】：碩士
【學位授予年份】：2016
【分類號】：R576
【相似文獻】
相關期刊論文 前10條
1 宋學,宋國權;重癥胰腺炎并發(fā)癥的臨床分析(附17例報道)[J];中國急救醫(yī)學;2003年03期
2 李芳霞,吳世紅,王艷芳;75例急性胰腺炎并發(fā)癥分析[J];臨床醫(yī)藥實踐;2004年02期
3 白楊;急性胰腺炎的最初處理:最初72小時中的關鍵性問題[J];現代消化及介入診療;2005年01期
4 左玲,張靜,任其文;急性胰腺炎的并發(fā)癥及醫(yī)院感染分析[J];醫(yī)學理論與實踐;2000年07期
5 劉漪淪,朱立新;重癥急性胰腺炎并發(fā)癥的防治研究[J];河南醫(yī)藥信息;2001年14期
6 陳建;重癥急性胰腺炎的內鏡治療[J];山東醫(yī)藥;2002年22期
7 盧巖松 ,辛維藩 ,吳新民 ,郭亞民;重癥胰腺炎并發(fā)癥的探討[J];青海醫(yī)藥雜志;2002年12期
8 宋漢明,方青流;急性胰腺炎并發(fā)癥的臨床分析[J];皖南醫(yī)學院學報;2002年04期
9 薛艷云,耿焱;重癥胰腺炎26例臨床分析[J];中醫(yī)藥研究;2002年04期
10 周大勝,周嘉良,高敏;重癥急性胰腺炎并發(fā)癥的防治[J];肝膽胰外科雜志;2003年02期
相關會議論文 前9條
1 盧巖松;辛維藩;吳新民;郭亞民;;88例重癥胰腺炎并發(fā)癥的探討[A];中華醫(yī)學會第十一屆全國胰腺外科學術研討會論文匯編[C];2006年
2 錢鋮;劉明東;李運紅;鄒曉平;;急性胰腺炎450例臨床特征和診治分析[A];中華醫(yī)學會第七次全國消化病學術會議論文匯編（上冊）[C];2007年
3 廖家智;王家(馬龍);;美國急性胰腺炎臨床指南(治療部分)[A];2008年貴州省醫(yī)學會消化及內鏡學分會學術大會論文匯編[C];2008年
4 王中秋;盧光明;;重癥急性胰腺炎并發(fā)癥的CT研究[A];中華醫(yī)學會第16次全國放射學學術大會論文匯編[C];2009年
5 廖家智;王家(馬龍);;美國急性胰腺炎臨床指南(診斷部分)[A];2008年貴州省醫(yī)學會消化及內鏡學分會學術大會論文匯編[C];2008年
6 李新江;趙建輝;;急性胰腺炎早期大劑量補液的臨床觀察及治療體會[A];中華醫(yī)學會急診醫(yī)學分會第十六次全國急診醫(yī)學學術年會論文集[C];2013年
7 尹麗敏;李明;;烏司他丁治療急性胰腺炎30例[A];2011年全國醫(yī)藥學術論壇交流會暨臨床藥學與藥學服務研究進展培訓班論文集[C];2011年
8 王芳;張學燕;施小惠;;胰腺炎的辨證施護[A];甘肅省中醫(yī)藥學會2012年學術年會論文匯編[C];2012年
9 朱生j;黃天生;;清下解胰方治療重癥急性胰腺炎的臨床療效評價[A];中華中醫(yī)藥學會脾胃病分會第二十次全國脾胃病學術交流會論文匯編[C];2008年
相關重要報紙文章 前1條
1 王迪;胰腺炎陰云籠罩Byetta[N];醫(yī)藥經濟報;2008年
相關博士學位論文 前3條
1 劉厚佳;急性胰腺炎應用抗菌藥物的循證研究[D];第二軍醫(yī)大學;2006年
2 丁震;急性胰腺炎血腦屏障變化規(guī)律及影響因素[D];華中科技大學;2007年
3 潘小季;甘遂和低分子量肝素聯(lián)合應用治療重癥急性胰腺炎的實驗和臨床研究[D];中南大學;2006年
相關碩士學位論文 前10條
1 郭現芳;生長抑素治療中重度急性胰腺炎的系統(tǒng)評價[D];新疆醫(yī)科大學;2015年
2 孫英偉;中西醫(yī)結合治療急性胰腺炎療效及安全性的Meta分析[D];遼寧中醫(yī)藥大學;2015年
3 陳鵬;新斯的明對急性胰腺炎合并腹內高壓治療價值的臨床研究[D];南昌大學;2016年
4 王燕慧;蛋白酶抑制劑治療急性胰腺炎有效性和安全性的Meta分析[D];上海交通大學;2015年
5 高道鍵;重癥急性胰腺炎轉歸的早期相關因素分析[D];浙江大學;2005年
6 柏愚;中國急性胰腺炎流行病學調查（附6，，223例病例分析）[D];第二軍醫(yī)大學;2006年
7 崔志剛;急性胰腺炎發(fā)病特點及嚴重程度預測指標的研究[D];天津醫(yī)科大學;2004年
8 梁運嘯;重癥急性胰腺炎死亡危險因素分析[D];廣西醫(yī)科大學;2007年
9 葉聰;87例重癥胰腺炎臨床分析[D];浙江大學;2012年
10 宋新苗;急性胰腺炎新分類的再評價的多中心臨床研究[D];第二軍醫(yī)大學;2014年
本文編號：2203324
本文鏈接：http://www.sikaile.net/yixuelunwen/xiaohjib/2203324.html
最近更新
教材專著
