Objective: To study the clinical characteristics of sepsis with systemic capillary leak syndrome(SCLS) and to evaluate the therapeutic effect and clinical significance of fluid therapy adjusted timely in these patients. Methods: The clinical data of 34 patients with sepsis and SCLS in the Department of Hepatobiliary Surgery ICU of General Hospital of People's Liberation Army General Hospital from July 2014 to January 2016 were retrospectively analyzed.There were 21 males and 13 females, aged from 21 to 74 years, with an average age of 56.3 years.Primary disease as follows: 18 cases with severe acute pancreatitis, 7 postoperative cases of subtotal hepatectomy, 5 postoperative cases of pancreatoduodenectomy, 4 postoperative cases of cholelithiasis.These patients were divided into survival group and death group according to their 28-day survival status.The clinical data including C-reactive protein(CRP), platelets (PLT), brain natriuretic peptide (BNP), the level of arterial blood lactic acid(LAC), oxygenation index(PaO2/FiO2, OI), net fluid balance(NFB) and norepinephrine dosage(NE) were collected and compared between two groups at three different intervals(day 1-3, day 4-6, day 7-9). The measurement data and numeration data were statistically analyzed with t test and χ2 test respectively to explore the inherent characteristics of the disease evolution and its clinical significance. Results: The survival group (n=23)and the death group(n=11)had no significant difference in the characteristics of basic clinical characters.The condition of the survival group and the death group were both in progress in 1-3 days period manifested as increased CRP(t=-0.473, P=0.640) and BNP levels(t=0.140, P=0.895), decreased PLT counts(t=-0.505, P=0.620) in the inflammatory response, decreased LAC(t=-1.008, P=0.320) and OI level (t=-2.379, P=0.020)in tissue perfusion index, and positive fluid balance(NFB: t=0.910, P=0.370), required NE(t=-0.853, P=0.400) to maintain effective perfusion pressure with systemic edema in both groups.There was no significant difference of all these clinical parameters between the two groups.The patients' condition of the survival group reached a plateau phase, whereas all relative indicators of the death group implied significant aggravation and deterioration of systemic infection(CRP: t=-3.438, P=0.000; PLT: t=1.649, P=0.110; BNP: t=-10.612, P=0.000), tissue perfusion (LAC: t=-11.305, P=0.000; OI: t=2.743, P=0.010)and tissue edema NFB(t=-4.257, P=0.000) and NE(t=-7.956, P=0.000) in 4-6 days period.In the last 7-9 days period the patients' condition of the survival group took a turn for improvement, yet the condition of the death group continued to deteriorate, refractory septic shock developed and multiple organ dysfunction syndrome followed afterwards inevitably(CRP: t=-10.036, P=0.000; PLT: t=6.061, P=0.000; BNP: t=-10.119, P=0.000; LAC: t=-24.466, P=0.000; OI: t=13.443, P=0.010; NFB: t=-8.345, P=0.000; NE: t=-7.121, P=0.000). Conclusions: The condition of patient with sepsis and SCLS would be improved markedly at the critical turning point around 7-9 days period since the effective systemic treatment began.If the infection does not be significantly constrolled and SCLS still remains in a sustained extravasation period in 7-9 days, the prognosis of these patients may be worse and the mortality may be higher than that of the patients mentioned before.
目的： 探讨脓毒症合并全身性毛细血管渗漏综合征(SCLS)的病程演变特点及适时调整的液体诊疗方案的治疗效果。 方法： 回顾性分析2014年7月至2016年1月解放军总医院肝胆外科重症监护病房收治的34例脓毒症合并SCLS患者的临床资料。男性21例，女性13例；年龄21～74岁，平均56.3岁。原发病：重症急性胰腺炎18例，肝大部切除术后7例，胰十二指肠术后5例，肝胆管结石行胆道探查T管引流术后4例。根据患者确诊后28 d的生存情况分为生存组(n＝23)和死亡组(n＝11)，比较两组患者在不同的治疗时间窗口C反应蛋白(CRP)、血小板计数(PLT)、脑利钠肽(BNP)、动脉血乳酸水平(LAC)、氧合指数(OI)、液体出入量(NFB)及去甲肾上腺素(NE)使用量等指标的变化差异。分别采用t检验和χ2检验分析计量资料和计数资料的差异。 结果： 生存组和死亡组在确诊脓毒症伴SCLS后1～3 d病情呈进展状态，炎症反应逐渐加重，表现为CRP(t＝－0.473，P＝0.640)和BNP水平(t＝0.140，P＝0.895)升高，PLT(t＝－0.505，P＝0.620)降低。组织灌注指标LAC水平(t＝－1.008，P＝0.320)和OI(t＝－2.379，P＝0.020)均有不同程度的下降，液体正平衡，均需NE维持有效灌注压，全身水肿明显，两组NFB(t＝0.910，P＝0.370)和NE(t＝－0.853，P＝0.400)差异均无统计学意义。第4～6天生存组达平台期，死亡组各指标呈恶化趋势，感染加重(CRP：t＝－3.438，P＝0.000；PLT：t＝1.649，P＝0.110；BNP：t＝－10.612，P＝0.000)，组织灌注进一步恶化(LAC：t＝－11.305，P＝0.000；OI：t＝2.743，P＝0.010)，NFB(t＝－4.257，P＝0.000)和NE(t＝－7.956，P＝0.000)呈较高水平。第7～9天生存组炎症反应减轻，CRP及BNP水平明显下降，PLT上升。液体治疗转为负平衡，组织水肿改善，各项指标趋于好转。死亡组继续恶化，脓毒性休克难以纠正，各器官不同程度衰竭(CRP：t＝－10.036，P＝0.000；PLT：t＝6.061，P＝0.000；BNP：t＝－10.119，P＝0.000；LAC：t＝－24.466，P＝0.000；OI：t＝13.443，P＝0.010；NFB: t＝－8.345，P＝0.000；NE：t＝－7.121，P＝0.000)。 结论： 有效的系统治疗7～9 d后脓毒症伴SCLS病情明显好转，应及时给予限制性液体治疗策略；若第7～9天感染未见好转，则患者预后较差，病死率增加。.
Keywords: Fluid therapy; Hemodynamics; Sepsis; Systemic capillary leak syndrome.