每日一题_2022.09.18

A 35-year-old woman is evaluated in the emergency department for fever, severe epigastric abdominal pain, and nausea that have worsened during the course of 12 hours. She denies any medical history; her father has a history of gallstones. Vital signs are: temperature 38.4°C (101.1°F), heart rate 115 beats/min, blood pressure 90/60 mm Hg, respiratory rate 19 breaths/min, oxygen saturation 93% on 2-L nasal cannula. After blood is drawn for laboratory testing, she is given 4 liters of lactated Ringer solution over four hours. She is also given IV hydromorphone, 1 mg, for pain, and vancomycin, 1 g, and cefepime, 2 g, for fever. An abdominal ultrasound is equivocal for gallbladder wall thickening, but shows pericholecystic fluid and a dilated pancreatic duct. The pancreas appears inflamed, but no necrosis or cyst is noted. Critical care service is consulted for severe pancreatitis. Vital signs after 4 liters of crystalloid are: temperature 38.9°C (102°F), heart rate 109 beats/min, blood pressure 110/75 mm Hg, respiratory rate 22 breaths/min, oxygen saturation 91% on 2-L nasal cannula. Laboratory testing reveals: blood urea nitrogen 45 mg/dL, creatinine 1.0 mg/dL, aspartate aminotransferase 235 U/L, alanine aminotransferase 129 U/L, amylase 2,023 U/L, bilirubin 2.9 mg/dL, lipase 4,320 U/L, white blood cell count 14,000/mm3, hemoglobin 15.5 g/dL, hematocrit 47%, platelets 450,000/mm3, lactate 2.1 mg/dL.

Which of the following principles applies to this patient’s management?

A. Immediate CT with contrast will provide the most prognostic information.

B. Empiric antibiotics should be continued, because they will decrease her risk of death.

C. Initially, she should be given bowel rest because enteral feeding may worsen prognosis.

D. Chest radiography may be helpful in determining her disease predicted mortality at 30 days.

E. Further IV fluids will decrease her risk of death.

答案解析：

急性胰腺炎使用最广泛的评分系统是急性生理和慢性健康评估 (APACHE) II，但它比较繁琐。 急性胰腺炎严重程度床边指数 (BISAP) 评分系统经过验证且更易于计算。 BISAP评分包括血尿素氮大于25、精神状态受损、全身炎症反应综合征、年龄>60岁和胸腔积液。 3分或更高的分数表明急性胰腺炎患者的死亡率显着增加。 该患者胸腔积液的存在使她的评分从 2 分变为 3 分，这增加了她 30 天的死亡率。 胸片还可以显示肺炎和急性呼吸窘迫综合征 (ARDS)； 它完成了临床图像。 腹部 CT 有助于坏死性胰腺炎的预后和风险分层，但腹部超声已经完成。 无需立即进行腹部 CT。

该患者群体具有显着的炎症反应，可以模拟感染性休克，但他们通常不需要经验性抗生素。 胰腺炎可以是无菌的、坏死的或感染的； 这些通常在临床表现方面彼此相似。 在没有其他混杂因素的情况下，美国胃肠病学会和美国胃肠病学协会的立场是在证实感染之前推迟使用抗生素。

多项研究表明，早期喂养可能会改善重症急性胰腺炎的预后； 建议是优化营养，因为它们的分解代谢状态。 该患者在重症监护会诊前接受了适当的液体推注，生命体征略有改善。 她可能需要进一步的容量负荷，但没有明显的迹象表明需要继续使用晶体液进行大容量复苏。 她还没有拍过胸片，而且她可能已经开始出现急性呼吸窘迫综合征。

正确答案：D