【作者】 吴海洋；

【导师】 李恭会；

【作者基本信息】 浙江大学 ， 腔内泌尿外科学， 2012， 博士

【摘要】 本课题研究目的是为了确定上尿路腔内碎石致急性感染性休克的早期预警指标变化,从而为临床尽早诊断、早处理提供依据。研究方法：建立肾盂内高压合并感染致急性感染性休克的动物模型来模拟上尿路腔内碎石致急性感染性休克的发病过程,分析动物模型建立后生命体征及血液指标变化,发现急性感染性休克的早期指标变化,进行早期预警分析。另一方面回顾性分析临床上尿路腔内碎石术致急性感染性休克的病例资料,统计分析临床资料各数据,结合动物模型结果及临床实际情况,确定手术后发生急性感染性休克的早期指标变化,尽早作出预警判断。我们通过动物实验及临床研究发现,肾盂内高压合并感染致急性感染性休克动物模型和临床上尿路腔内碎石术致急性感染性休克患者资料,均提示术后2小时内血白细胞和(或)中性粒细胞一过性明显急剧性下降至正常值以下,甚至出现在临床表现和生命体征变化之前。而术后4小时,血白细胞和(或)中性粒细胞开始逐渐升高,术后12小时均高于正常值上界。术后2小时血内血内毒素及TNFα的测定显示急剧性升高,4小时后开始逐步下降。同时,动物实验显示,肾盂内注入大肠杆菌浓度越高,白细胞或粒细胞下降越低,动物血压下降越明显,且死亡率越高。我们得出结论,术后2小时内血白细胞或中性粒细胞急剧性下降是上尿路腔内碎石致急性感染性休克早期预警的最为简单有效的客观指标,术后2小时内血内毒素及TNFα的测定对术后感染性休克的预测亦有重要的意义。同时血白细胞或粒细胞下降程度与肾盂内高压合并感染致急性感染性休克的病情严重程度呈正相关。一旦发现术中或术后血白细胞或中性粒细胞急剧性下降,表明术后发生急性感染性休克的概率明显增高,需尽早积极处理。本课题创新之处在于通过动物实验和临床资料分析证实,术后早期血白细胞和(或)中性粒细胞急剧性下降是腔内碎石术致急性感染性休克的最为简单有效的客观早期预警指标。术后2小时内血内毒素及TNFa的测定对术后感染性休克的预测有重要的意义。同时,血白细胞或粒细胞下降程度与感染的严重程度呈正相关。第一部分肾盂内高压合并感染致急性感染性休克动物模型的建立及早期预警研究目的：建立肾盂内高压合并感染致急性感染性休克的动物模型,并分析相关早期预警指标。方法：新西兰兔分对照组(A)、实验组(B、C、D、E),对照组按2ml/kg肾盂内注入生理盐水,实验组按2ml/kg肾盂内注入标准大肠杆菌株,浓度分别为1.5×108cfu/ml(B组)、3.0×108cfu/ml(C组)、6.0×108cfu/ml(D组)、9.0×108cfu/ml(E组)。分别测定术前术后平均动脉压(MAP)、体温及血白细胞、中性粒细胞水平,ELISA法测定血浆内毒素、TNFα、IL1β、C-反应蛋白(CRP)水平。实验动物脏器行病理切片检查,并分析对照组及各实验组死亡率。结果行统计学分析,组内比较进行T检验,组间比较采用单因素方差分析。结果：动物模型中,发现对照组(A)、实验组B、C,术后各时间段平均动脉压(MAP)下降不明显。而实验D、E, MAP在术后的1小时及之后各时间段明显下降。而体温变化,与对照组相比,各实验组,除E组外,各组术后体温呈逐步上升过程。E组术后2小时体温与术前相比,呈一过性下降,之后逐步上升术后12小时自然死亡率,D组为16.7%(1/6),E组为37.5%(3/8)；3天自然死亡率,D组为50%(3/6),E组为62.5%(5/8)。而其余各组术后3天生存率均为100%。术后实验组死亡新西兰兔各脏器病理切片提示,肺、肝、病肾、及心肌均可见明显弥漫性出血病灶,尤其肺、肝及病肾内可见广泛的炎性粒细胞浸润。证实实验组新西兰兔死于全身多脏器功能衰竭。内毒素对照组术前、后无明显变化,而各实验组术后2小时均明显高于术前,之后逐步回落。TNFα除对照组外,各实验组术后2小时呈急剧性增高后逐步回落。而IL1β及CRP与术前相比,对照组及各实验组未见明显变化。血白细胞或中性粒细胞,除对照组外,各实验组术后2小时内均呈下降趋势,且D、E组白细胞绝对值低于3×109/L,粒细胞低于2×109/L,而之后血白细胞及中性粒细胞开始逐步上升。同时,实验显示,肾盂内注入大肠杆菌浓度越高,白细胞或粒细胞下降越低,动物血压下降越明显,且死亡率越高。结论：当肾盂内以2ml/kg注入标准大肠杆菌浓度为6.0×108cfu/ml、9.0×108cfu/ml时,可以得到一个相对稳定的肾盂内高压致急性感染性休克动物模型,可以用于模拟临床上尿路腔内碎石致急性感染性休克的病变过程。术后2小时内血内毒素及TNFα的测定对术后感染性休克的预测有重要的意义。术后2小时内血白细胞和(或)中性粒细胞急剧性下降在肾盂内高压合并感染致急性感染性休克的病程中,可以作为最简单、理想的早期预警指标。而且,血白细胞或粒细胞下降程度与病情严重程度呈正相关。第二部分上尿路腔内碎石术致急性感染性休克的回顾性分析及早期预警研究目的：分析上尿路腔内碎石术致急性感染性休克的临床特征,探讨其相关早期预警指标变化。方法：回顾性分析2005年1月至2011年10月上尿路腔内碎石术的临床资料,包括经皮肾镜543例及输尿管镜碎石术1802例,总共2345例,男1452例,女893例。术后发生急性感染性休克患者共10例,年龄30-58岁,平均45.3岁。分别收集并分析患者术前及术后各时间段的血压、脉搏等临床指标,及血常规、超敏C反应蛋白等实验室指标变化。SIRS的诊断标准：1.体温>38℃/<36℃；2.心率>90次/分；3.呼吸>20次/分,或过度通气,动脉血PaCO2<32mmHg;血白细胞>12×109/L或<4×109/L或未成熟中性粒细胞>10%。满足以上2点即可诊断SIRS,作为早期判断术后感染严重性的指标。感染性休克的诊断标准：SIRS+收缩压<90mmHg(1mmHg=O.133kPa)或舒张压<40mmHg。诊断为感染性休克后立即进行抗休克治疗,根据细菌培养结果使用敏感抗生素抗感染治疗,未获得细菌培养结果者经验性应用广谱抗生素。结果：本组10例患者中女性9例,男性1例。均在术后2至6h内出现急性感染性休克的临床表现,表现血压下降,呼吸急促,血氧饱和度下降。患者平均动脉压(MAP)术后2h与术前相比下降不明显,而术后6h则下降明显(P<0.05)。血白细胞(WBC)及中性粒细胞(NE)术后2h与术前相比明显下降(P<0.05),绝对值平均分别为<3×109/1及<2×109/1；而术后12h与术前相比则明显上升(P<0.05),平均绝对值均>10×109/1。血红蛋白(HGB)及血小板(PLT)术后2h、12h与术前相比均明显下降(P<0.05)。超敏C反应蛋白(CRP)术后6小时内升高不明显,但术后12小时开始明显升高(P<0.001)。所有患者,均予积极抗休克、抗感染等抢救治疗。8例患者经治疗后,于术后7-14天出院。1例患者全身多脏器功能衰竭,治疗42天后病情平稳出院,1例抢救无效,于术后19小时后死亡。结论：上尿路腔内碎石术后发生急性感染性休克,是严重的并发症,多在术后6小时内出现。CRP在6h内无显著变化,而血白细胞或粒细胞急剧下降均发生于术后2h内。因此,血白细胞或粒细胞是其早期发生的实验室最为重要的变化指标之一。尽早诊断是抢救成功的关键。更多还原

【Abstract】 The objective of the paper is studying acute septic shock following endoscopic lithotripsy for upper tract stone, and find the change of early indicators.The methods are establishing a animal model of renal pelvic high pressure with infection. The animal model will imitate the clinical pathogenesis of septic shock after endoscopic lithotripsy for upper urinary tract calculi. We analyzed the indicators of the animal model, and find the the change of early indicators. And the other hand, we retrospective the clinical data about septic shock post operation of endoscopic lithotripsy for upper urinary tract stones. To combine the data of animal model, we want to find the change of early indicators.The animal models of renal pelvic high pressure with infection and clinical data about septic shock post operation of endoscopic lithotripsy for upper urinary tract stones showed the white blood cell and neutrophil were sharp declined two hours after operation. With times going, the animal model showed the WBC and neutrophil were ascending gradually from four hours post-operation. And the clinical data showed the amount of mean leukocyte and neutrophil were obviously ascended twelve hours comparing with pre-operation. The animal model showed the lower WBC or netrophil was, the more obviously MAP decreased with higher mobidity was, when higher concertration of E.coil were injected in to renal pevis. We concluded the WBC and neutophil are the objective early warning indicators of acute septic shock following endoscopic lithotripsy for upper tract stones. Once the WBC and neutrophil were sharp declined during or post-operation, we need high alerting the occurring of acute septic shock post-operation. The decrease levels of WBC or neutrophil is positively related to the severity of acute septic shock followed by renal pelvic high pressure with infection.Part one:Establishing a animal model and study on prediction of acute septic shock following renal pelvic high pressure with infectionObjective:To establish a animal model of acute septic shock following renal pelvic high pressure with infection, and find the change of early indicators.Methods:New Zealand rabbits were divided into5groups as control group (A) and experiment groups(B, C, D, E). Group A was injected saline to renal pelvis by2ml/kg. Groups B, C, D and E were injected E.coli1.5×108cfu/ml,3.0×108cfu/ml,6.0×108cfu/ml,9.0×108cfu/ml, respectively. Mean arterial pressure(MAP), rectal temperature were recorded and white blood cell as well as neutrophil level were counted by flow cytometry and the plasma level of endotoxin, TNFα、ILβ、C-response protein weren determined by ELISA before and after the operation. Pathological biopsy of related organs was performed and mortality differences between control group and experiment ones were analyzed. All results were statistically analyzed by t test and one-way ANOVA.Results:There was no obvious difference of MAP between pre-operation and post-operation in A, B and C groups. But MAP was obvious declined one hour after operation in D and E groups. The rectal temperature were ascended gradually post-operation in A, B, C, D groups. But the temperature was declined two hours post-operation in E group compared with pre-operation, and then it was asecending gradually.The mortality of12h after operation for group D was16.7%(1/6), for group E was37.5%(3/8), while the mortality of3days after operation for group D and E were50%(3/6) and62.5%(5/8)respectively。For other3groups, All rabbits were alive3days after operation.Pathological biopsy showed diffuse hemorrhage in lung, liver, operative kidney and cardiac muscle. And there are diffuse and serious inflammatory infiltration in lung, liver and operative kidney. The results confirmed the rabbits died for multiple organ dysfunction.The endotoxin and TNFa levels were ascended two hours after operation and then declined gradually in every experiment groups but not control group. Neither of IL1β or CRP level had obvious change in each groups.The white blood cell and neutrophil were sharp declined two hours after operation in group B, C, D, E but not group A. And the mean amount of WBC and neutrophil of D and E groups were less than3×109/L and2×109/L, respectively two hours after operation. The WBC and neutrophil were ascending gradually from four hours post-operation in all experiment groups. The results showed the lower WBC or netrophil was, the more obviously MAP decreased with higher mortality was, when higher concertration of E.coil were injected into renal pevis.Conclusions:We successfully established a stable model of acute septic shock following endoscopic lithotripsy for upper tract stone when the renal pelvis were injected E.coli6.0×108cfu/ml or9.0×108cfu/ml by2ml/kg. To certain extend, measuring endotoxin and TNF-a was helpful. Amount of Leukocyte and neutrophil were always sharply declined in patients in two hours after operation which are a perfect earlier indicator for urosepsis. The decrease levels of WBC and neutrophil are positively related to the severity of acute septic shock. Part two:Retrospective analysis and Study on prediction of acute septic shock following endoscopic lithotripsy for upper tract stonesObjective:To investigate clinical charicteristics and early indicators of acute septic shock after endoscopic lithotripsy for upper urinary tract calculi.Methods:A clinical data was retrospective analyzed collected10cases of septic shock after endoscopic lithotripsy including uroscopic lithotripsy and percutaneous nephrolithotripsy for upper urinary tract calculi from January2005to October2011. There are2345cases who accepted endoscopic lithotripsy including1802cases for uroscopic lithotripsy and543cases for percutaneous nephrolithotripsy. The age of ten cases ranged from30to58years old with average45.3years old. We collected the data of ten patients’blood pressure, heart rate, blood routine, high-sensitivity c-reactive protein(CRP), etc. SIRS was diagnosed in patients who met two or more of the following four criteria:1. body temperature lower than36℃or higher than38℃;2. heart rate greater than90beats/min;3. respiratory rate greater than20breaths/min or PaCO2less than4.3kPa; and4. white blood cell count (WBC) greater than12×109/L or less than4×109/L or immature neutrophil more than10%. Septic shock criteria:SIRS plus systolic pressure<90mmHg(1mmHg=0.133kPa) or diastolic pressure<40mmHg. When the patients were diagnosed as acute septic shock, they were accepted anti-shock therapy and adjust the antibiotics by the result of urine and blood culture. Results:The mean arterial pressure (MAP) did not change obviously two hours post-operation comparing with pre-operation, while the MAP obviously decreased six hours post-operation comparing with pre-operation (P<0.05). Heart rate were ascended two hours post-operation (P<0.05). Amount of mean leukocyte and neutrophil were less than3×109/L and2×109/L respectively in2hours after operation. And the amount of mean leukocyte and neutrophil were obvious declined comparing with pre-operation (P<0.001). But the amount of mean leukocyte and neutrophil were obviously ascended twelve hours comparing with pre-operation (P<0.05). The amount of mean hemoglobin was declined two or twelve hours post-operation comparing with pre-operation as well as platelet (P<0.05). CRP was no obviously ascended six hours post-operation camparing with pre-operation, but it was obvious ascended twelve hours post-operation (P<0.001). All the cases were accepted anti-shock and antibiotics.Eight cases were fully recovered after7-14days after operation, respectively.1patient with multiple organ dysfunction syndrome (MODS) was discharged42days post operation. And1patient died19hours post operation.Conclusions:Septic shock is one of serious complications after endoscopic lithotripsy for upper urinary tract calculi. The patients were diagnosised as urosepsis according to the clinical manifestation in six hours post-operation. CRP had no obvious change in6hours post-operation. Amount of Leukocyte was always less than3×109/L in patients in2hours after operation which is an earlier indicator for urosepsis. The key to the successful treatment is early diagnosis and proper treatmeat for urosepsis.更多还原