摘要
目的探讨上尿路结石梗阻并发尿脓毒症的特点及急诊处理策略。方法回顾性分析安徽医科大学第一附属医院2018年1月至2019年12月收治的28例因上尿路结石致尿脓毒症患者的临床资料。男6例,女22例;中位年龄54(32~93)岁。均有发热,中位病程3(1~14)d,体温38.5~41.0℃。患者急诊入院时收缩压76~138 mmHg(1mmHg=0.133kPa),将收缩压<90 mmHg的患者定义为低血压组;收缩压≥90 mmHg者定义为正常血压组。低血压组12例,男3例,女9例;年龄中位值57(32~93)岁;左侧结石7例,右侧5例;结石位于输尿管上段5例、中段2例、下段4例,肾结石1例;结石长径中位值10(6~20)mm;合并糖尿病6例,神经系统疾病1例,近期有体外冲击波碎石术(ESWL)史3例。正常血压组16例,男3例,女13例;年龄中位值53(33~76)岁;左侧结石5例,右侧9例,双侧2例;结石位于输尿管上段10例、中段4例、下段2例;结石长径中位值10(8~14)mm;合并神经系统疾病3例,近期有ESWL史3例。两组年龄、性别、结石侧别、结石大小、结石位置的差异均无统计学意义(P>0.05),两组合并糖尿病比例的差异有统计学意义(P=0.024)。两组患者均急诊查血常规、C反应蛋白(CRP)、降钙素原等,行血、尿细菌培养,评估序贯器官衰竭(SOFA)评分,同时予经验性应用抗菌药物治疗,低血压者予扩容,扩容后血压仍低时加用血管活性药物。血压稳定后行集合系统减压治疗。比较两组感染指标及治疗方法的差异。结果低血压组与正常血压组的白细胞[16.34(2.55~41.65)×10^(9)/L与13.97(6.23~26.65)×10^(9)/L,P=0.577]、CRP[143.0(74.2~200.0)ng/ml与110.0(22.7~200.0)ng/ml,P=0.771]差异无统计学意义。低血压组与正常血压组的血小板[65.5(14.0~170.0)×10^(9)/L与73.0(17.0~412.0)×10^(9)/L,P=0.030]、降钙素原[95.5(26.5~200.0)ng/ml与57.6(1.0~200.0)ng/ml,P=0.040]差异均有统计学意义。低血压组与正常血压组SOFA评分[8.5(3.0~13.0)分与5.0(2.0~8.0)分,P=0.001]差异有统计学意义。低血压组双J管置入10例,肾造瘘2例;正常血压组双J管置入13例,肾造瘘3例,两组集合系统减压方式的差异无统计学意义(P=0.887)。低血压组有8例入重症监护室治疗。低血压组与正常血压组抗菌药物使用时间差异无统计学意义[8(3~12)d与5(3~7)d,P=0.453]。两组经集合系统减压、液体复苏和抗感染治疗等,脓毒症均治愈。结论上尿路结石梗阻并发尿源性脓毒症严重者可发生感染性休克,病情急、重、凶险,对其早期识别及干预非常重要。低血压患者较血压正常者有更高的降钙素原和SOFA评分,更低的血小板。及时行集合系统减压、扩容以及早期有效抗感染治疗至关重要。
Objective To investigate the characters and emergency treatment strategy of upper urinary tract stone obstruction complicated with urosepsis.Methods Clinical data of 28 cases of urosepsis,caused by upper urinary tract stone obstruction and arranged for emergency admission in our hospital during January 2018 to December 2019,were retrospectively analyzed.There were 6 males and 22 females.The median age was 54(32-93)years old.All patients had fever with the temperature ranged from 38.5 to 41.0℃.The median course of disease was 3(ranging 1-14)days.The systolic blood pressure ranged from 76 to 138 mmHg at admission.Hypotension group was defined as the systolic blood pressure<90 mmHg after admission.Normotensive group was defined as the systolic blood pressure≥90 mmHg.There were 12 cases in hypotension group,including 3 males and 9 females.The median age was 57(ranging 32-93)years old.The stones located at left side in 7 cases and right side in 5 cases.The stones located at the upper ureter in 5 cases,middle ureter in 2 cases,lower ureter in 4 cases and renal calculi in one case.The median length of the stone was 10(ranging 6-20)mm.Six cases suffered with diabetes mellitus.One case suffered with neuron system disease.3 cases have history of recent extracorporeal shock wave lithotripsy(ESWL).There were 16 cases in normotensive group,including 3 males and 13 females with the median age of 53(ranging 33-76)years old.The stones located at left side in 5 cases,right side in 9 cases and bilateral in 2 cases.The stones located at the upper ureter in 10 cases,middle ureter in 4 cases,lower ureter in 2 cases.The length of the stone was 10(ranging 8-14)mm.There were 3 cases with neurological diseases and 3 cases with recent ESWL history.There was significant difference between hypotension group and normotensive group in ration of diabetes mellitus(P=0.024).Blood routine examination,C-reactive protein(CRP),procalcitonin(PCT),blood and urine bacterial culture were performed in both groups.The patients were treated with empiric antibiotics after the evaluation based on the sequential organ failure assessment(SOFA).Patients with hypotension were given blood volume expansion,and vasoactive drugs were added when the blood pressure was still low.After the blood pressure was stable,the collection system decompression was performed.The difference of infection indicators and therapeutic methods between the two groups was compared.Results There was no significant difference in median WBC[16.34(2.55-41.65)×10^(9)/L vs.13.97(6.23-26.65)×10^(9)/L,P=0.577],median CRP[143.0(74.2-200.0)ng/ml vs.110.0(22.7-200.0)ng/ml,P=0.771]between hypotension group and normotensive group.The difference of PCT[95.5(26.5-200.0)ng/ml vs.57.6(1.0-200.0)ng/ml,P=0.040]and PLT[65.5(14.0-170.0)×10^(9)/L vs.73.0(17.0-412.0)×10^(9)/L,P=0.030]between hypotension group and normotensive group was statistically significant.The median SOFA scores of hypotension group and normotensive group were significantly different[8.5(3.0-13.0)vs.5.0(2.0-8.0),P=0.001].Ureteral stent placement was performed in 23 cases,and nephrostomy was performed in 5 cases.There was no significant difference in surgical drainage between the two groups(P=0.887).Eight patients in hypotension group were admitted to ICU.There was no significant difference in the duration of antibiotic use between hypotension group and normotensive group[8(3-12)d vs.5(3-7)d,P=0.453].Sepsis was cured in both groups after decompression,fluid resuscitation and antibiotic treatment.Conclusions In severe cases of upper urinary tract stone obstruction complicated with urogenic sepsis,septic shock may occur.The condition is urgent,severe and dangerous.Patients with hypotension had higher PCT and SOFA scores,and lower PLT.It is very important to carry out the collection system decompression drainage in time,liquid resuscitation,early effective antibiotic use.
作者
赵磊
王伟
王建忠
樊松
郝宗耀
梁朝朝
Zhao Lei;Wang Wei;Wang Jianzhong;Fan Song;Hao Zongyao;Liang Chaozhao(Department of Urology,the First Affiliated Hospital of Anhui Medical University,Hefei 230021,China)
出处
《中华泌尿外科杂志》
CAS
CSCD
北大核心
2021年第7期507-512,共6页
Chinese Journal of Urology
关键词
尿路结石
尿脓毒症
特点
急诊治疗
Urinary calculi
Urosepsis
Characters
Emergency treatment
