摘要目的:探讨重症急性胰腺炎相关急性呼吸窘迫综合征(SAP-ARDS)的临床特征及预测指标。方法:回顾性分析2000年1月至2020年1月间北京协和医院收治的313例SAP患者的临床资料，根据是否发生ARDS分为ARDS组(258例)和非ARDS组(55例)，根据ARDS严重程度进一步分为轻度ARDS组(165例)和中重度ARDS组(93例)。记录各组患者的临床症状、实验室检查及影像学结果，入住ICU时间及临床转归，患者局部和全身并发症，入院24 h的急性生理与慢性健康(APACHEⅡ)、急性胰腺炎严重程度床旁指数(BISAP)、CT严重程度指数(CTSI)、序贯器官衰竭(SOFA)及快速序贯器官衰竭(qSOFA)评分。采用单因素及多因素logistic回归分析SAP并发中重度ARDS的独立危险因素。绘制受试者工作特征曲线(ROC)，计算曲线下面积(AUC)，评估血WBC、超敏C反应蛋白(hsCPR)预测SAP并发中重度ARDS的价值，及APACHEⅡ、BISAP、CTSI、SOFA和qSOFA评分预测SAP-ARDS气管插管的价值。结果:ARDS组患者入住ICU时间显著长于非ARDS组[(8.3±11.6)d比(5.7±7.7)d]，病死率显著高于非ARDS组(12.4%比3.6%)，差异均有统计学意义( P<0.05)。单因素分析结果显示，入院时血WBC( OR 4.52，95% CI1.64~12.4)和hsCRP( OR 3.69，95% CI1.29~10.48)水平升高是预测SAP并发中重度ARDS的独立危险因素。WBC、hsCRP预测SAP并发中重度ARDS的AUC值分别为0.651(95 CI 0.532~0.770)、0.615(95 CI 0.500~0.730)，预测的临界值(Cut-off值)分别为17.5×10 9/L、159 mg/L，灵敏度分别为53.1%、78.1%，特异度分别为78.1%、48.4%。入院24 h的APACHEⅡ、BISAP、CTSI、SOFA和qSOFA评分预测气管插管的AUC值分别为0.739(95% CI 0.626~0.840)、0.705(95% CI 0.602~0.809)、0.753(95% CI 0.650~0.849)、0.737(95% CI 0.615~0.836)和0.663(95% CI 0.570~0.794)。Cut-off值分别为14、3、5、7、2分，灵敏度分别为58.8%、79.4%、73.5%、38.2%、45.5%，特异度分别为81.4%、60.0%、67.1%、98.6%、83.3%。 结论:入院时血WBC和hsCRP水平升高是预测SAP相关中重度ARDS的独立危险因素。入院24 h APACHEⅡ≥14分、BISAP≥3分、CTSI分≥5分、SOFA≥7分或qSOFA≥2分提示SAP患者接受气管插管的风险较高。

abstractsObjective:To explore the clinical characteristics and predictors of severe acute pancreatitis complicated with acute respiratory distress syndrome (SAP-ARDS).Methods:Clinical data of consecutive 313 SAP patients hospitalized from January 2000 to January 2020 in Peking Union Medical College Hospital, were retrospectively analyzed, including 258 cases with ARDS (ARDS group) and 55 cases without ARDS (non-ARDS group). According to the severity of ARDS, ARDS group were further divided into mild ARDS group (165 cases) and moderate to severe ARDS group (93 cases). Clinical symptoms, laboratory examination and imaging results, ICU admission time and clinical outcome, as well as the local and systemic complications, acute physiology and chronic health evaluation (APACHEⅡ) within 24 h after admission, bedside index for severity in acute pancreatitis (BISAP), CT severity index (CTSI), sequential organ failure assessment (SOFA) and quick sequenctial organ failure assessment(qSOFA) score were recorded. Univariate and multivariate logistic regression were performed to analyze independent risk factors of SAP complicated with moderate to severe ARDS. Receiver operating characteristics curves (ROC) was drawn to calculate area under the ROC curve (area under curve, AUC) and evaluate the performance of WBC and hsCRP in predicting SAP complicated with moderate to severe ARDS, and assess the performance of APACHEⅡ, BISAP, CTSI, SOFA and qSOFA scores in predicting SAP-ARDS endotracheal intubation.Results:The ICU length of stay and mortality rate of SAP-ARDS patients were significantly higher than those without ARDS [(8.3±11.6 day vs 5.7±7.7 day, 12.4% vs 3.6%, all P value <0.05)]. Univariate analysis showed that elevated WBC ( OR 4.52, 95% CI 1.64-12.4) and hsCRP ( OR 3.69, 95% CI 1.29-10.48) on admission were independent risk factors for moderate to severe ARDS with SAP. The AUC of WBC and hsCRP for predicting SAP with moderate to severe ARDS at admission were 0.651(95% CI 0.532-0.770) and 0.615 (95% CI 0.500-0.730), respectively. The predicted cut-off values (Cut-off values) were 17.5×10 9/L and 159 mg/L, respectively, and the sensitivity was 53.1% and 78.1%, the specificity was 78.1% and 48.4% respectively. The area under the ROC curve for APACHEⅡ, BISAP, CTSI, SOFA, and qSOFA score 24 h after admission in the early prediction of endotracheal intubation were 0.739 (95% CI 0.626-0.840), 0.705 (95% CI 0.602-0.809), 0.753 (95% CI 0.650-0.849 ), 0.737 (95% CI 0.615-0.836) and 0.663 (95% CI 0.570-0.794), and the optimum Cut-off values were 14 points, 3 points, 5 points, 7 points, 2 points, and the sensitivity and specificity for these predictors were 58.8% and 81.4%, 79.4% and 60.0%, 73.5% and 67.1%, 38.2% and 98.6%, 45.5% and 83.3%, respectively. Conclusions::Elevated blood WBC and hsCRP on admission were independent risk factors for moderate to severe ARDS in SAP. APACHEⅡ≥14, BISAP≥3, CTSI≥5, SOFA≥7, or qSOFA≥2 within the 24 h admission indictaed that the risk of SAP patients to receive endotracheal intubation was high.