恒压灌注下经皮肾镜取石术后尿源性脓毒血症危险因素分析与防治策略

发布时间：2018-08-12 16:45

【摘要】：目的:探讨恒压灌注下PCNL术后尿源性脓毒血症的危险因素及防治策略。方法:回顾性分析496例我院行PCNL术患者的临床资料。术中灌注泵压力均为30kpa,分别对患者年龄、性别、术前尿培养、结石面积、鹿角形结石、手术时间、术中灌注液体量、狭窄盏颈型结石与术后尿源性脓毒血症发生率的相关性进行分析。结果:496例恒压灌注下行PCNL的患者术后发生尿源性脓毒血症者16例,发病率为3.2%。单因素分析显示:尿源性脓毒血症组在女性、结石面积(800mm2)、术前尿培养阳性、手术时间(90min)、术中灌注液体量(20L)、狭窄盏颈型结石这些因素与对照组比较存在显著性差异(P0.05)。多因素Logistic回归分析显示:术前尿培养阳性、结石面积(800mm2)、手术时间(90min)和狭窄盏颈型结石是PCNL术后发生尿源性脓毒血症的独立危险因素(P0.05)。结论:在恒定压力灌注下,术前尿培养阳性、结石面积(800mm2)、手术时间(90min)、狭窄盏颈型结石是经皮肾镜取石术后发生尿源性脓毒血症的独立危险因素。此外,女性、灌注液体量20L也与恒压灌注下PCNL术后尿源性脓毒血症发生有关。鉴于这些危险因素的存在,我们应该做到:(1)术前发现尿培养阳性者,应积极抗感染治疗,必要时先留置双J管或肾造瘘管,待感染控制再行手术;女性患者,提高警惕;重视患者的基础疾病,严格控制病情。(2)术中应严格控制手术时间、减少灌注量,必要时分期手术;处理狭窄盏颈型结石时,扩张盏颈后,尽量将peel-away鞘置入盏内,保证灌注液回流通畅;酌情应用糖皮质激素及利尿剂。(3)术后保证引流通畅。当PCNL术后发生尿源性脓毒血症时,立即抗感染及液体复苏,病情加重时,还要使用血管活性药物、缩血管药物和激素等,尽早转移至ICU治疗。
[Abstract]:Objective: to investigate the risk factors and prevention and treatment of urinary sepsis after PCNL under constant pressure perfusion. Methods: the clinical data of 496 PCNL patients in our hospital were analyzed retrospectively. The intraoperative pump pressure was 30 kpa.An age, sex, urine culture before operation, stone area, antler calculi, operative time, intraoperative fluid volume were measured, respectively. The relationship between the incidence of urinal sepsis and the incidence of calyceal stricture calculi was analyzed. Results there were 16 cases of urogenic sepsis after PCNL under constant pressure perfusion in 16 cases, and the incidence was 3.2%. Univariate analysis showed that there were significant differences between female and control group in urogenic sepsis group (800mm2), positive urine culture before operation, operation time (90min), intraoperative fluid volume (20L) and narrow calyceal calculus (P0.05). Multivariate Logistic regression analysis showed that positive urine culture before operation, stone area (800mm2), operation time (90min) and calyceal stricture stone were independent risk factors of urinary sepsis after PCNL (P0.05). Conclusion: under constant pressure perfusion, positive urine culture before operation, stone area (800mm2), operation time (90min) and narrow calyceal calculi are independent risk factors for urogenic sepsis after percutaneous nephrolithotomy. In addition, 20 L perfusion volume in women was also associated with urogenic sepsis after PCNL under constant pressure perfusion. In view of the existence of these risk factors, we should: (1) those who found positive urine culture before operation should be actively treated with anti-infection, if necessary, double J tube or nephrostomy tube should be placed first, and then the infection control should be performed again, and the female patients should be on their guard; Attention should be paid to the basic diseases of the patients and the condition should be strictly controlled. (2) the operative time should be strictly controlled during the operation, the perfusion should be reduced, and the operation should be carried out by stages when necessary, and when the narrow calyceal calculi were treated, the peel-away sheath should be placed into the calyx after dilatation of the calyx neck. Ensure the flow of perfusion fluid unobstructed; use glucocorticoid and diuretic as appropriate. (3) ensure smooth drainage after operation. When urogenic sepsis occurs after PCNL, immediate anti-infection and fluid resuscitation, as well as the use of vasoactive drugs, vasoconstrictors and hormones, should be used to transfer to ICU as soon as possible.
【学位授予单位】：南昌大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R699

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