中国血液净化 ›› 2016, Vol. 15 ›› Issue (08): 396-400.doi: 10.3969/j.issn.1671-4091.2016.08.004

• 临床研究 • 上一篇    下一篇

连续性血液净化治疗危重疾病合并严重ARDS的临床研究

周瑞祥,戴伟   

  1. 武汉市第一医院重症医学科一病区
  • 收稿日期:2016-01-05 修回日期:2016-06-26 出版日期:2016-08-12 发布日期:2016-07-12
  • 基金资助:

    2015 年湖北省卫生计生西医类一般项目(WJ2015MB240);2015 年武汉市临床医学科研项目(WX15A09)

Clinical study of CRRT on critical disease patients combined with ARDS.

  • Received:2016-01-05 Revised:2016-06-26 Online:2016-08-12 Published:2016-07-12

摘要: 目的探讨连续性血液净化治疗对危重疾病合并严重ARDS 患者的血流动力学、呼吸力学和预后的影响。方法危重疾病合并严重急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)患者68 例,随机分为治疗组(给予连续性血液净化治疗)和对照组(不给予连续性血液净化治疗),每组34 例。在连续性血液净化治疗开始及治疗后24、48、72h,观察两组患者治疗前后临床生化、危重评分、血浆和超滤液中炎性因子水平、临床指标;监测两组患者血流动力学和呼吸力学参数。结果治疗后72h,治疗组白细胞计数(t=2.456,P=0.039)、降钙素原(t=2.508,P=0.037)、内毒素(t=2.546,P=0.036)、尿素氮(t=2.361,P=0.043)、血肌酐(t=2.135,P =0.048)、丙氨酸转氨酶(t=2.387,P =0.041)、N 末端脑钠肽前体(t=2.316,P =0.045)较对照组下降显著,尿量较对照组显著升高(t=2.223,P=0.047);治疗组患者心脏指数(t =2.391,P=0.041)、胸腔内血容量指数(t=2.317,P=0.045)、全心舒张末期容积指数(t=2.234,P=0.047)、血管外肺水指数(t=2.379,P=0.041)、肺血管通透性(t=2.216,P=0.047)和乳酸(t=2.297,P=0.046)较对照组显著下降,而氧合指数较对照组显著升高(t=2.484,P=0.038);治疗组气道峰(t=2.310,P=0.045)、气道平台压(t=2.384,P=0.041)、气道平均压(t=2.351,P=0.043)、有效静态总顺应性(t=2.230,P=0.047)较对照组显著降低;治疗组血浆炎性因子如肿瘤坏死因子-a(tumor necrosis factor- a、TNF- a) (t=2.495,P=0.037)、白细胞介素- 6(interleukin- 6、IL- 6) (t=2.392,P=0.041)较对照组显著降低,治疗组超滤液中可检测到炎性因子(TNF-α、IL-6),与血浆水平下降趋势基本一致;治疗组急性生理与慢性健康评分Ⅱ(t=2.452,P=0.039)、多器官功能综合征(multiple organ dysfunction syndrome,MODS)评分(t=2.487,P=0.038)、Murray 肺损伤评分(t=2.460,P=0.039)和全身炎症反应综合征评分(t=2.320,P=0.045)较对照组显著降低。治疗2 周后,治疗组患者MODS 发生率(χ2=4.542,P=0.037)、死亡率(χ2=4.032,P=0.045)、机械通气时间(t=2.367,P=0.040)、住ICU 时间(t=2.389, P=0.041) 均明显低于对照组。结论连续性血液净化治疗能降低炎症因子水平,改善危重疾病合并严重ARDS患者的血流动力学、呼吸力学状况,提高患者预后。

关键词: 危重疾病, ARDS, 连续性血液净化, 临床指标

Abstract: Objective To observe the effect of continuous renal replacement therapy (CRRT) on prognosis, hemodynamics and respiratory mechanics in critical disease patients combined with ARDS. Methods A total of 68 critical disease patients combined with ARDS were randomized into control group (n=34) and CRRT group (n=34). They were all received conventional therapy. Patients in CRRT group underwent continuous veno- venous hemofiltration (CVVH) as well at the earlier disease stage. Blood biochemistry, critical scores (APACHEⅡ, MODS, Murray lung injury and SIRS), inflammatory cytokines (TNF-α and IL-6) in serum and ultrafiltrate, parameters of hemodynamics and respiratory mechanics, and clinical indicators (MODS rate, fatality, duration of mechanical ventilation, length of stay in ICU) were observed at 24, 48 and 72 hours after CVVH. Results In CRRT group after CRRT for 72h, clinical and biochemical indicators, parameters
of hemodynamics and respiratory mechanics, levels of inflammatory cytokines, and critical scores tended to be improved. When comparisons were made between CRRT group and control group, WBC (t=2.456, P= 0.039), procalcitonin (t=2.508, P=0.037), endotoxin (t=2.546, P=0.036), BUN (t=2.361, P=0.043), SCr (t= 2.135, P=0.048), ALT (t=2.387, P=0.041), and NT- proBNP (t=2.316, P=0.045) decreased significantly and urine volume increased significantly (t=2.223, P=0.047) in CRRT group; cardiac index (t=2.391, P=0.041), intrathoracic blood volume index (ITBVI) (t=2.317, P=0.045), global end diastolic volume index (GEDVI) (t= 2.234, P=0.047), extravascular lung water index (EVLWI) (t=2.379, P=0.041), pulmonary vascular permeabili-ty index (PVPI) (t=2.216, P=0.047), and lactic acid (LAC) (t=2.297, P=0.046) decreased significantly in CRRT group; while oxygenation index (t=2.484, P=0.038) increased significantly in CRRT group; peak inspiratory pressure (PIP) (t=2.310, P=0.045), plateau airway pressure (Pplat) (t=2.384, P=0.041), mean pressure of airway (MPaw) (t=2.351, P=0.043), and effective static compliance (Cst) (t=2.230, P=0.047) decreased significantly in CRRT group; serum TNF-α (t=2.495, P=0.037) and IL-6 (t=2.392, P=0.041) decreased significantly in CRRT group, and TNF-α and IL-6 were found in ultrafiltrate; scores of APACHEⅡ (t=2.452, P = 0.039), multiple organ dysfunction syndrome (MODS) (t=2.487, P=0.038), Murray lung injury (t=2.460, P= 0.039) and systemic inflammatory response syndrome (SIRS) (t=2.320, P=0.045) decreased significantly in CRRT group. After the treatment for 2 weeks, the prevalence of MODS (χ2=4.542, P=0.037), fatality (χ2= 4.032, P=0.045), length of stay in ICU (t=2.389, P=0.041), duration of mechanical ventilation (t=2.367, P= 0.040) were lower in CRRT group than in control group. Conclusion CRRT can decreased the levels of inflammatory cytokines, reverse the abnormal hemodynamics and respiratory mechanics, and improve the prognosis
in critical disease patients combined with ARDS.

Key words: critical disease, ARDS, CRRT, clinical indicators