中国血液净化

中国血液净化 ›› 2016, Vol. 15 ›› Issue (12): 664-668.doi: 10.3969/j.issn.1671-4091.2016.12.004

• 临床研究 • 上一篇    下一篇

连续性静脉-静脉血液滤过联合血液灌流治疗急性胰腺炎时机的研究

罗建宇,王晓源,蒋文芳,吕光宇   

  1. 广西柳州市人民医院重症医学科
  • 收稿日期:2016-01-11 修回日期:2016-10-19 出版日期:2016-12-12 发布日期:2016-12-05
  • 通讯作者: 罗建宇 ljy613@126.com LUO Jian-yu E-mail:ljy613@126.com
  • 基金资助:

    血液灌流联合连续性血液滤过在脓毒症中的应用(广西壮族自治区卫生厅科研课题) (编号：Z 2014547); 广西壮族自治区临床重点专科建设资助项目

The optimal timing of continuous venovenous hemofiltration combined with hemoperfusion for the treatment of patients with acute pancreatitis

  • Received:2016-01-11 Revised:2016-10-19 Online:2016-12-12 Published:2016-12-05

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摘要： 目的探讨连续性静脉-静脉血液滤过(continuous venovenous hemofiltration，CVVH)联合血液灌流(hemoperfusion，HP)治疗急性胰腺炎的最佳时机。方法选取入住重症医学科的50 例经内科常规治疗48h 后病情无改善且继发器官功能障碍的急性胰腺炎患者，按随机数字表法将其分为A、B2 组各25 例。所有患者均行CVVH 联合HP，其中A 组治疗时机为继发一个器官功能障碍时开始，B 组治疗时机为继发两个器官功能障碍时开始进行。腹痛症状消失且器官功能改善(Marshall 评分至少上升1分)时停止CVVH+HP 治疗。对比2 组患者CVVH+HP 治疗前后的生理指标变化情况、疗效及预后情况。结果开始CVVH+HP 治疗距发病的时间A 组比B 组早[(69.3±5.4)h 比(89.4±6.9)h，t=11.446，P=0.000]；2 组患者APACHEII 评分治疗前对比差异无统计学意义(χ2=1.893,P=0.064)，治疗后均低于治疗前[A 组:
(10.5 ± 1.9) 比(15.7 ± 3.2)，t=10.157，P＜0.001；B 组:(13.6 ± 3.9) 比(17.4 ± 3.3),t=7.192,P=0.000]，并且治疗后A 组低于B 组(t=2.388，P=0.024)；28 天病死率A 组比B 组明显下降(12.0%比36.0%，χ2=3.947，P=0.047)；28 天手术率两组对比差异无统计学意义(12.0%比32.0%，χ2= 2.914，P=0.088)；ICU住院时间[(7.8±1.8)d 比(9.5±2.6)d，t=2.659，P=0.011]、机械通气时间[(5.6±1.6)d 比(7.0±2.4)d，t=2.385，P=0.021]、血液净化治疗总时间[(65.4±14.6)h 比(78.8±4.7)h，t=4.388，P=0.000]A 组明显短于B 组。2 组患者治疗后较治疗前氧合指数(A 组:t=10.715，P=0.000;B 组:t=11.634，P=0.000)、呼吸频率(A 组:t=11.974，P= 0.000; B 组: t=9.721，P=0.001)、血肌酐(A 组:t=13.910，P=0.000;B 组:t=13.939, P=0.000)、血乳酸(A 组:t=11.886，P=0.000;B 组:t=9.494，P=0.000)均明显改善，且上述指标A 组治疗后较B 组治疗后均明显改善(氧合指数:t=2.388，P=0.024;t=4.211，呼吸频率:P=0.008;血肌酐:t=4.823，P=0.006; 血乳酸:t=4.950，P= 0.004)。2 组患者治疗前后平均动脉压及心率对比差异无统计学意义(P＞0.05)。结论使用CVVH+HP 治疗急性胰腺炎效果显著，当急性胰腺炎继发一个器官功能障碍且常规治疗效果不佳时应尽早开始血液净化治疗。

关键词: 血液滤过, 血液灌流, 急性胰腺炎, 时机

Abstract: Objective To investigate the optimal timing of continuous venovenous hemofiltration (CVVH) combined with hemoperfusion (HP) for the treatment of patients with acute pancreatitis (AP). Methods A total of 50 AP patients treated in ICU with the disease conditions not improved after conventional treatment for 48 hours and the presence of secondary organ dysfunction were recruited for this study. They were randomly divided into group A (n=25) and group B (n=25). Group A received CVVH+HP in the presence of one organ dysfunction, and group B received CVVH+HP when dysfunctions of two organs emerged. The disappearance
of abdominal pain and the improvement of organ functions (Marshall score increased for at least one score) were the indicators for the discontinuing of CVVH + HP. Changes of physiological parameters, clinical efficacy and prognosis before and after CVVH+ HP were compared between the two groups. Results In group A, the period from onset to the treatment was significantly shorter than that in group B [(69.3±5.4)h vs. (89.4±6.9)h, t=11.446, P=0.000]. APACHE II score had no difference between the two groups before the treatment [(15.7±3.2) vs. (17.4±3.3), χ2=1.893, P=0.064]. The score became decreased after the treatment in both groups [(10.5±1.9) vs. (15.7±3.2), t=10.157, P=0.000 for group A; (13.6±3.9) vs. (17.4±3.3), t=7.192, P=0.000 for group B], and was lower in group A than in group B after the treatment [(10.5±1.9) vs. (13.6±3.9), t=2.388, P=0.024]. The mortality with 28 days was lower in group A than in group B (12.0% vs. 36.0%, χ2=3.947, P=0.047), but the rate of surgical treatment within 28 days had no difference between the two groups (12.0% vs. 32.0%, χ2= 2.914, P=0.088). Compared between groups A and B, length of stay in ICU [(7.8±1.8)d vs. (9.5±2.6)d, t=2.659, P=0.011], duration of mechanical ventilation [(5.6±1.6)d vs. (7.0±2.4)d, t=2.385, P= 0.021] and blood purification [(65.4±14.6)h vs. (78.8±4.7)h, t=4.388, P=0.000] were significantly shorter in group A. After the treatment, oxygenation index (OI) (t=10.715, P=0.000 for group A; t=11.634, P=0.000 for group B), respiratory rate (RR) (t= 11.974, P=0.000 for group A; t=9.721, P=0.001 for group B), blood serum creatinine (Scr) (t=13.910, P=0.000 for group A; t=13.939, P=0.000 for group B) and blood lactic acid (BLA) (t=11.886, P=0.000 for group A; t=9.494, P=0.000 for group B) improved in both groups, and the improvement was more significant in group A than in group B (t=2.388, P=0.024 for OI; t=4.211, P=0.008 for RR; t= 4.823, P=0.006 for Scr; t=4.950, P=0.004 for BLA). The mean arterial pressure (MAP) and heart rate had no differences before and after the treatment in both groups (P＞0.05). Conclusion CVVH+HP is an effective method for the treatment of patients with AP. The treatment should be initiated as soon as possible when conventional treatment fails and dysfunction of one organ appears.

Key words: Hemofiltration, Hemoperfusion, Acute pancreatitis, timing