血液灌流联合连续性血液滤过在脓毒症患者中的临床应用观察
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摘要
目的观察血液灌流(hemoperfusion,HP)联合连续性静脉-静脉血液滤过(continuous venovenous hemofiltration,CVVH)治疗脓毒症患者的临床疗效、安全性。方法选取70例符合脓毒症标准的重症医学科患者,按随机数字表法将其分为A、B两组,各35例。A组患者在内科治疗基础上联合CVVH治疗,B组在内科治疗基础上采用HP联合CVVH治疗。结果 A组治疗120 h时超敏C-反应蛋白(hs-CRP)、肿瘤坏死因子α(TNF-α)、白细胞介素6(IL-6)和降钙素原(PCT)、脂多糖(LPS)均有下降(P<0.05);B组治疗第72、120小时上述指标均有下降(P<0.05),且B组比A组相比下降更显著(P<0.05)。治疗120 h时两组患者平均动脉压(MAP)较前均有改善(P<0.05),但两组对比无明显差异(P>0.05);B组治疗120 h时的心率(HR)、血管活性药物评分(VIS)、氧合指数(OI)、急性生理学和慢性健康评分II(APACHEⅡ)、序贯性器官功能评分(SOFA)均有下降(P<0.05),且B组比A组相比下降更显著(P<0.05)。两组患者血肌酐(Scr)、总胆红素(TBIL)治疗后均呈下降趋势(P<0.05),但两组同时间点对比无明显差异(P>0.05)。两组患者血液净化时间、严重出血事件发生率、28 d死亡率无明显差异(P>0.05),ICU住院时间、机械通气时间B组短于A组(P<0.05),ICU死亡率B组小于A组(P<0.05)。结论 HP联合CVVH治疗脓毒症患者与单纯CVVH治疗相比能够更有效清除炎症介质,改善脏器功能及预后,出血并发症发生率无明显增加。
Objective To observe the clinical efficacy and safety of hemoperfusion(HP) therapy combined with continuous venovenous hemofiltration(CVVH) for patients with sepsis.Methods A total of 70 ICU patients meeting the sepsis criteria was selected to divide into two groups(group A and B,35 patients for each group) based on the random number table method.The patients in group A were treated in combination with CVVH on the basis of the medical treatment,and the ones in group B received combination of HP with CVVH on the basis of the medical treatment.Results In group A,the hypersensitivity C-reactive protein(hs-CRP),tumor necrosis factor a(TNF-a),interleukin 6(IL-6) and calcitonin protoxin(PCT) and lipopolysaccharide(LPS) decreased in at 120 h of treatment(P<0.05).In group B,the above indexes decreased at 72 h and 12 h of treatment,and the decrease for group A was more significant than that for group A(P<0.05).The mean arterial pressure(MAP) was improved in the two groups(P<0.05) at 120 h of treatment,but there was no significant difference between the two groups(P>0.05).In group B,at 120 h of treatment,heart rate(HR),vasoactive-inotropic score(VIS),oxygenation index(OI),acute physiology and chronic health evaluation(APACHE II) score and sequential organ failure assessment score(SOFA) were all decreased(P<0.05),and the decrease for group B was more significant than for group A(P<0.05).After treatment,the levels of blood serum creatinine(Scr) and total bilirubin(TBIL) decreased in both groups(P< 0.05),but there was no significant difference between the two groups at the same time point.There was no significant difference in blood purification time,incidence of serious bleeding events and 28-day mortality rate between the two groups(P>0.05);and,ICU hospitalization time and mechanical ventilation time in group B were shorter than those in group A(P<0.05),and ICU mortality rate in group B was smaller than that in group A(P<0.05).Conclusions Compared to alone CVVH,HP therapy combined with CVVH for patients with sepsis can remove inflammatory mediators more effectively and improve organ functions and prognosis,with no significant increase in incidence of the complication of bleeding.
Objective To observe the clinical efficacy and safety of hemoperfusion(HP) therapy combined with continuous venovenous hemofiltration(CVVH) for patients with sepsis.Methods A total of 70 ICU patients meeting the sepsis criteria was selected to divide into two groups(group A and B,35 patients for each group) based on the random number table method.The patients in group A were treated in combination with CVVH on the basis of the medical treatment,and the ones in group B received combination of HP with CVVH on the basis of the medical treatment.Results In group A,the hypersensitivity C-reactive protein(hs-CRP),tumor necrosis factor a(TNF-a),interleukin 6(IL-6) and calcitonin protoxin(PCT) and lipopolysaccharide(LPS) decreased in at 120 h of treatment(P<0.05).In group B,the above indexes decreased at 72 h and 12 h of treatment,and the decrease for group A was more significant than that for group A(P<0.05).The mean arterial pressure(MAP) was improved in the two groups(P<0.05) at 120 h of treatment,but there was no significant difference between the two groups(P>0.05).In group B,at 120 h of treatment,heart rate(HR),vasoactive-inotropic score(VIS),oxygenation index(OI),acute physiology and chronic health evaluation(APACHE II) score and sequential organ failure assessment score(SOFA) were all decreased(P<0.05),and the decrease for group B was more significant than for group A(P<0.05).After treatment,the levels of blood serum creatinine(Scr) and total bilirubin(TBIL) decreased in both groups(P< 0.05),but there was no significant difference between the two groups at the same time point.There was no significant difference in blood purification time,incidence of serious bleeding events and 28-day mortality rate between the two groups(P>0.05);and,ICU hospitalization time and mechanical ventilation time in group B were shorter than those in group A(P<0.05),and ICU mortality rate in group B was smaller than that in group A(P<0.05).Conclusions Compared to alone CVVH,HP therapy combined with CVVH for patients with sepsis can remove inflammatory mediators more effectively and improve organ functions and prognosis,with no significant increase in incidence of the complication of bleeding.
引文
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[10] 陈泽宇,刘俊,徐志坚,等.持续血液滤过联合血液灌流治疗脓毒症的临床效果观察[J].广西医学,2017,39(2): 258-260.
[11] 袁超,王夜明,李鲲,等.血液灌流联合血液滤过治疗脓毒症休克临床疗效观察[J].中国临床医生杂志,2015,9: 44-46.
[12] Singer M,Deutschman CS,Seymour CW,et al.The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)[J].JAMA,2016,315(8): 801.
[13] 孟晓丽,于冬梅,王巍巍.常规血液透析与血液灌流对终末期肾脏疾病患者微炎症状态的影响[J].临床肾脏病杂志,2015,15(8): 489-492.
[14] 张莉.早期应用持续高容量血液滤过联合血液灌流对严重脓毒症治疗效果观察[J].中华临床医师杂志(电子版),2012,6(4):3976-3980.
[15] 胡强,陈安宝,洪霞,等.血液灌流治疗过程中并发症的防治[J].临床急诊杂志,2008,9(3): 149-151.
[2] 尧国胜,黄高,覃晓结.血液滤过联合血液灌流救治脓毒症的临床疗效研究[J].河北医学,2015,21(5): 793-796.
[3] 滕琰,丁铭,李昊.血液灌流治疗脓毒症时对炎症因子的影响[J].昆明医科大学学报,2016,37(5):114-117.
[4] 中华医学会重症医学分会.中国严重脓毒症/脓毒性休克治疗指南[J].中华内科杂志,2015,54(6):557-581.
[5] 陆伟.血液灌流联合连续肾脏替代疗法治疗危重症合并急性肾衰竭的疗效观察[J].现代中西医结合杂志,2015,(13): 1427-1429.
[6] 陈志琴,李继鹏.血液灌流联合高容量血液滤过对急性呼吸窘迫综合征患者动脉血气分析指标及血清炎症介质的影响[J].中国中西医结合肾病杂志,2017,18(6): 524-526.
[7] 林华新,容永璋,莫玉华.早期持续高容量血液滤过联合血液灌流治疗严重脓毒症的疗效观察[J].现代中西医结合杂志,2014,23(26): 2937-2938.
[8] Mcintosh A,Schmidt S,Tong S,et al.Validation of the vasoactive-inotropic score in pediatric sepsis.[J].Pediatr Crit Care Med,2017,18(8): 750-757.
[9] 李彦嫦.CRRT联合灌流在脓毒症休克患者中的疗效观察及安全性研究[J].内蒙古医学杂志,2017,49(2): 156-158.
[10] 陈泽宇,刘俊,徐志坚,等.持续血液滤过联合血液灌流治疗脓毒症的临床效果观察[J].广西医学,2017,39(2): 258-260.
[11] 袁超,王夜明,李鲲,等.血液灌流联合血液滤过治疗脓毒症休克临床疗效观察[J].中国临床医生杂志,2015,9: 44-46.
[12] Singer M,Deutschman CS,Seymour CW,et al.The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)[J].JAMA,2016,315(8): 801.
[13] 孟晓丽,于冬梅,王巍巍.常规血液透析与血液灌流对终末期肾脏疾病患者微炎症状态的影响[J].临床肾脏病杂志,2015,15(8): 489-492.
[14] 张莉.早期应用持续高容量血液滤过联合血液灌流对严重脓毒症治疗效果观察[J].中华临床医师杂志(电子版),2012,6(4):3976-3980.
[15] 胡强,陈安宝,洪霞,等.血液灌流治疗过程中并发症的防治[J].临床急诊杂志,2008,9(3): 149-151.