连续性血液净化治疗全身炎症反应综合征及脓毒症治疗中止指征的临床研究

Clinical investigation about the indicator of stopping continuous blood purification in patients with SIRS/Sepsis

目的 探讨连续性血液净化 (CBP)治疗全身炎症反应综合征 (SIRS)及脓毒症 (Sepsis)治疗中止的合理指征。方法 选择 4 4例SIRS及Sepsis的病人按随机双盲原则分为Ⅰ、Ⅱ、Ⅲ、Ⅳ4组 ,分别采取CBP治疗 2 4、4 8、72、96h。动态观察反应机体整体病情变化的APACHE -Ⅱ评分 ,炎症指标CRP、IL - 6 ,免疫指标IL - 10、HLA -DR三个方面的水平变化 ,并筛选出CRP、IL - 6、IL - 10、HLA -DR四项指标变化异常病人 ,结合临床转归进行统计分析。结果 ①Ⅰ组与Ⅱ组之间上述四个方面均有显著差异 ,而Ⅲ组与Ⅳ组之间均无显著差异 ;此外 ,Ⅱ组与Ⅲ组之间 ,虽住院时间稍有延长 ,并有统计学意义 ,但在并发症发生率方面并无显著差异 ,且有关血浆指标及APACHE -Ⅱ评分在CBP治疗中止 2 4h后与Ⅲ组无差异。②停机时P≤ 90次 /min和R≤ 2 0次 /min病例百分比 ,Ⅰ组明显低于Ⅱ、Ⅲ、Ⅳ组。③CRP、IL - 6、IL - 10、HLA -DR四指标变化异常病人 ,经及时介入有关治疗后 ,死亡率降低。结论 ①中止CBP治疗SIRS及Sepsis的指征 :以总疗程 4 8～ 72h为基础 ,在无水电解质酸碱平衡紊乱的情况下 ,结合全身炎症反应的临床指标P、R ,若治疗 4 8h时P≤ 90次 /min和R≤ 2 0次 /min ,则中止CBP治疗 ;若治疗 4 8h时P >90次 /min和R >2 0次

Objective To investigate the reasonable indicator of stopping continuous blood purification(CBP)on systemic inflammatory reactive syndrome (SIRS)/sepsis.Method Forty-four patients who were diagnosed SIRS/Sepsis in this study were divided into 4 groups by randomization principle and underwent CBP at 24,48,72,96 hours respectively.The APACHE-Ⅱ scores about total change of patients condition and the level changes of CRP,IL-6,IL-10,HLA-DR were observed by sequential determination.We chose the patients with abnormal changes in CRP,IL-6,IL-10,HLA-DR, and did the statistics-analysis on the basis of the clinical results.Results ①The first group was significantly different from the second group while there were no difference between the third and the fourth group on the above four markers;although the second group had a longer hospitalization days and had the significance of statistics as the third group,there was no great difference in the incidence of complication,meantime,the correlative marker of plasma and the APACHE-Ⅱscores had no difference on 24 hours after stopping CBP. ②There was a significant decrease of patients percent with P≤90/min and R≤20/min in the first group. ③ The death rate of the patients with abnormal levels of CRP,IL-6,IL-10,HLA-DR was decreased after correlative treatments were carried on timely.Conclusions ①The indicator of stopping CBP:based on 48～72 h treatment,under circumstance without electrolyte imbalance,according to the clinical marker (P,R) of systemic inflammatory reaction,if P≤90/min and R≤20/min after CBP-48 h,stopping CBP;if P>90/min and R>20/min after CBP-48 h,stopping CBP fixedly after CBP-72h.In addition to, with the severe impairment of liver and kidney function,the treatment time should be prolonged accordingly.②During CBP treatment for SIRS/Sepsis,sequential determination of level changes of CRP,IL-6,IL-10,HLA-DR should be done.CBP should be stopped and correlative treatments should be given to abnormal patients in time.[