高容量血液滤过对脑再灌注损伤脑水肿及其预后的影响

Effect of high volume hemofiltration on outcome of cerebral edema following cerebral reperfusion injury

目的:探讨高容量血液滤过(highvolumehemofiltration,HVHF)治疗心肺复苏后对血流动力学不稳定的脑水肿患者临床效果和对预后的影响。方法:24例行心肺复苏后出现脑水肿患者同时存在低血压,但无肾功能衰竭患者分为两组:治疗组(11例),行HVHF,血流量为250～300mL,置换液为3.0～4.0L/h;对照组(13例)按常规治疗。观察生命体征,格拉斯哥昏迷量表(GCS)评分,检测乳酸和细胞因子水平等变化,3个月后行格拉斯哥预后量表(GOS)评估预后。结果:治疗组在行HVHF治疗期间均无死亡,与对照组比较,治疗后4～6h血压开始显著上升,多巴胺输注速度减少,血气分析pH,HCO3-,PCO2均可维持在正常参考值范围,氧合指数(PO2/FiO2)显著上升,血清乳酸、白细胞介素1β,白细胞介素6,肿瘤坏死因子-α水平显著下降。3个月后GOS评估,GOS4或5级:治疗组7例(7/11,64%),对照组1例(1/13,8%),两组比较差异有显著性意义(P<0.01);死亡:治疗组2例(2/11,18%),对照组8例(8/13,62%),两组比较差异有显著性意义(P<0.05)。结论:HVHF能较好地改善心肺复苏后的血流动力学,稳定内环境,清除体内细胞因子和乳酸等炎性递质,从而减轻脑再灌注损伤,并能改善其预后。

AIM:To investigate the clinical effect of high volume hemofiltration(HVHF) on outcome and prognosis of cerebral edema with allo hemodynamics following cardiopulmonary resuscitation(CPR). METHODS:Twenty three patients(Glasgow coma scale,GCS 5-6)with cerebral edema after CPR and hypotension but without renal failure were divided into two groups: treatment group(n=11),which underwent HVHF,the blood flow was about 250-300 mL and the infusion rate of replacement fluid was about 3.0-4.0 L per hour;control group group(n=13) ,which was treated with rountine treatment.During the observation on vital signs,GCS,lactic acid and cytokine contents in plasma were measured and Glasgow Outcome Scale(GOS)was used to evaluate prognosis after 3 months. RESULTS:None died in the treatment group during HVHF,and compared with the control group, there was a significant increase in arterial pressure and a decrease in infusion rate of vasoactive drugs after 4-6 hours. pH,HCO3-, PCO2 in blood were all maintained in the normal range,while a significant increase in PO2/FiO2 and a decrease in the levels of plasma lactic acid,interleukin 1beta,interleukin 6,tumor necrosis factor alpha.After 3 months, according to GOS,outcome of the treatment group(n=7) was improved,GOS 4-5(7/11,64%vs 1/13,8%)with a significant difference(P< 0.01);the mortality rate was 18%(2/11)for the treatment group and 62%(8/13)for the control group with a significant difference(P< 0.05). CONCLUSION:HVHF may improve the hemodynamics following CPR,stabilize internal environment,clear internal cytokines and inflammatory transmitter, thereby relieve the damage induced by cerebral reperfusion and improve the prognosis.