连续性血液滤过在急性呼吸窘迫综合征患者中的应用

Application of continuous veno-venous hemofiltration in patients with acute respiratory distress syndrome

目的观察急性呼吸窘迫综合征（ARDS）患者血清中自介素6（IL-6）含量的变化以及连续性肾脏替代治疗（CRRT）对其影响和临床意义。方法随机将40例ARDS患者分成常规治疗组（A组20例）和常规治疗＋CRRT治疗组（B组20例）。B组患者在确诊为ARDS时即给予CRRT治疗。通过酶联免疫吸附试验（ELISA）分别检测两组患者ARDS诊断建立即刻（0h）和病程中（12、24、钙、72h）血清IL-6的变化，同时采用动态APACHEⅡ评分（0、24、48、72h）对患者整体病情变化进行评价。比较两组呼吸机相关性肺炎（VAP）发生率、重症监护病房（ICU）病死率、机械通气时间和人住ICU时间。结果ARDS患者血清中IL-6水平明显高于正常对照组（P〈0．01），死亡组血清IL-6水平亦明显高于生存组（P〈0．01）。无论在生存组还是死亡组，血清IL-6水平和APACHEⅡ评分均呈正相关性（r=0．560、0．518，P=0．008、0．023）。在ARDS病程中，相对于A组，B组有持续降低的血清IL-6水平和APACHEⅡ评分（均P〈0．05）。A组与B组VAP发生率分别为80％和45％（P=0．022）；ICU病死率分别为55％和40％（P=0．342）；机械通气时间分别为（16±5）d和（12±5）d（P=0．027）；住ICU时间分别为（19±5）d和（16±5）d（P=0．030）。结论ARDS患者血清中升高的IL-6水平与肺损伤程度有关。早期应用CRRT治疗可以有效降低患者血清中的IL-6水平，缩短机械通气和住ICU时间，降低VAP发生率。

Objective To investigate the changes of interleukin （IL） -6 serum level in patients with acute respiratory distress syndrome （ARDS） and the effects of continuous renal replacement therapy （CRRT） on IL-6 level and its clinical significance. Methods Forty ARDS patients were randomly divided into 2 equal groups： Group A undergoing conventional treatment and Group B receiving conventional treatment plus CRRT at onset of ARDS. Serum IL-6 level was measured by enzyme linked immunosorbent assay （ELISA） at the onset （0 h） and 12, 24, 48, and 72 hours later. Dynamic APACHE II score was also evaluated at the time points of 0, 24, 48, and 72 h. The incidence of ventilator-associated pneumonia （VAP）, intensive care unit （ICU） mortality rate, duration of total mechanical ventilation, and ICU stay were assessed. Twenty-five healthy examinees were used as controls. Results The serum IL-6 level of the whole ARDS patients was significantly higher then that of the normal controls （ P 〈 0.01 ）, and the serum IL- 6 level of the ARDS patients who died was significantly higher than that of the ARDS patients who survived （P 〈 0. 01 ）. The IL-6 serum level was correlated well with the APACHE II score either in the survival subgroup or the non-survival subgroup （for the former： r =0. 560 P =0. 008, and for the latter： r =0. 518 P=0.023）. Group B, contrary to Group A, had persistently decreased serum IL-6 levels and APACHE Ⅱ scores at the onset and during the progression of ARDS （ all P 〈 0.05 ）. The incidence of VAP in Group B was 45%, significantly lower than that in Group A （80%, P --0. 022） while the ICU mortality rate didn＇t differ between the two groups （40% vs 55%, P = 0.342）. The duration of total mechanical ventilation and ICU stay of the Group B patients who underwent early CRRT were （ 12 ± 5 ） days and （ 16 ± 5 ） days respectively, both significantly shorter than those of Group A patients [ （ 16 ± 5 ） days, P = 0. 027 and （19 ±5） days, P = 0. 030 ]. Conclusion The elevated serum IL-6 level in ARDS patients seems to be correlated well with the severity of lung injury, and appears to be a good marker to judge the prognosis of the disease combined with APACHE Ⅱ score. In the early phase of ARDS, CRRT can decrease the high serum level of IL-6, shorten the duration of total mechanical ventilation and ICU stay, and decrease the incidence of VAP. Removal of the circulating proinflammatory cytokines by CRRT may be one of the most vital mechanisms to treat ARDS.