连续性高容量血液滤过对重症脓毒血症患者血流动力学及存活率的影响

Effects of continuous high-volume haemofiltration on hemodynamics and survival in severe sepsis

目的:探讨连续性高容量血液滤过对重症脓毒血症患者血流动力学及存活率的影响。方法:30例重症脓毒血症患者,在连续性高容量血液滤过治疗期间及治疗结束后24 h分别监测患者血流动力学参数及去甲肾上腺素的需要量,使平均动脉压维持在>70 mm Hg。采用ELISA法测定白介素-2、白介素-6、白介素-8、白介素-10、肿瘤坏死因子α、内毒素,连续性高容量血液滤过治疗时调节血流量在250～350 mL/min,维持超滤比率在20%～25%,碳酸氢盐置换液以前置换与后置换按1∶1比例同时输入。结果:所有治疗均顺利进行,经过连续性高容量血液滤过的治疗,血流动力学较治疗前改善,收缩压提高(P<0.05),去甲肾上腺素的需要量有明显减少,并且能维持到治疗结束后24 h(P<0.01),而体温、心脏指数、氧合状况无明显变化(P>0.05)。治疗结束时血浆内毒素、白介素-6、肿瘤坏死因子α水平较前均明显下降(P<0.05)。预测病死率为71%(基于APACHEⅡ评分)和66%(基于SAPSⅡ评分),实际28 d病死率为47%(14/30)。结论:连续性高容量血液滤过能改善重症脓毒血症患者的血流动力学状况,提高患者的存活率,是一种可行、有益的辅助治疗重症脓毒血症及脓毒血症休克的方法。

Objective To investigate the effects of continuous high-volume haemofiltration on hemodynamics and survival rate in severe sepsis. Methods Thirty patients with severe sepsis underwent continuous high-volume haemofiltration, and were measured the changes in haemodynamic parameters and evaluated the dose of noradrenaline required to maintain mean arterial pressure above 70 mm Hg during and after therapy at 12 and 24 hours. The concentrations of interleukin-2, interleukin-6, interleukin-8, interleukin-10, tumor necrosis factor-a and endotoxin were measured with ELISA. Continuous high-volume haemofiltration was performed at 250 to 350 mL/min blood flow rate. The bicarbonate-based replacement fluid was used at 1 ： 1 ratio in simultaneous pre-dilution and post-dilution. Results After continuous high-volume haemofiltration, all treatment was successfully continued, haemodynamic parameters were improved, systolic blood pressure increased （P〈0.05）, noradrenaline dose reduced and maintained at 12 and 24 hours after treatment （P〈0.01）. There were no changes in the temperature, cardiac index and oxygenation. There were significant decreases in concentrations of endotoxin, tumor necrosis factor-a, interleukin-6 in the end of treatment（P〈0.05）. The predicting fatality rates were 71% （based on APACHE 11 score） and 66% （based on SAPS Ⅱ score）, and the fatality rate was 47% in the 28 days. Conclusion Continuous high-volume haemofiltration can haemodynamics and the patient survival rate. It is a feasible method for severe sepsis and septic shock.