不同血液净化方式治疗多器官功能障碍综合征的疗效比较

The curative effect of various blood purification therapies for multiple organ dysfunction syndrome

目的探讨高容量血液滤过(high-volume hemofiltration,HVHF)和连续性静静脉血液透析滤过(continuous veno-venous hemodiafiltration,CVVHDF)在多器官功能障碍综合征(multiple organdysfunction syndrome,MODS)救治中的疗效。方法选择MODS患者85例,随机分为2组:HVHF组(44例),置换液流速4～6L/h,血流速度250～300ml/min;CVVHDF组(41例),置换液流速2L/h,透析液流速2L/h,血流速度250～300ml/min。比较两组治疗24h后心率、平均动脉压(MAP)、中心静脉压(CVP)、PH值、HCO3-、氧合指数(PaO2/FiO2)、多巴胺剂量、血清肌酐(SCr)、尿素氮(BUN)、K+、Na+、Ca2+、肿瘤坏死因子α(TNF-α)、白细胞介素6(IL-6)、C反应蛋白(CRP)水平的变化,并比较2组的存活率。结果 HVHF组存活28例,存活率63.6%,CVVHDF组存活26例,存活率63.4%,两组差异无统计学意义(P>0.05);两组治疗后与治疗前比较心率、CVP、SCr、BUN降低(P<0.05),多巴胺用量减少(P<0.05),MAP、HCO3-升高(P<0.05),但两组间比较差异无统计学意义(P>0.05);患者电解质紊乱、酸碱失衡均得到纠正;两组治疗后PaO2/FiO2都明显改善,但HVHF组改善更明显(P<0.05);两组治疗后TNF-á、IL-6、CRP均有下降,与治疗前比较差异有显著性,但HVHF组患者下降的幅度大于CVVHDF组(P<0.05)。结论 HVHF和CVVHDF均能有效地清除溶质和水分,调整离子和酸碱平衡,改善组织缺氧,且具有稳定的血流动力学,HVHF较CVVHDF更能有效地清除MODS患者的炎症介质,调节免疫。

Objective To investigate the efficacy of high volume hemofiltration （HVHF） and continuous venovenous hemodiafiltration （CVVHDF） in the treatment of multiple organ dysfunction syndrome （MODS）. Methodology Eighty-five patients with MODS were randomly divided into 2 groups： the HVHF group （n=44）, in which the ultrafiltrate rate was set at 4～6L/h and blood flow at 250～300ml/min, and the CVVHDF group （n=41）, in which the flow rate of substitution fluid was 2L/h, that of dialysate fluid was 2L/h, and that of blood was 250～ 300ml/min. Changes of heart rate （HR）, mean arterial pressure （MAP）, central venous pressure （CVP）, hydrogen ion concentration, HCO3, oxygenation index （PaO2/FiO2）, dose of dopamine administrated, serum creatinine （Scr）, BUN, K^＋, Na^＋, Ca^2＋, TNF-á, IL-6, and CRP were compared between the 2 groups before and after the treatment for 24 hours. Mortality rate was compared at the end of the study. Results In HVHF group, 28 cases survived and the mortality rate was 63.6%. In CVVHDF group, 26 cases survived and the mortality rate was 63.4%. There were no differences between the 2 groups. After the treatment, the levels of HR, CVP, Scr and BUN decreased （P〈0.05）, the dose of dopamine reduced （P〈0.05）, and the levels of MAP and HCO3 increased （P〈0.05）, in both groups and without statistical differences between the 2 groups. Electrolyte and acid-base disturbances were corrected in both groups. PaO2/FiO2 increased, and the levels of TNF-á, IL-6, and CRP decreased after the treatment in both groups （P 0.05）, as compared with those of before the treatment. However, these changes were more evident in HVHF group than in CVVHDF group （P〈0.05）. Conclusion Although both HVHF and CVVHDF are effective to excrete extra solutes and water, recover ionic and acid-base balances, and ameliorate tissue hypoxia with little disturbance in blood flow dynamics, HVHF has better abilities in elimination of inflammatory factors and normalization of immune system in MODS patients.