床旁连续性血液净化救治儿童急性肺损伤和呼吸窘迫综合征

Efficacy of continuous blood purification on rescue therapy of the critically ill children with acute lung injury and acute respiratory distress syndrome

目的 探讨床旁持续性血液净化（continuous blood purification,CBP）治疗在救治危重病儿童急性肺损伤和急性呼吸窘迫综合征（acute lung injury/acute respiratory distress syndrome,ALI/ARDS）中作用.方法 2006年6月至2011年5月,我院共收治ALI/ARDS患儿147例,对其中32例在常规治疗基础上进行CBP治疗.模式为连续性静-静脉血液滤过透析（continuous vein-vein hemodialysis/filtration,CVVHDF）,置换液＋透析液剂量为35 ～100 ml/（kg·h）.观察CBP治疗患儿呼吸指数（ FiO2/PO2）、动态肺顺应性（Cdyn）、血气指标、机械通气参数、血管活性药物剂量和肺部X线等指标变化,比较病死率.结果 143例中,男89例（60.5％）,女58例（39.5％）,平均年龄（43.4±36.7）个月.死亡54例,总病死率为36.7％.ALI/ARDS原因主要为重症肺炎、严重脓毒症和白血病及肿瘤性疾病.CBP治疗组病情程度评分较非CBP治疗组严重,PRISMⅢ分别为15.3和12.7（P＜0.05）,儿童危重评分分别为66.8 ±19.3和74.6±17.7（P ＜0.05）.CBP治疗平均持续时间为52 h（12～232 h）.CBP治疗后2 h PaO2/FiO2和Cdyn有改善,较治疗前比较差异有统计学意义（P＜0.05）,X线见肺部渗出减轻,呼吸机参数中吸入氧指数（FiO2）吸气峰压（PiP）和呼吸末正压（PEEP）可以下调,合并MODS或休克患儿血管活性药物剂量逐渐下调.CBP治疗组和非CBP治疗组病死率分别为37.5％和36.5％,差异无统计学意义（P＞0.05）,两组平均机械通气时间差异无统计学意义（P＞0.05）.结论 CBP辅助治疗ALI/ARDS患儿可以减轻肺水肿,改善PaO2/FiO2和Cdyn,及时下调机械通气参数,达到改善肺部病变的作用,可能是ALI/ARDS治疗有发展潜力的治疗手段.

Objective To investigate the efficacy of continuous blood purification （CBP）in the treatment of acute lung injury/acute respiratory distress syndrome （ ALI /ARDS ） in children.Methods One hundred and forty seven cases of ALI/ARDS were hospitalized to our pediatric intensive care unit,and 32 cases were treated with continuous blood purification （CBP） from June,2006 to May,2011.The model for CBP was continuous veno-venous hemofiltration dialysis （CVVHDF）.CBP treatment persisted for at least 8 hours and replacement ＋ dialysis fluid dose was 35-100 ml/（ kg · h）. The clinical outcome measures included the mortality rate at 28th day,respiratory index （ FiO2/PO2 ）,dynamic lung compliance （ Cdyn）,arterial partial pressure of oxygen （ PaO2 ）,arterial partial pressure of carbon dioxide （ PaCO2 ）,mechanical ventilation parameters,vasoactive drug dose and lung X-ray changes.Results In totally 147 cases of ALI/ARDS,89 cases （60.5% ） were male and 58 （ 39.5% ） were female,mean age was （43.4 ± 36.7 ）months.Death occurred in 54 cases,the total mortality was 36.7%.The cause of ALI/ARDS was mainly severe pneumonia,severe sepsis,and leukemia or tumor diseases. There were significant differences in severity of illness between the CBP treatment group and non-CBP treatment group on Pedialric risk of score mortality （ PRISM ） Ⅲ score （ 15.3 vs.12.7,P 〈 0.05 ） and pediatric critical illness score （ 66.8 ± 19.3 vs.74.6 ± 17.7,P 〈0.05）.The average duration of CBP treatment was 52 hours （ 12 hours to 232 hours）.PaO2/FiO2 and Cdyn were improved after 2 hours CBP treatment compared with those before CBP treatment （P 〈 0.05 ）,mechanical ventilation parameters including fraction of inspired oxygen （FiO2 ）,peak inspiratory pressure （PiP） and positive end expiratory pressure （PEEP） were reduced. The use of vasoactive drugs in patients with MODS and shock gradually declined.The average ventilator-free days of the two groups did not show significant difference （P 〉 0.05）.The mortality on CBP treatment group and nontreatment group were 37.5% and 36.5%,respectively,the difference was not significant （P 〉 0.05 ）.Conclusion CBP adjuvant treatment for ALI/ ARDS could reduce pulmonary edema,improve PaO2/FiO2and Cdyn,and improve mechanical ventilation parameters.CBP may be a very promising treatment for ALI/ARDS in children.