采用中性树脂的直接血液灌流早期辅助治疗革兰氏阴性菌脓毒症休克

The effect of direct hemoperfusion with neutral resin on patients with septic shock caused by gram-negative bacteria infection

目的评价采用中性树脂的直接血液灌流（NS-DHP）治疗革兰氏阴性杆菌脓毒血症的临床疗效及安全性。方法广州市第一人民医院重症医学科2008年至2010年革兰氏阴性杆菌脓毒血症42例，随机（随机数字法）分为治疗组（D组）18例和对照组（C组）24例。两组患者均予脓毒症集束化治疗，D组在确诊后即行NS-DHP治疗。采用Baxter床旁连续性血液净化机，使用HA330血液灌流器治疗，使用低分子肝素抗凝，血液灌流每次治疗2．5h，每隔24h治疗1次，连续治疗3次。两组患者分别于治疗前及治疗24、48、72h时点监测APACHEⅡ评分、氧合指数（OI）、平均动脉压（MAP）、多巴胺用量（DA），静脉采血监测血浆内毒素水平（ET）、血清TNF-α水平、IL-6水平、IL-10水平和C反应蛋白水平（CRP），并比较两组患者28d病死率及ICU停留时间。结果D组患者均能耐受血液灌流治疗，无不良并发症发生。两组患者均未接受连续性肾替代治疗。与治疗前比较，两组在治疗24、48、72h时点，其APACHEⅡ评分、DA、CRP、ET、TNF-α及IL-6水平均有显著下降（P〈0．05），OI、MAP均明显上升（P〈0．05），而IL-10比较差异均无统计学意义。在治疗24、48、72h时点，D组的APACHEⅡ评分、DA、CRP、TNF-α及IL-6水平均低于C组（P〈0．05），而OI和MAP均高于C组（P〈0．05），但两组问ET、IL-10比较差异均无统计学意义。结论早期采用中性树脂的血液灌流可降低革兰氏阴性菌脓毒症休克患者APACHEII评分和多巴胺用量，降低C反应蛋白、TNF-α和IL-6水平，提高氧合指数及平均动脉压，而对内毒素水平、28d病死率、ICU停留时间无影响。

Objective To evaluate clinical effect and safety of direct hemoperfusion with neutral resin （NS-DHP） on patients with septic shock caused by Gram-negative bacteria infection. Methods A total of 42 patients were enrolled in the study and randomly （ random number） divided into two groups. Patients of control group （n = 24 ） received sepsis bundle therapy, and patients of group D （n = 18 ） were treated with NS-DHP in addition to sepsis bundle therapy. HA330 hemoperfusion device were used in each patient of group D. The procedure of hemoperfusion lasted 2. 5 hours and carried out trice a 24 hours. Clinical data including APCHE Ⅱ score, PO2/FiO2 （OI） , mean arterial pressure （MAP） , dopamine usage （DA） , plasma level of endotoxin （ET） , C-reactive protein （CRP） , TNF-α, IL-6 and IL-10 were recorded during the treatment. Results Patients well tolerated NS-DHP without any complication in group D. All patients in both two groups did not receive long-term renal replacement therapy. At 24 h, 48 h and 72 h after the initiation of treatment, APACHE Ⅱ score, OI, MAP, DA, ET, CRP, TNF-α and IL-6 improved obviously both groups （ P 〈 0. 05 ） , but there was no significant difference in serum levels of IL-10 in bothgroups. In the group D, APCHEⅡ score, OI, MAP, DA, CRP, TNF-α and IL-6 were improved more obviously than those in the group C （P 〈 0. 05） ）. There was no significant difference in plasma levels of ET in both groups during the treatment. Conclusions NS-DHP can improve APACHE Ⅱ score, PO2/FiO2 and MAP in patients with septic shock caused by gram-negative bacteria infection and reduce the levels of CRP, TNF-α and 1L-6, but has no effect on the levels of ET and IL-10 as well as on 28-day mortality and ICU stay.