急性重型高原病集束化治疗方案的建立

Bundle program of treatment for acute severe type high altitude disease

目的探讨急性重型高原病的集束化治疗方案。方法采用前瞻性研究方法，选择高原肺水肿（HAPE）、高原脑水肿（HACE）确诊病例203例，按随机数字表法分为集束化方案治疗组（125例）和一般疗法治疗对照组（78例）。合并多器官功能障碍综合征（MODS）的极重型患者转入重症监护病房（ICU），并对其进行加强监测和治疗（即集束化治疗方案）；伴有呼吸衰竭、严重低氧血症的患者给予机械通气治疗（包括有创和无创）；伴有循环不稳定者给予液体复苏及血管活性药物；伴有肾功能不全／衰竭的患者可给予利尿及血液透析治疗；同时预防消化道出血和纠正凝血功能紊乱。按照HAPE和HACE的分期和分型，比较两种治疗方案组的住院时间、总治愈率、总病死率及不同分型患者的病死率。结果集束化方案治疗组的平均住院时间（d：5．28±3．17）较一般疗法治疗对照组（6．94±4．05）缩短了1．66d（P〈0．05）；总治愈率提高了7．06％（96．80％比89．74％，P〈0．05）；重型和极重型患者的病死率分别下降了5．59％和31．15％，总病死率较一般疗法治疗对照组明显下降（3．20％比10．26％，P〈0．05）。结论高原医学与重症医学紧密结合的集束化治疗方案能有效降低重型和极重型HAPE、HACE患者的病死率。

Objective To discuss Bundle treatment of the acute severe type high altitude disease. Methods The prospective and randomized controlled trial was conducted. Two hundred and three patients with high altitude pulmonary edema （HAPE） or high altitude cerebral edema （HACE） met inclusion criteria were included, and were randomly divided into Bundle treatment group （n = 125 ） and conventional treatment control group （n = 78 ）. Critical patients with multiple organ dysfunction syndrome （ MODS ） were admitted to intensive care unit （ ICU ） ; with respiratory failure or serious hypoxia of the patients were given mechanical ventilation （ invasive or noninvasive ） ; fluid resuscitation and vasoaetive agents were given in the unstable hemodynamies patients; diuretics and continuous veno-venous hemofihration were given in acute renal dysfunction or failure. The gastrointestinal bleeding and blood coagulation disorders were concerned. The hospital stay time, cure rate and mortality were compared according to the stages and classification of HAPE or HACE among two groups. Results The hospital stay time was significantly decreased 1.66 days in the Bundle treatment group （days： 5.28 ± 3.17 ） compared with conventional treatment control group （6.94 ± 4.05, P〈0.05）, the cure rate was significantly increased 7.06% （96.80% vs. 89.74%, P〈0.05 ）, mortality of severe and fatal patients were decreased 5.59% and 31.15%, the mortality of patients in Bundle treatment group was significantly lower than conventional treatment control group （3.20% vs. 10.26% , P〈0.05）. Conclusion The standardized treatment which was integrated with plateau medicine and critical care medicine can effectively reduce the mortality of critical or severe patients with HAPE or HACE.