重症心脏瓣膜病瓣膜置换术后持续血液滤过技术应用疗效分析

Analysis of continuous renal replacement therapy during post-operative period among patients with severe heart valve diseases

目的观察与分析持续血液滤过技术（CRRT）在重症心脏瓣膜病术后的应用效果。方法对2010年10月至2012年4月阜外心血管病医院收治的重症心脏瓣膜病术后因肾功能不全、循环功能障碍、严重电解质紊乱或感染性休克等原因实施CRRT的32例患者的病例资料进行回顾性分析，应用过程中监测患者生命体征、生化等指标，在患者病情稳定后撤除；对血肌酐、转氨酶、氧分压、中心静脉压、尿量等指标进行CRRT应用前后对比。结果患者体外循环中位时间为140．00（79．50，207．75）min，主动脉阻断中位时间为98．00（45．50，130．75）min，于术后应用CRRT的中位时间46．50（21．25，110．00）h，CRRT应用中位时程为52．50（42．25，72．25）h，应用CRRT治疗后尿量升高[0．77（0．17，1．34）mE／（kg·h）比0．42（0．29，0．61）ml／（kg·h），P=0．007]、动脉收缩压升高[（106±25）mmHg（1mmHg=0．133kPa）比（97±24）mmHg，P=0．014]，中心静脉压[（9±4）cmH：O（1cmH，O=0．098kPa）比（12±3）cmH2O，P=0．001]、血肌酐值[129．00（100．60，161．30）g／L比209．00（153．70，268．30）g／L，P〈0．001]、尿素氮[12．70（6．93，17．33）g／L比15．20（10．10，28．90）g／L，P=0．017]、转氨酶水平[79．00（42．25，134．00）g／L比195．00（70．25，689．50）g/L，P=0．003]等均有明显下降，治愈患者中位ICU治疗时长10d，中位住院时长29d，术后3例患者死于循环衰竭（术后第5、6、6天），1例死于心脏骤停（术后第2天），1例因肾功能不全转院行专科治疗。结论对于重症心脏瓣膜病患者，术后积极应用CRRT技术，可以有效帮助患者安全、平稳地度过术后危险期，效果显著。

Objective To observe patients with severe heart valve diseases who had continuous renal replacement therapy（CRRT） after cardiopulmonary bypass. Methods Patients with severe heart valve diseases who underwent cardiac surgery between October 2010 and April 2012 were treated with CRRT due to renal dysfunction, cardiovascular dysfunction, severe electrolyte disturbance or infectious shock （n = 32 ）. CRRT was removed when the condition was stable. Creatinine level, blood urea nitrogen （BUN） level, aspartate aminotransferase level, oxygen partial pressure, central venous pressure （CVP）and urine output were compared before and after CRRT. Results The cardiopulmonary bypass time of the patients was 140.00 （79.50, 207.75 ） rain ; the aortic cross time was 98.00（45.50, 130.75）rain; the time until CRRT after admission to the ICU was 46.50（21.25, 110.00） h. After 52.50 （42.25, 72.25 ） h of CRRT application, the renal function and heart function of the patients were improved. The urine output[0.77（0.17, 1.34）ml/（kg h） vs0.42（0.29, 0.61） ml/（kg h）, P=0.0071 and systolic pressure[ （106 ±25） mm Hg（ 1 mm Hg = 0. 133 kPa） vs （97 ± 24） mm Hg, P = O. 014] increased obviously; central venous pressure [ （9±4）cm H20（ 1 cm H20 =0. 098 kPa） vs （ 12±3）cm H20, P =0. 001 J, creatinine level[ 129.00 （ 100.60, 161.30） g/L vs 209.00 （ 153.70, 268.30） g/L, P 〈 0. 001 ] , blood urea nitrogen level[ 12.70（6.93, 17.33 ） g/L vs 15.20（ 10.10, 28.90） g/L, P = 0. 017 ] and aspartate aminotransferase level [ 79.00 （42.25, 134.00） g/L vs 195.00 （70.25,689.50） g/L, P = 0. 003 ] all decreased. Three patients died of heart failure; one patient died of cardiac arrest; one patient was sent to other hospital for further renal treatment; the others discharged from hospital after completely cured. Conclusion The effective use of CRRT can help patients with severe heart valve diseases during the post-operative period.