脉冲式高容量血滤对术后急性肺水肿的肺水清除作用

The Effect of Pulse High-volume Hemofiltration on EVLW of Perioperativeacute Pulmonary Edema

目的：术后急性肺水肿是一较严重的术后并发症，除与液有关外其主要的发生机制为全身炎症反应。纠正低氧和迅速清除肺水是其主要的治疗。当患者血流动力学不稳，血液净化技术目前广泛应用于临床，研究证实脉冲式高容量血液滤过（PHVHF）既有效清除大量体内多余液体，又能清除可溶性炎症介质，改善患者预后。但针对急性肺水肿应用PHVHF临床治疗尚未见报道；本研究旨在探讨PHVHF对ARDS患者的肺血管通透性。肺功能、血流动力学的影响。方法：术后急性肺水肿伴休克少尿患者18例，所有患者均接受了综合治疗；积极治疗休克。采用PHLIPS MP50监护仪，记录患者心电、呼吸及Picco血流动力学参数：血管外肺水、肺血管，通透指数，胸内血容量、心排量。PHVHF方法；前后稀释各50％，血流星200-250ml／min,超滤及抗凝依临床需求需定。72h连续性血液滤过治疗，前后稀释各50％，血流量200—250ml／min．超滤及抗凝临床需求而定。72h连续性血液滤过治疗，其中每日HVHF[85ml（kg·h）]治疗6-8h后，续行CVVH治疗， [35ml/（kg·h）]。结果：本组患者平均置换液流量69.3±8.6升/日。接受PHVHF治疗前后，患者心率、血压改善，HPACHEll评分、SOFA评分显著降低（P〈0．05），生命体征趋于稳定。PHVHIF治疗后24小时，患者氧合指数、吸氧浓度、气道峰压显著降低，肺顺应性升高（p〈0.5）,PHVHF后48小时、72小时血管外肺水、肺血管通透指数较治疗前显善降低。胸内血容量，全心舒张末容积降低，而心排量趋于稳定。结论：针对创伤和术后急性肺水肿患者。早期应用PVHF可能改善的血流动力学、呼吸功能、肺水肿及肺毛细血管通透性。PHVHF充分利用了早期滤过膜通透性及吸附性能好，而随时间延长HVHF清除率逐渐降低这一特性，临床操作简化，应用前景广泛。

Objectives： Trauma and operation are occasionally causes of acute pulmonary edema. The main mechanism is systemic inflammatory response syndrome （SIRS）. The core cures are rectifying the low oxygen and pulmonary liquid clearance. Hemofiltrationis are needed when the patient＇s hemodynamics are unstable. Pulse high-volume hemofiltration （PHVHF） improves has exhibited beneficial effects in SIRS, improving hemodynamics and unselectively removing proinflammatory and anti-inflammatory mediators. The study is to investigate the effect of PHVHF on extravascular lung water index, respiration, hemodynamics in acute pulmonary edema. Methods： Eighteen patients with acute pulmonary edema received conventional treatment and PHVHF for 72hours. PHVHF was performed with 250 ml/min blood flow rate. The bicarbonate-based replacement fluid was used at a 1：1 ratio in simultaneous pre-dilution and post-dilution. HVHF （85ml/ kg per hour） for 6-8 hours followed by CRRT （35 ml/kg per hour） for 16-18hours.The heart rate （HR）, mean artery pressure （MAP）, central venous pressure （CVP） were recorded with PHILIPS MP50 monitor. The cardiac output, EVLWI, PVPI, ITBVI were investigated by PiCCO monitor. Results： The APACHEII, SOFA, PaOJFiO2, peak airway pressure（Peak） were significant improved after this treatment （ P〈0.05 ） . EVLWI, ITBVI and GEDVI were significantly reduced after 48 or 72 hours of PHVHF （P〈0.05）. Cardiac output and respiration variables were stabilized. Conclusion： There are significant beneficial effects on EVLWI, respiration, hemodynamics of acute pulmonary edema patients in perioperation by PHVHF in early stage. PHVHF may be a beneficial adjuvant treatment for pulmonary edema. It can be a potential therapeutic approach.