应用CVVH治疗重症急性胰腺炎

CONTINUOUS VENO VENOUS HEMOFILTRATION IN TREATMENT OF SEVERE ACUTE PANCREATITIS

目的 :研究连续性静脉 静脉血液滤过 (CVVH)治疗重症急性胰腺炎 (SAP)的疗效及机制。 方法 :13例SAP患者诱因分别为酒精性胰腺炎 2例 ,胆源性胰腺炎 11例。CT扫描示 2例患者 33%胰腺组织坏死 ,3例坏死 6 7% ,其余 8例为 10 0 %坏死 ,CT严重度评分为 8.9± 2 .1。CVVH至少持续 72h ,距离起病平均间隔 5 .2± 3.2天 ,中心静脉置管建立血管通路 ,使用AN6 9膜滤器 ,面积为 1.2m2 ,每 2 4h更换一次。 结果 :CVVH治疗过程中 ,患者血流动力学状态稳定 ,ICU存活率为 76 .9% ,13例患者中 2例死于霉菌性败血症 ,1例死于颅内感染 ,另 1例患者在出院前死于与SAP无关的原因 ,只有 9例患者出院。CVVH后发热、心动过速、呼吸急促等症状明显缓解。CVVH前APACHEII评分为 15 .2± 6 .5 ,CVVH 2 4h ,48h和 72h分别降至 8.1± 5 .3,7.5± 4.9和 8.0± 5 .2 ,差异非常显著。ICU存活组行CVVH早于ICU死亡组 ,CVVH后临床缓解更明显。在CVVH过程中 ,外周血IL 1β和TNF α浓度在使用每一新滤器后的第 6h达到最低水平 ,第 12h逐渐升高至CVVH前水平直到第 2 4h。CVVH停止后 ,两种细胞因子水平均明显升高 ,与治疗前相比差异均十分显著。 结论 :SAP合并多器官功能障碍综合征患者行CVVH时血流动力学稳定 ,并发症少 。

Severe case of acute pancreatitis(SAP)has been associated with increased production of cytokines.which might be implicated in the process of inflammation reaction and prognosis of the patients.In this study,we cooperated continuous veno venous hemofiltration(CVVH)in treatment of SAP and investigated the efficacy of CVVH in treatment of SAP. METHODOLOGY ]13 SAP patients were involved, including 4 females and 9 males, with an average age of 50.6±10.8 years. SAP was associated with alcoholism in 2 and biliary diseases in 11 of the patients. CT scan on admission revealed 33% necrosis of pancreas body in 2 patients, 67% necrosis in 3 patients and 100% necrosis in 8 patients; the CT severity score was 8.9±2.1. CVVH was started 5.2±3.2 (1～13) days after onset of disease and sustained for at least 72 hours, AN69 hemofilter (1.2m 2) was applied and changed every 24 hours. Complications of pancreatitis before CVVH included culture positive infections in 10 patients, shock in 3 patients,ARDS needing mechanical ventilation in 9 patients,ARF in 4 patients and pancreatitic encephalopathy in 4 patients. During CVVH,the ultrafiltration rate was 2993.9±983.0 ml/h, blood flow rate was 250～300 ml/min, and the substitute fluid was infused by a pre dilution rout.Low molecular weight heparin was used for anticoagulation. RESULTS 13 SAP patients were involved, including 4 females and 9 males, with an average age of 50.6±10.8 years. SAP was associated with alcoholism in 2 and biliary diseases in 11 of the patients. CT scan on admission revealed 33% necrosis of pancreas body in 2 patients, 67% necrosis in 3 patients and 100% necrosis in 8 patients; the CT severity score was 8.9±2.1. CVVH was started 5.2±3.2 (1～13) days after onset of disease and sustained for at least 72 hours, AN69 hemofilter (1.2m 2) was applied and changed every 24 hours. Complications of pancreatitis before CVVH included culture positive infections in 10 patients, shock in 3 patients,ARDS needing mechanical ventilation in 9 patients,ARF in 4 patients and pancreatitic encephalopathy in 4 patients. During CVVH,the ultrafiltration rate was 2993.9±983.0 ml/h, blood flow rate was 250～300 ml/min, and the substitute fluid was infused by a pre dilution rout.Low molecular weight heparin was used for anticoagulation. RESULTS CVVH was well tolerated in all the patients. The average treatment hour of CVVH was 204±346.Abdominal cavity bloody drainage was observed in two of the patients,no other severe side effect associated with CVVH was observed.Three patients died of fungi infection including 1 patient died of intracranial fungi infection.The ICU mortality rate was 23 1%.After CVVH,APACHEⅡ score decreased significantly(pre CVVH:15.2±6.5,24 hours post CVVH:8.1±5.3;48 hours post CVVH 7.5±4.9;72 hour post CVVH 8 0±5 2, P <0.01). Serum concentrations of IL 1β and TNFα were decreased to the trough at the 6th hour after a new hemofilter was used.The sieving coefficients(SC)of IL 1β and TNFα were 0 33±0 11 and 0 16±0 08 respectively. CONCLUSION CVVH is an effective therapeutic option for SAP.The early clearance of IL 1β and TNFα by CVVH might be one of the mechanisms*'forthe improved outcome.