重度烧伤并发高钠血症行CRRT治疗后死亡因素分析

Factors related to death after CRRT in patients with severe burn complicated with hypernatremia

目的 探讨重度烧伤感染期合并高钠血症行连续肾替代疗法（CRRT）的时机和价值.方法 回顾性分析2004年3月～2014年3月期间我科收治的8例大面积重度烧伤感染期合并高钠血症患者行CRRT治疗前后生命体征、血钠、血氯变化情况及患者的预后.结果 3例由于血钠值降低过快[12 ～17 mmol/（L·d）],CRRT治疗24 h后,患者出现严重的低渗性脑水肿症状,虽经积极抢救仍死于脑疝、呼吸衰竭.5例经CRRT治疗24 h后生命体征及生化指标有所改善,但此时未能及时手术切除痂皮清除坏死组织,治疗后48 h后相关指标逐渐恶化,最终于治疗后72 h相继死于感染性休克导致的多脏器功能衰竭.结论 大面积烧伤感染期合并高钠血症的主要原因是全身性感染,CRRT可以暂时稳定生命体征、降低血钠值,但手术清除坏死组织是治疗的关键.CRRT治疗要掌握好方法和适应证,不可过度依赖.

Objective To discuss the time and value of continuous renal replacement therapy（CRRT） for patients with severe burn complicated with hypernatremia.Methods A retrospective analysis was made to the clinical data of 8 cases with severe burn at the infection stage complicated with hypernatremia hospitalized in the period from March,2004 to March,2014,including the vital signs,the changes of serum sodium and chlorine before and after CRRT and the prognosis.Results Due to the fast decrease of serum sodium[12-17 mmol/（L · d）],24 hours after CRRT,3 cases suffered from severe hypotonicity cerebral edema and died of cerebral hernia and respiratory failure ;5 cases had certain improvement in vital signs and biochemical index 24 hours after CRRT,while because of failure of immediate surgery to cut off the crust and remove the necrotic tissue,the related index kept deteriorating and died of multi organ failure caused by septic shock 72 hours after treatment.Conclusions Systemic infection is the main cause of large area burn at the infection stage complicated with hypernatremia; CRRT may temporarily stabilize the vital signs and decrease the serum sodium,but surgical measure to remove the necrotic tissue is the key-point;it is important to master the method and indications in CRRT.