连续性高容量血液滤过对脓毒症合并重度急性呼吸窘迫综合征的疗效分析

Therapeutic efficiency of continuous high-volume hemofiltration in patients with sepsis and severe acute respiratory distress syndrome

目的探讨连续性高容量血液滤过(continuous high-volume hemofiltration,CHVHF)治疗脓毒症相关重度急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)的临床疗效。方法回顾性分析2008年1月至2014年12月入住我院重症监护室(ICU)的117例脓毒症相关重度ARDS患者的临床资料,按是否接受CHVHF分为血滤组(49例)和常规组(68例),常规组接受常规治疗,血滤组在常规治疗基础上应用CHVHF治疗。观察两组患者治疗前及治疗后6、24、48、72 h氧合指数(Pa O2/Fi O2)、血管外肺水指数(EVLWI)、动脉血二氧化碳分压(Pa CO2)等呼吸功能指标以及血流动力学参数如心率(HR)、平均动脉压(MAP)、中心静脉压(CVP)的变化;检测治疗前及治疗后6、24、48、72 h白介素6(IL-6)、C反应蛋白(CRP)的变化;并观察机械通气的持续时间、住ICU时间、撤机成功率、28 d存活率。结果两组治疗后血流动力学指标HR、MAP、CVP较治疗前均有明显改善(P<0.05),两组间没有显著差异(P>0.05)。血滤组的24 h Pa O2/Fi O2[(122.4±9.6)mm Hg]、24 h EVLWI[(10.6±2.5)m L/kg]、24 h Pa CO2[(46.7±6.2)mm Hg]等肺功能指标较常规组[(91.2±12.5)mm Hg、(12.8±2.6)m L/kg、(50.8±4.4)mm Hg]改善明显(P<0.05)。血滤组的IL-6、CRP明显比常规组下降快,6 h时血滤组IL-6[(51.61±6.09)pg/m L]、CRP[(22.97±4.24)mg/L]显著低于常规组[(61.31±2.90)pg/m L、(31.37±5.81)mg/L,P<0.05];血滤组机械通气时间(11.5±4.3)d、住ICU时间(19.5±9.2)d与常规组[(20.6±7.4)、(35.0±6.3)d]比较,明显缩短(P<0.05)。血滤组撤机成功率(89.7%)、28 d存活率(83.8%)较常规组(61.2%、63.3%)明显增高(P<0.05)。结论脓毒症合并重度ARDS患者采用CHVHF治疗能迅速改善肺功能,缩短机械通气时间,提高机械通气撤机成功率,降低病死率。

Objective To investigate the efficacy of continuous high-volume hemofiltration（ CHVHF） in patients with sepsis and severe acute respiratory distress syndrome（ ARDS）. Methods A retrospective study was conducted on a total of 117 patients with sepsis and severe ARDS,who were admitted to our intensive care unit（ ICU） from January 2008 to December 2014. They were divided into a control group（ n = 49） and a treatment group（ n = 68）. The patients in the treatment group were treated with CHVHF and routine treatments,while the patients in the control group received routine treatments only. The oxygenation index（ Pa O2/ Fi O2）,extravascular lung water index（ EVLWI）,arterial partial pressure of carbon dioxide（ Pa CO2）,heart rate（ HR）,mean arterial pressure（ MAP）,central venous pressure（ CVP）,interleukin-6（ IL-6）,and C-reactive protein（ CRP） were compared between the control group and the treatment group before treatment and at 6,24,48,and 72 h after treatment. The duration of mechanical ventilation（ MV）,ICU stay time,percentage of weaning from MV,and 28-day survival rate were observed. Results The indexes of pulmonary function in the 2 groups were improved after treatment. Along with the treatment time increase,Pa O2/ Fi O2 was elevated while EVLWI and Pa CO2 were lowered,and the improvements were more significant in the treatment group than in the control group（ 24 h Pa O2/ Fi O2： 122. 4 ± 9. 6 vs 91. 2 ± 12. 5mm Hg; 24 h EVLWI： 10. 6 ± 2. 5 vs 12. 8 ± 2. 6 m L / kg; 24 h Pa CO2： 46. 7 ± 6. 2 vs 50. 8 ± 4. 4 mm Hg,P 0. 05）. HR,MAP and CVP were also improved after treatment（ P 0. 05）,but there was no significant difference between the 2 groups（ P 0. 05）. Compared with the control group,6 h IL-6 and CRP levels were lower in the treatment group（ IL-6： 51. 61 ± 6. 09 vs 61. 31 ± 2. 90 pg / m L; CRP： 22. 97 ± 4. 24 vs 31. 37 ±5. 81 mg / L,P 0. 05）. Compared with the control group,the duration of MV and ICU stay time were shorter in the treatment group（ duration of MV： 11. 5 ± 4. 3 vs 20. 6 ± 7. 4; ICU stay time： 19. 5 ± 9. 2 vs 35. 0 ±6. 3,P 0. 05）,and the percentage of successful weaning from MV and 28-day survival rate were higher（ percentage of successful weaning from MV： 89. 7% vs 61. 2%; 28-day survival rate： 83. 8% vs 63. 3%,P 0. 05）. Conclusion CHVHF is an effective adjuvant treatment for severe ARDS through improving the lung function,shortening the duration of MV,improving the percentage of successful weaning from MV and the survival rate,and lowering the mortality.