重症烧伤患者救治中CRRT的应用

Application of continuous renal replacement for the treatment of severely burned patients

严重烧伤患者仍面临死亡率高、预后差的问题,临床需要应用更积极方法来救治。严重烧伤患者面临强烈的系统性反应,表现为应激状态、高细胞因子血症及高分解状态,这些情况是促使患者病情恶化及预后差的重要因素。烧伤患者的急性肾损伤具有一些特点,如小球性及小管性损伤明显,传统肾功能指标如血清肌酐可能无法准确反映其功能状态及损伤程度。还可能存在横纹肌溶解相关肾损伤。虽然目前没有循证医学证据,从烧伤病理生理、临床经过,连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)其他疾病应用的疗效、机制及临床实践经验来看,应用CRRT治疗严重烧伤患者可能有助于改善患者应激反应、高分解代谢及持续清除毒素、维持内环境稳定,从而稳定患者临床状态及改善预后。当然,在应用CRRT过程中需解决好一些实际问题,包括导管感染、抗凝及药物剂量调整等。

Severely burned patients remain to have high mortality and serious prognosis, and are in need of efforts to improve their treatment. Strong systemic response to bum injury manifested as stress status, hypercytokinemia and hypermetabolism plays an important role in the deterioration to severe clinical condition and unfavorable outcome in these patients. Acute kidney injury （AKI） in burned patients has some characteris- tics such as apparent glomerular and tubular damages, of which the malfunctional status and damage severity may not be exactly reflected by conventional parameters such as the increase of serum creatinine. Rhabdomyolysis and associated AKI may also be common in these patients. Despite the lack of clinical experience on evidence-based medicine about continuous renal replacement of therapy （CRRT） for severely burned patients, CRRT may stabilize clinical conditions and obtain a better outcome by alleviating stress reactions and hype metabolism, continuously removing toxins from circulation, and maintaining homeostasis from the point of view of pathological changes and clinical course in burn injury. However, several practical issues about CRRT including catheter-related infection, anticoagulation and drug dose adjustment need to be studied further.