连续性血浆吸附滤过治疗急性药物中毒患者的临床应用及干预策略研究

Continuous plasma adsorption filtration and other intervention strategies for the treatment of acute drug intoxication

目的探讨应用连续性血浆吸附滤过技术治疗急性药物中毒患者的生命体征监测、血液净化装置压力评估及体外循环抗凝血方法等临床应用干预策略。方法回顾性分析2010年1月~2015年05月武警后勤学院附属医院中毒急救中心收治的急性药物中毒行连续性血浆吸附滤过(continuous plasma filtration adsorption,CPFA)89例(A组),连续性静-静血液滤过(continuous veno-venous hemofiltration,CVVH)89例(B组),连续性血浆吸附治疗89例(C组)患者的临床资料。对比分析3组患者在连续性血液净化治疗技术(continuous blood purification,CBP)治疗前10min,开始后10min、30min、60min患者收缩压、心率、静脉压变化;CBP治疗前10min,开始后3h、6h、12h患者的凝血功能;CBP治疗开始后30min、3h、6h、12h血流速、动脉压、滤前压、静脉压、跨膜压、滤压降。结果 3组患者在性别(χ~2=0.069,P=0.753)、年龄(χ~2=0.012,P=0.839)、临床诊断(χ~2=0.173,P=0.236)比较差异均无统计学意义,抗凝方式比较有统计学意义(χ~2=6.596,P=0.013);3组患者在CBP治疗前10min,治疗开始后10min、30min、60min患者收缩压(F=1.154,2.732,2.132,1.117;P=0.532、0.367、0.473、0.532)、心率(F=2.183,1.105,1.127,1.165;P=0.463,0.537,0.517,0.567)、静脉压(F=2.132,1.974,2.118,2.734;P=0.162,0.423,0.397,0.476)比较差异均无统计学意义;3组患者在CBP治疗前10min,开始后3h、6h、12h患者的活化凝血时间(activated clotting time,ACT)(F=1.389,0.832,0.764,0.967;P=0.132,0.475,0.619,0.397)、活化的部分凝血活酶时间(activated partial thromboplastin time,APPT)(F=0.893,1.287,1.769,1.197;P=0.513,0.195,0.096,0.197)、静脉游离钙(F=2.174,2.165,1.135,0.973;P=0.093,0.089,0.298,0.498)比较差异均无统计学意义;CBP治疗开始后30min、3h、6h、12h血流速(F=0.985,1.125,0.932,0.845;P=0.316,0.367,0.513,0.579)、动脉压(F=0.983,0.875,0.927,1.107;P=0.326,0.516,0.321,0.225)、静脉压(F=1.832,1.974,0.893,1.134;P=0.187,0.129,0.132,0.176)比较差异均无统计学意义;CBP治疗开始后30min、3h、6h、12h滤前压(F=17.985,20.125,18.932,25.845;P均<0.001)、滤压降(F=19.983,23.875,19.927,17.107;P均<0.001)有统计学意义。结论 3组患者在CBP治疗期间抗凝方式存在统计学差异,但是治疗期间不同时间点凝血功能均无统计学差异;3组患者开始治疗后滤前压、滤压降存在统计学意义,但是其压力范围均在CBP正常值范围内。因此虽然CPFA体外循环血容量相对CVVH、连续性血浆吸附治疗增加,但是通过有效的临床干预措施可以应用于急性药物中毒患者临床救治。

Objective To study continuous plasma adsorption filtration and other intervention strategies including monitoring of vital signs, pressure measurement in blood purification instrument, and anticoagulant during extracorporeal circulation for the treatment of acute drug poisoning. Methods This was a retrospective study for acute drug poisoning patients treated in the period of Jan. 2010 to May 2010 in the Center for Intoxication Emergency, Affiliated Hospital of Logistics College of Armed Police Force. Patients were treated with continuous plasma filtration adsomtion （CPFA： grouv A, n=89）, continuous venovenous hemofiltration （CVVH; group B, rF89）, or continuous plasma adsorption （group C, n=89）. Systolic blood pressure, heart rate and venous pressure before continuous blood purification （CBP） and after CBP for 10, 30, and 60 minutes, blood coagulation function before CBP and after CBP for 3, 6, 12 hours, and blood flow velocity, arterial pres- sure, pressure before the filter, venous pressure, transmembrane pressure, and pressure difference across the filter after CBP for 0.5, 3, 6, and 12 hours were compared among the 3 groups. Results There were no differences in gender, age, and clinical diagnosis among the 3 groups （for gender：x^2=0.069, P=-0.753; for age： 2;= 0.012, P=0.893; for clinical diagnosis： 2;=0.173, P=0.236）. However, anticoagulation method was statistically different among the 3 groups （x^2=6.596, P=0.013）. There were no statistical differences in systolic blood pressure, heart rate and venous pressure before CBP and after CBP for 10, 30 and 60 minutes among the 3 groups （for systolic blood pressure： F=1.154, 2.732, 2.132 and 1.117, P=-0.532, 0.367, 0.473 and 0.532; for hear rate： F=2.183, 1.105, 1.127 and 1.165, P=-0.463, 0.537, 0.517 and 0.537; for venous pressure： F=2.132, 1.974, 2.118 and 2.734, P=-0.162, 0.423, 0.397 and 0.476, before CBP and after CBP for 10, 30 and 60 minutes respectively）. There were no statistical differences in activated clotting time （ACT）, activated partial thromboplastin time （APPT）, and venous free Ca＋2 before CBP and after CBP for 3, 6 and 12 hours among the 3 groups （for ACT： F=1.389, 0.832, 0.764 and 0.967, P=-0.132, 0.475, 0.619 and 0.397; for APPT： F=0.893, 1.287, 1.769 and 1.197, P=-0.513, 0.195, 0.096 and 0.197; for venous free Ca＋2： F=2.174, 2.165, 1.135 and 0.973, P=-0.093, 0.089, 0.298 and 0.498, before CBP and after CBP for 3, 6 and 12 hours respectively）. There were no differences in blood flow velocity, arterial pressure and venous pressure after CBP for 0.5, 3, 6, and 12 hours among the 3 groups （for blood flow velocity： F=0.985, 1.125, 0.932 and 0.845, P=-0.316, 0.367, 0.513 and 0.579; for arterial pressure： F=0.983, 0.875, 0.927 and 1.107, P=-0.326, 0.516, 0.321 and 0.225; for venous pressure： F=1.832, 1.974, 0.893 and 1.134, P=-0.187, 0.129, 0.132 and 0.176, after CBP for 30 min- utes, 3, 6, and 12 hours respectively）. However, there were statistical differences in pressure before the filter and pressure difference across the filter after CBP for 30 minutes, 3, 6, and 12 hours among the 3 groups （for pressure before the filter： F=I 7.985, 20.125, 18.932, 25.845, P^0.001; for pressure difference across the fil- ter： F=19.983, 23.875, 19.927, 17.107, P〈0.001, after CBP for 30 minutes, 3, 6, and 12 hours respectively）. Conclusion Although anticoagulation method was dissimilar, the coagulation function at several time points during CBP had no differences among the 3 groups. Pressure before the filter and pressure difference across the filter after CBP were statistically different among the 3 groups, but they were still in the normal ranges of CBE The extracorporeal blood volume in CPFA is larger than that of CVVH and continuous plasma adsorp- tion, but it can still be used for the treatment of drug intoxication through sophisticated intervention strategies.