连续性静脉-静脉血液滤过对重症患者 经肺热稀释法测量心排血量的影响

The influence of continuous veno-venous hemofiltration on cardiac output value monitored by transpulmonary thermodilution technique in critical patients

目的：探讨重症患者进行连续性静脉-静脉血液滤过（CVVH）时对经肺热稀释法监测心排血量（CO）值及血流动力学指标的影响。方法采用前瞻性队列研究方法，选择2011年1月至2015年10月遵义医学院附属医院重症加强治疗病房（ICU）收治的62例重症患者。所有患者经股静脉穿刺置管成功后进行CVVH，分别在CVVH运行前、运行后即刻（动脉端泵出血后立即注射8℃生理盐水）、运行后5min、突然中断即刻（运行10min按暂停键），以及重新恢复运行后即刻、15min、30min应用脉搏指示连续心排血量（PiCCO）监测仪监测CO值，同时观察各时间点心率（HR）、平均动脉压（MAP）、中心静脉压（CVP）及中心血温的变化。结果从CVVH运行前至运行后5min，患者的CO值均未出现明显变化，波动在6.96（7.33，8.67）～6.98（6.43，7.45）L/min；直至CVVH突然中断即刻，CO值突然升高并达峰值8.04（7.36，8.77）L/min，且与其他时间点比较差异有统计学意义（均P＜0.01）；CVVH重新恢复运行后即刻，CO值骤降至4.71（4.14，7.26）L/min，且明显低于其他时间点（均P＜0.01）；随着CVVH恢复运行，患者CO值逐渐恢复到中断前的稳定运行水平〔4.71（4.14，7.26）～6.85（6.08，7.26）L/min〕。CO监测期间，患者HR、MAP、CVP等其他血流动力学指标以及中心血温均处于稳定水平，未见明显变化。结论 CVVH中断即刻PiCCO监测的CO值明显升高，CVVH恢复运行后即刻CO值明显降低，而CVVH正常运行时不影响CO值的监测；CVVH正常运行对HR、MAP、CVP等其他血流动力学及中心血温均无明显影响。

Objective To investigate the influence of continuous veno-venous hemofiltration （CVVH） on cardiac output （CO） value and parameters of hemodynamics monitored by transpulmonary thermodilution technique in critical patients. Methods A prospective cohort study was conduced. Sixty-two critical patients admitted to intensive care unit （ICU） of Zunyi Medical College Affiliated Hospital from January 2011 to October 2015 were enrolled. All of the patients received CVVH through femoral vein puncture catheter. The CO value was monitored before CVVH operation, immediately after CVVH operation （8 ℃ normal saline was injected immediately after the output of blood from the arterial end）, 5 minutes after operation, the time at the sudden interruption （press pause key after 10 minutes of operation） and resumed immediately, 15 minutes and 30 minutes after operation by pulse-indicated continuous cardiac output （PiCCO） with transpulmonary thermodilution method. The changes in heart rate （HR）, mean arterial pressure （MAP）, central venous pressure （CVP）, and blood temperature were observed at all time points. Results From CVVH before start to 5 minutes thereafter, CO values were not significantly changed in patients, fluctuating in 6.96 （7.33, 8.67）-6.98 （6.43, 7.45） L/min. When CVVH was suddenly interrupted, CO value was immediately increased to the peak 8.04 （7.36, 8.77） L/min, which showed statistically significant difference as compared with other time points （all P 〈 0.01）. Immediately after the CVVH recovery from interruption, the CO value dropped to 4.71 （4.14, 7.26） L/min, and it was significantly lower than those at other time points （all P 〈 0.01）. With the CVVH recovery, the patients＆#39; CO value was gradually restored to the stable operation ahead of interruption [4.71 （4.14, 7.26）-6.85 （6.08, 7.26） L/min]. During CO monitoring, HR, MAP, CVP and blood temperature of the patients were at the same level, and no significant changes were founded. Conclusions CVVH interruption of immediate PiCCO monitoring CO value were significantly increased, immediately after the CVVH recovery the CO value were significantly reduced, and the normal operation of CVVH did not affect the CO value monitoring. Hemodynamics and blood temperature of all patients were stable during CVVH.