超声在ICU对连续性肾灌注时血流变学观察的研究

Study and observation of ultrasound on hemorheology of continuous renal replacement therapy in ICU

目的:通过观察床旁超声对连续性肾脏替代治疗(CRRT)血流变的影响,探讨床旁超声在ICU急性肾损伤(AKI)患者CRRT容量管理中的临床价值。方法:选取CRRT的AKI患者311例,随机分为观察组和对照组,观察组应用床旁超声技术,监测三尖瓣环平面收缩位移(TAPSE)、下腔静脉内径(IVC)、下腔静脉管径呼吸变异指数(RVI)和左室Tei指数的变化,于CRRT前、治疗后30 min及6、12、18、24、36、48 h根据各参数的变化调节CRRT的液体平衡;对照组根据CVP的变化调节液体平衡。两组于治疗开始前均用超声测量肾脏大小排除两组异质性,并于治疗后48 h对比两组肾主动脉内径、肾主动脉阻力指数(RRI)和肾血流量的差异。结果:两组在治疗前肾脏长径、肾实质厚度及肾实质回声强度均具有可比性(P>0.05)。观察组中RVI在CRRT6 h后各时间点明显升高,IVC值在治疗6 h后各时间点逐渐下降,于36 h后趋于较稳定的水平(F=27.746、15.446,P<0.05);而TAPSE在治疗12 h后各时间点逐渐增加,左室Tei指数在治疗后12 h逐渐下降,在随后24 h处于较稳定的趋势(F=36.213、17.127,P<0.05);观察组各指标在显著变化时间点时均有统计学差异(P<0.05),而对照组中CVP值在各时间点均无统计学差异(F=2.189,P>0.05)。在治疗48 h后观察组的肾主动脉内径和肾血流量较对照组明显增加(t=2.356、2.075,P<0.05),RRI较对照组明显下降(t=2.244,P<0.05),差异均有统计学意义(P<0.05)。结论:床旁超声能有效的指导AKI患者CRRT的容量管理,同时对肾脏的灌注也能进行很好地评估。

Objective:To observe the influence of bedside ultrasound on hemodynamics of continuous renal replacement therapy,and explore the clinical value of bedside ultrasound technique in acute kidney injury(AKI)patients with continuous renal replacement therapy(CRRT)and capacity management.Methods:Totally 311 cases of AKI patients with CRRT were divided randomly into observation group and control group.Bedsides,ultrasound technique was used in the observation group,by monitoring tricuspid annular plane systolic excursion(TAPSE),internal diameter of inferior vena cava(IVC),respiratory variation index of the inferior vena cava internal diameter(RVI)and left vertical Tei index changes.Meanwhile,each parameter change was mediated by ultrasound detection from before,to 30 min,6 h,12 h,36 h,48 h after of CRRT to sustain liquid balance in observation group,however,CVP change was modulated in control group.The difference of kidney length in pre-CRRT were examined to exclude,and of renal aortic diameter,renal resistance index(RRI)and renal blood flow in post-48 h of CRRT were compared in two groups.Results:Renal length,renal parenchyma thickness and echo strength of renal parenchyma weren’t different statistically in pre-CRRT of two groups(P>0.05).In observation group,the RVI level started to increase significantly and IVC internal diameter to decrease at 6 h,which would tend to be stable at 36 h(F=27.746 and 15.446 respectively);the TAPSE level was gradual ascending and Tei index was descending at 12 h with a stable tendency at 24 h of CRRT(F=36.213 and 17.127 respectively),and there was difference statistical among time of obvious change in TAPSE,IVC internal diameter,RVI and Tei index(P<0.05);In control group,there was no difference statistical among each time in CVP(F=2.189,P>0.05).Compared with control group,renal aortic diameter and renal blood flow were increased significantly(t=2.356 and 2.075),while RRI was decreased obviously in observation group(t=2.244),which was statistically significant(P<0.05).Conclusion:the application of bedside ultrasound technique in AKI patient’s capacity management with CRRT was more effective and can provide better evaluation for the kidney perfusion.