配对血浆滤过吸附与连续性静脉-静脉血液滤过治疗脓毒性休克并发急性呼吸窘迫综合征疗效比较

Comparison of the effect of coupled plasma filtration adsorption and continuous veno-venous hemofiltration in the treatment of patients with septic shock and acute respiratory distress syndrome

目的比较配对血浆滤过吸附(CPFA)与连续性静脉-静脉血液滤过(CVVH)治疗脓毒性休克并发急性呼吸窘迫综合征(ARDS)的临床效果,探讨CPFA在脓毒性休克并发ARDS患者中的应用价值。方法选择2018年1月至2020年12月郑州大学附属郑州中心医院呼吸重症监护室(RICU)收治的60例脓毒性休克并发ARDS患者为研究对象,根据血液净化模式将患者分为CVVH组和CPFA组,每组30例。分别于治疗前及治疗后第1、2、3天检测2组患者血清C反应蛋白(CRP)、降钙素原(PCT)、白细胞介素-6(IL-6)、白细胞介素-10(IL-10)、肿瘤坏死因子-α(TNF-α)水平;分别于治疗前及治疗后第1、2、3、7天检测2组患者动脉血乳酸(LAC)水平,并测量收缩压及舒张压,计算平均动脉压(MAP);分别于治疗前及治疗后第3、7天检测2组患者淋巴细胞(LY)及T淋巴细胞亚群CD3^(+)、CD4^(+)、CD8^(+)水平,并测定动脉血氧分压,计算CD4^(+)/CD8^(+)、氧合指数;分别于治疗前及治疗后第3、7天对2组患者进行序贯器官衰竭(SOFA)评分;分别于治疗前及治疗后第1、2、3、7天检测2组患者红细胞(RBC)、白细胞(WBC)及血小板(PLT)水平;记录2组患者RICU机械通气时间、RICU住院时间、去甲肾上腺素(NE)应用情况及28 d生存率。结果治疗前2组患者血清PCT、CRP、IL-6、IL-10及TNF-α水平比较差异无统计学意义(P>0.05);2组患者治疗后第1、2、3天血清PCT、CRP、IL-6、IL-10及TNF-α水平均呈下降趋势(P<0.05),CPFA组患者血清IL-6、IL-10、TNF-α水平降低程度大于CVVH组(P<0.05);治疗后第1、2、3天,CPFA组患者血清IL-10水平显著低于CVVH组(P<0.05);治疗后第1、2天,CPFA组患者血清IL-6、TNF-α水平显著低于CVVH组(P<0.05);治疗后第1、2、3天,2组患者血清CRP、PCT水平比较差异无统计学意义(P>0.05)。治疗前2组患者MAP及动脉血LAC水平比较差异无统计学意义(P>0.05);2组患者治疗后1、2、3、7天MAP呈上升趋势,动脉血LAC水平呈下降趋势(P<0.05);治疗后第2天,CPFA组患者动脉血LAC水平显著低于CVVH组(P<0.05);治疗后1、2、3、7天,2组患者MAP比较差异无统计学意义(P>0.05);治疗后1、3、7天,2组患者动脉血LAC水平比较差异无统计学意义(P>0.05)。治疗前2组患者LY、CD3^(+)、CD4^(+)、CD8^(+)水平及CD4^(+)/CD8^(+)比较差异无统计学意义(P>0.05);2组患者治疗后第3、7天LY、CD3^(+)、CD4^(+)、CD8^(+)水平均呈上升趋势(P<0.05),CPFA组患者LY、CD3^(+)、CD4^(+)、CD8^(+)的上升程度显著大于CVVH组(P<0.05);CVVH组患者治疗后第3、7天CD4^(+)/CD8^(+)呈下降趋势(P<0.05),CPFA组患者治疗后第3、7天CD4^(+)/CD8^(+)呈上升趋势(P<0.05)。治疗后第3天,2组患者LY、CD3^(+)、CD4^(+)、CD8^(+)水平比较差异无统计学意义(P>0.05);治疗后第7天,CPFA组患者LY、CD3^(+)、CD4^(+)、CD8^(+)水平显著高于CVVH组(P<0.05);治疗后第3、7天,2组患者CD4^(+)/CD8^(+)比较差异均无统计学意义(P>0.05)。治疗前2组患者氧合指数比较差异无统计学意义(P>0.05);2组患者治疗后第3、7天氧合指数均呈上升趋势(P<0.05);治疗后第3天CPFA组患者氧合指数显著高于CVVH组(P<0.05),治疗后第7天2组患者氧合指数比较差异无统计学意义(P>0.05)。治疗前2组患者SOFA评分比较差异无统计学意义(P>0.05);2组患者治疗后第3、7天SOFA评分呈下降趋势(P<0.05);治疗后第3、7天2组患者SOFA评分比较差异无统计学意义(P>0.05)。治疗前及治疗后1、2、3、7天2组患者RBC、WBC及PLT水平比较差异均无统计学意义(P>0.05),2组患者组内不同时间点间RBC、WBC、PLT水平比较差异均无统计学意义(P>0.05)。CPFA组患者RICU机械通气时间、NE使用时间显著短于CVVH组,NE使用量显著少于CVVH组(P<0.05);2组患者RICU住院时间比较差异无统计学意义(P>0.05)。CPFA组和CVVH组患者28 d存活率分别为66.67%(20/30)、60.00%(18/30),2组患者28 d存活率比较差异无统计学意义(χ^(2)=0.447,P>0.05)。结论对于脓毒性休克并发ARDS患者,CPFA在清除机体炎症介质、稳定血流动力学、调节免疫功能、改善氧合指数、缩短RICU机械通气时间等方面较CVVH更具有优势。

Objective To investigate the clinical value of coupled plasma filtration adsorption(CPFA)by comparing the clinical efficacy of CPFA and continuous veno-venous hemofiltration(CVVH)in patients with septic shock and acute respiratory distress syndrome(ARDS).Methods Sixty patients with septic shock and ARDS received in the respiratory intensive care unit(RICU)of Zhengzhou Central Hospital Affiliated to Zhengzhou University from January 2018 to December 2020 were selected as the research subjects.The patients were divided into CVVH group and CPFA group according to the blood purification mode,with 30 cases in each group.The levels of serum C-reactive protein(CRP),procalcitonin(PCT),interleukin-6(IL-6),interleukin-10(IL-10),tumor necrosis factor-α(TNF-α)in the two groups were detected before treatment and on the 1^(st),2^(nd),3^(rd) day after treatment.The level of arterial blood lactic acid(LAC)were detected before treatment and on the 1^(st),2^(nd),3^(rd),7^(th) day after treatment;meanwhile,the systolic and diastolic blood pressure were measured,and the mean arterial pressure(MAP)was calculated.The levels of lymphocyte(LY)and T-lymphocytes subgroups(CD3^(+),CD4^(+),CD8^(+))in the two groups were detected before treatment and on the 3^(rd),7^(th) day after treatment;meanwhile,the arterial partial pressure of oxygen was measured,and oxygenation index and CD4^(+)/CD8^(+) were calculated.The sequential organ failure assessment(SOFA)score of patients in the two groups was performed before treatment and on the 3^(rd),7^(th) day after treatment.The levels of red blood cell(RBC),white blood cell(WBC)and platelet(PLT)were detected before treatment and on the 1^(st),2^(nd),3^(rd),7^(th) day after treatment.The mechanical ventilation time in RICU,hospitalization time of RICU,the use of noradrenaline(NE)and the 28-day survival rate of patients in the two groups were recorded.Results There was no significant difference in the levels of serum PCT,CRP,IL-6,IL-10 and TNF-αbetween the two groups before treatment(P>0.05).The levels of seurm CRP,PCT,IL-6,IL-10 and TNF-αof patients in both groups showed a downward trend on the 1 ^(st),2^(nd) and 3^(rd) day after treatment(P<0.05),and the reduction of serum IL-6,IL-10 and TNF-αlevels in the CPFA group was greater than those in the CVVH group(P<0.05).The level of serum IL-10 in the CPFA group was significantly lower than that in the CVVH group on the 1^(st),2^(nd) and 3^(rd) day after treatment(P<0.05).The levels of serum IL-6 and TNF-αin the CPFA group were significantly lower than those in the CVVH group on the 1^(st) and 2^(nd) day after treatment(P<0.05).There was no significant difference in the levels of serum CRP and PCT between the two groups on the 1^(st),2^(nd)and 3^(rd) day after treatment(P>0.05).There was no significant difference in the levels of MAP and arterial blood LAC between the two groups before treatment(P>0.05).The MAP showed an upward trend,and the arterial blood LAC level showed a downward trend on the 1^(st),2^(nd),3^(rd),7^(th) day after treatment in the two groups(P<0.05).The level of arterial blood LAC in the CPFA group was significantly lower than that in the CVVH group on the 2^(nd) day after treatment(P<0.05).There was no significant difference in the MAP between the two groups on the 1^(st),2^(nd),3^(rd),7^(th) day after treatment(P>0.05).There was no significant difference in the level of arterial blood LAC between the two groups on the 1^(st),3^(rd),7^(th) day after treatment(P>0.05).There was no significant difference in the levels of LY,CD3^(+),CD4^(+),CD8^(+) and CD4^(+)/CD8^(+) between the two groups before treatment(P>0.05).The levels of LY,CD3^(+),CD4^(+) and CD8^(+) in the two groups showed an upward trend on the 3^(rd) and 7^(th) day after treatment(P<0.05),and the increases of LY,CD3^(+),CD4^(+),CD8^(+) in the CPFA group were significantly higher than those in the CVVH group(P<0.05).On the 3^(rd) and 7^(th) day after treatment,the CD4^(+)/CD8^(+) in the CVVH group showed a downward trend(P<0.05),while the CD4^(+)/CD8^(+)showed an upward trend in the CPFA group(P<0.05).There was no significant difference in the LY,CD3^(+),CD4^(+),CD8^(+) levels between the two groups on the 3^(rd) day after treatment(P>0.05).The levels of LY,CD3^(+),CD4^(+) and CD8^(+) in the CPFA group were significantly higher than those in the CVVH group on the 7^(th) day after treatment(P<0.05).There was no significant difference in CD4^(+)/CD8^(+) between the two groups on the 3^(rd) and 7^(th) day after treatment(P>0.05).There was no significant difference in the oxygenation index between the two groups before treatment(P>0.05).The oxygenation index in the two groups showed an upward trend on the 3^(rd) and 7^(th) day after treatment(P<0.05).The oxygenation index in the CPFA group was significantly higher than that in the CVVH group on the 3^(rd) day after treatment(P<0.05),but there was no significant difference in the oxygenation index between the two groups on the 7^(th) day after treatment(P>0.05).There was no significant difference in the SOFA score between the two groups before treatment(P>0.05).The SOFA score in the two groups showed a downward trend on the 3^(rd) and 7^(th) day after treatment(P<0.05).There was no significant difference in the SOFA score between the two groups on the 3^(rd) and 7^(th) day after treatment(P>0.05).There was no significant difference in the RBC,WBC and PLT levels between the two groups before treatment and on the 1^(st),2^(nd),3^(rd),7^(th) day after treatment(P>0.05).There was no significant difference in the RBC,WBC and PLT levels at different time points in the two groups(P>0.05).The mechanical ventilation time in RICU and NE using time in the CPFA group were significantly shorter than those in the CVVH group,and the dose of NE in the CPFA group was significantly less than that in the CVVH group(P<0.05).There was no significant difference in the hospitalization time in RICU between the two groups(P>0.05).The 28-day survival rate in the CPFA group and CVVH group was 66.67%(20/30)and 60.00%(18/30),respectively.There was no significant difference in the 28-day survival rate between the two groups(χ^(2)=0.447,P>0.05).Conclusion For the patients with septic shock and ARDS,CPFA has more advantages than CVVH in removing pro-inflammatory mediators,stabilizing hemodynamics,regulating immune function,improving oxygenation index and shorting the mechanical ventilation time in RICU.