双重血浆分子吸附治疗重度胡蜂蜇伤患者的疗效和安全性--一项多中心历史对照研究

Effect and safety of double plasma molecular absorption in treatment of patients with severe wasp stings injury:a multicenter historical cohort study

目的:比较连续性静脉-静脉血液滤过(CVVH)+双重血浆分子吸附(DPMA)+血液灌流(HP)方案和CVVH+HP或CVVH +血浆置换(PE)方案救治重度胡蜂蜇伤患者的疗效及安全性。方法:采用多中心、历史队列研究和优效性检验的方法。自2020年7月至2022年10月,连续筛查5家研究中心医院重症监护病房(ICU)收治的重症胡蜂蜇伤患者,招募进入CVVH+DPMA+HP组(干预组)。采用倾向性评分方法,收集2016年1月至2020年6月各研究中心收治的重度胡蜂蜇伤病例,与干预组进行1∶1匹配,建立历史对照组。历史对照组按其实际的血液净化方案,分为CVVH+HP组和CVVH+PE组。主要观察指标为治疗后3 d和7 d的急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ);次要观察指标包括并发症、ICU住院时间、总住院时间和全因死亡事件。采用多因素Cox比例风险回归法分析患者预后。结果:经过倾向性得分匹配,干预组与两个历史对照组分别有56例患者匹配成功。匹配后,各组在年龄、性别、基础病、生化检查指标和危重症评分等基线指标方面比较差异均无统计学意义。治疗后,3组APACHEⅡ评分均明显降低,干预组下降更快;接受DPMA治疗〔风险比( HR)=1.04,95%可信区间(95% CI)为1.02~1.08, P=0.00〕及体温( HR=1.02,95% CI为1.00~1.03, P=0.02)、血中肌酸激酶(CK;HR=0.98,95% CI为0.96~1.00, P=0.05)和肌红蛋白(MYO;HR=2.88,95% CI为1.24~6.69, P=0.01)水平降低是使APACHEⅡ评分降至目标值(15分)的独立危险因素。各组间出血并发症、滤器或灌流器血栓形成、血压降低、导管相关感染和过敏反应的发生率比较差异均无统计学意义。 结论:CVVH+DPMA+HP方案能显著降低重症胡蜂蜇伤患者的APACHEⅡ评分,效果优于CVVH+HP和CVVH+PE方案,且安全性较好。

Objective To compare the effect and safety of continuous veno-venous hemofiltration(CVVH)+double plasma molecular absorption(DPMA)+hemoperfusion(HP),CVVH+HP,and CVVH+plasma exchange(PE)in treatment of patient with severe wasp stings injury.Methods Multicenter,historical cohort study and superiority test were used.From July 2020 to October 2022,patients with wasp sting injury and multiple organ damage admitted to the intensive care units(ICU)of five hospitals were consecutively screened and recruited into the CVVH+DPMA+HP group(intervention group).Propensity score matching was used to establish historical cohorts.Patients with severe wasp sting injury who hospitalized from January 2016 to June 2020 in each ICU were collected and matched 1∶1 with the intervention group,and divided into CVVH+HP group and CVVH+PE group according to their actual hemopurification protocols(historical control groups).The primary outcome was the acute physiology and chronic health evaluationⅡ(APACHEⅡ)score on days 3 and 7 after initiation of treatment.Secondary outcomes included complications,length of ICU and hospital stays,and all-cause mortality.Multivariate Cox proportional risk regression was used to analyze the prognosis of patients.Results After propensity score matching,56 patients in intervention group and each of the two historical control groups were matched successfully.There were no significant differences in age,gender,comorbidities,biochemical test indices and critical illness scores among the groups.After treatment,APACHEⅡscore markedly declined in all groups,and the decrease was faster in the intervention group;treatment with DPMA[hazard ratio(HR)=1.04,95%confidence interval(95%CI)was 1.02-1.08,P=0.00],the decreased levels of body temperature(HR=1.02,95%CI was 1.00-1.03,P=0.02),serum creatine kinase(CK;HR=0.98,95%CI was 0.96-1.00,P=0.05)and myoglobin(MYO;HR=2.88,95%CI was 1.24-6.69,P=0.01)were independent risk factors for APACHEⅡscore decline to the target value(15 scores).There were no significant differences in the incidence of bleeding complications,filter or perfusion thrombosis,blood pressure reduction,catheter-related infection and anaphylaxis among the groups.Conclusion CVVH+DPMA+HP regimen can significantly reduce the APACHEⅡscore of patients with severe wasp sting injury,and the efficacy is superior to CVVH+HP and CVVH+PE regimens,with safety.