连续性肾脏替代治疗联合体外二氧化碳清除技术在儿童急性呼吸衰竭中的应用体会

Application of continuous renal replacement therapy combined with extracorporeal carbon dioxide removal in children with acute respiratory failure

目的探讨连续性肾脏替代治疗(continuous renal replacement treatment,CRRT)联合体外二氧化碳清除(extracorporeal CO_(2) removal,ECCO_(2)R)技术在呼吸衰竭患儿救治过程中的作用。方法回顾性分析2020年7月至2022年8月本院PICU收治的12例进行CRRT联合ECCO_(2)R治疗的呼吸衰竭患儿临床资料,观察患者的转归、体外管路使用情况,利用单因素方差分析比较前1 h,后1、6、12、24 h血气分析数值、呼吸机参数的差异,并进一步采用LSD方法进行两两比较。结果6例顺利撤离CRRT+ECCO_(2)R及机械通气,3例转ECMO治疗。自动放弃3例,死亡2例,总病死率41.7%。CRRT+ECCO_(2)R连续治疗时间15~112 h,2例出现体外管路堵塞。治疗1 h后PaCO_(2)由(64.67±24.4)mmHg降至(49.42±15.54)mmHg,pH值由(7.28±0.20)升至(7.38±0.11),FiO_(2)由(0.85±0.13)降至(0.78±0.15),PC由(19.42±4.34)cmH_(2)O降至(17.75±4)cmH2O;治疗24 h,PaCO_(2)降至(39.2±5.55)mmHg,pH值升至(7.41±0.04),FiO_(2)降至(0.46±0.11),PC降至(13.8±3.36)cmH_(2)O,较治疗前比较差异有统计学意义(P<0.05)。结论CRRT联合ECCO_(2)R治疗可以安全替代部分肺通/换气功能,并在保护右心功能、改善肺-肾交互发挥作用,可作为体外呼吸、循环、肾脏联合支持的一种选择,具有广阔的前景。

Objective To explore the role of continuous renal replacement therapy(CRRT)combined with extracorporeal carbon dioxide removal(ECCO_(2)R)in the treatment of children with respiratory failure.Methods The clinical data of 12 children with respiratory failure who were treated with CRRT+ECCO_(2)R in PICU of Jinan Children's Hospital from July 2020 to August 2022 were collected and analyzed retrospectively.The outcomes and the external pipeline usage of the patients were observed,and the blood gas analysis and ventilator parameters before 1 h and after 1,6,12 and 24 h of the treatment were compared by one-way ANOVA with LSD post hoc correction.Results Six patients successfully withdrew from CRRT+ECCO_(2)R and mechanical ventilation,three patients were transferred to ECMO treatment.Three cases died after voluntary withdrawal of treatment,and two cases died due to treatment failure.The mortality rate was 41.7%.After continuous treatment of CRRT+ECCO_(2)R for 15 to 112 h,two cases experienced extracorporeal circuit obstruction.After 1 h of treatment,PaCO_(2) decreased from(64.67±24.4)mmHg to(49.42±15.54)mmHg,pH increased from(7.28±0.20)to(7.38±0.11),FiO_(2) decreased from(0.85±0.13)to(0.78±0.15),PC decreased from(19.42±4.34)cmH2O to(17.75±4)cmH_(2)O.After 24 h of treatment,PaCO_(2) decreased to(39.2±5.55)mmHg,pH increased to(7.41±0.04),FiO_(2) decreased to(0.46±0.11),and PC decreased to(13.8±3.36)cmH_(2)O,and the differences were statistically significant compared with before treatment(P<0.05).Conclusions The combination of CRRT and ECCO_(2)R therapy can safely substitute for partial lung ventilation/perfusion function,and play a role in protecting right heart function and improving lung-kidney interaction.It can be considered as an option for extracorporeal respiratory,circulatory,and renal support,and consequently has broad prospects.