血浆置换联合血液滤过治疗儿童严重脓毒症并多器官功能障碍综合征分析

Analysis of therapeutic plasma exchange combined with continuous venovenous hemofiltration in the treatment of children with severe sepsis and multiple organ dysfunction syndrome

目的:探讨血浆置换(TPE)联合连续性静脉-静脉血液滤过(CVVH)对儿童严重脓毒症并多器官功能障碍综合征(MODS)的治疗价值。方法:本研究为前瞻性随机对照研究。纳入2019年2月至2023年2月安阳市妇幼保健院收治的严重脓毒症并MODS患儿70例。按随机数字表法,将患儿分为联合组与CVVH组(各35例)。CVVH组采用CVVH治疗,联合组采用TPE联合CVVH治疗。观察2组抗生素使用时间,并采用t检验进行比较。对2组治疗前及治疗48 h、72 h的凝血酶原时间(PT)、凝血酶时间(TT)、部分凝血酶原时间(APTT)、纤维蛋白原(FIB)以及血清白细胞介素(IL)-1β、IL-6、肿瘤坏死因子-α(TNF-α)、高迁移率族蛋白B1(HMGB1)、Toll样受体4(TLR4)、可溶性受体(sFLT)水平进行分析,多时点整体比较采用重复测量方差分析,两两比较采用LSD-t检验。记录2组患儿28 d生存率,并采用χ^(2)检验进行比较。结果:联合组治疗48 h及72 h的PT、TT、APTT均低于CVVH组(均P<0.05)。联合组治疗48 h、72 h的FIB分别为(2.15±0.42)g/L、(2.89±0.27)g/L,高于CVVH组的(1.84±0.31)g/L、(2.49±0.20)g/L(均P<0.05)。联合组抗生素使用时间为(11.33±1.16)d,短于CVVH组的(13.54±1.92)d(t=5.828,P<0.05)。联合组治疗48 h及72 h的血清IL-1β、IL-6、TNF-α水平均低于CVVH组(均P<0.05)。联合组治疗48 h及72 h的血清HMGB1、TLR4、sFLT水平均低于CVVH组(均P<0.05)。联合组28 d存活率为94.29%,高于CVVH组的77.14%(χ^(2)=4.200,P=0.040)。结论:TPE联合CVVH能改善严重脓毒症并MODS患儿的凝血功能、炎症因子水平,其可能通过调节HMGB1、TLR4、sFLT水平达到治疗目的,改善短期预后。

ObjectiveTo investigate the therapeutic potential of therapeutic plasma exchange(TPE)combined with continuous venovenous hemofiltration(CVVH)in the treatment of children with severe sepsis and multiple organ dysfunction syndrome(MODS).MethodsIt was a prospective randomized controlled study(RCT)involving 70 children with severe sepsis and MODS admitted to Anyang Maternal and Child Health Hospital from February 2019 to February 2023.According to random number table method,they were randomly divided into combination group(35 cases)and CVVH group(35 cases).Patients in the CVVH group were treated with CVVH alone,and those in the combination group were treated with TPE combined with CVVH.The antibiotic use time of the two groups was recorded and compared by thet test.The prothrombin time(PT),thrombin time(TT),partial prothrombin time(APTT),fibrinogen(FIB),and serum levels of interleukin(IL)-1β,IL-6,tumor necrosis factor-α(TNF-α),high mobility group protein B1(HMGB1),Toll-like receptor 4(TLR4)and soluble receptor(sFLT)levels before treatment and 48 h and 72 h after treatment were compared by the repeated measurementANOVA for the overall comparison at multiple time points,and LSD-t test for pair-wise comparison.The 28-day survival of the two groups was recorded and compared by the Chi-square test.ResultsThe PT,TT and APTT at 48 h and 72 h after treatment were significantly lower in the combination group than those of CVVH group(all P<0.05).The FIB at 48 h[(2.15±0.42)g/Lvs.(1.84±0.31)g/L]and 72 h after treatment[(2.89±0.27)g/Lvs.(2.49±0.20)g/L]were significantly higher in the combination group than those of CVVH group(allP<0.05).The duration of antibiotic use in the combination group was significantly shorter than that of CVVH group[(11.33±1.16)dvs.(13.54±1.92)d,t=5.828,P<0.05].Serum levels of IL-1β,IL-6 and TNF-αat 48 h and 72 h were significantly lower in the combination group than those of CVVH group(allP<0.05).Serum levels of HMGB1,TLR4 and sFLT at 48 h and 72 h were significantly lower in the combination group than those of CVVH group(allP<0.05).The 28-day survival of the combination group was significantly higher than that of CVVH group(94.29%vs.77.14%,χ2=4.200,P=0.040).ConclusionsTPE combined with CVVH can improve the coagulation function and inflammatory factor levels in children with severe sepsis and MODS,which may achieve therapeutic objectives by regulating the levels of HMGB1,TLR4 and sFLT,and improve the short-term prognosis.