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目的观察日间高容量血液滤过(high volume hemofiltration,HVHF)治疗感染性休克伴急性肾损伤(acute kideny injury,AKI)、多脏器功能不全(multiple organ dysfunction syndrome,MODS)患者的临床疗效。方法 50例患者分为对照组和治疗组,每组25例患者。采集患者炎症介质:肿瘤坏死因子-α(Tumor necrosis factor-α,TNF-α)、白细胞介素-10(Interleukin-10,IL-10)的浓度;中心静脉压力、维持患者平均动脉压(mean arterial pressure,MAP)在65~70mm Hg(1mm Hg=0.133kpa)时的去甲肾上腺(noradrenaline,NE)的剂量及动脉血乳酸浓度,氧和指数;血肌酐、尿素氮水平,急性生理与慢性健康评分(acute physiology and chronic health evaluationⅡ,APACHEⅡ);并记录2组患者住院期间机械通气时间、2组实验结束后需要继续血液透析患者人数、ICU住院时间、总住院时间、住院病死率、28天病死率。结果 ?血液净化治疗后,2组患者血液中TNF-α,IL-10浓度均下降,治疗组下降更加明显:IL-10在48h和72h与对照组相比,差异有统计学意义(t分别为2.425、2.893;P分别为0.019、0.006),TNF-a在72h差异有统计学意义(t=2.646,P=0.011)。(2)治疗后2组患者呼吸、循环、肾功能指标及APACHEⅡ评分均改善,治疗组改善显著:在维持患者MAP在65~70mm Hg所需NE剂量治疗组在24h、48h、72h较对照组降低更显著,差异有统计学意义(t为2.228、2.490、3.674;P分别为0.031、0.016、0.001);在治疗后48h和72h,治疗组氧合指数升高程度较对照组更显著,差异有统计学意义(t为-2.343、-2.225;P为0.023及0.031)。治疗组平均机械通气时间显著少于对照组,差异有统计学意义(t=6.363,P<0.001);治疗组在24h、48h、72h的APACHEⅡ评分分低于对照组,差异有统计学意义(t为3.732、2.502、2.771;P为0.001、0.016、0.008);治疗组机械通气时间(t=6.363,P<0.001)、ICU住院时间(t=2.409,P=0.020)、总住院时间(t=2.527,P=0.015)均显著少于对照组。结论日间高容量血液滤过可以改善患者的呼吸循环指标,降低APACHEⅡ评分,减少ICU及总住院时间,减少住院及28天病死人数。
Objective To observe the clinical efficacy of high volume hemofiltration (HVHF) in the treatment of patients with septic shock and acute kindey injury (AKI) and multiple organ dysfunction syndrome (MODS). Methods 50 patients were divided into control group and treatment group, each group of 25 patients. The inflammatory mediators of patients were collected: the concentrations of Tumor necrosis factor-α (TNF-α), Interleukin-10 (IL-10), central venous pressure, mean arterial pressure arterial blood pressure (MAP), noradrenaline (NE) dose and arterial blood lactic acid concentration, oxygen and index at 65-70 mm Hg (1 mm Hg = 0.133 kPa), serum creatinine, urea nitrogen level, acute physiology and chronic (APACHEⅡ). The duration of mechanical ventilation during hospital stay was recorded in both groups. The number of hemodialysis patients, ICU hospital stay, total hospital stay, hospital mortality, 28 days after the end of the two groups were recorded Case fatality rate. Results After the blood purification treatment, the concentrations of TNF-α and IL-10 in the blood of the two groups decreased, and the decrease of the treatment group was more obvious: the difference of IL-10 between the two groups was statistically significant at 48h and 72h P = 0.019, 0.006 respectively). There was a significant difference in TNF-a at 72h (t = 2.646, P = 0.011). (2) Respiratory, circulatory, renal function indexes and APACHEⅡscores in both groups were improved after treatment, and the treatment group improved significantly. Compared with the control group, the dose of NE required for maintaining MAP was 65 ~ 70mm Hg in the treatment group at 24h, 48h and 72h (T = 2.228,2.490,3.674; P = 0.031,0.016,0.001 respectively). At 48h and 72h after treatment, the increase of oxygenation index in the treatment group was more significant than that in the control group, and the difference was statistically significant Statistically significant (t = -2.343, -2.225; P = 0.023 and 0.031). The average time of mechanical ventilation in the treatment group was significantly less than that of the control group (t = 6.363, P <0.001). APACHEⅡscore of the treatment group was lower than that of the control group at 24h, 48h and 72h, the difference was statistically significant (t = 6.363, P <0.001), ICU hospitalization time (t = 2.409, P = 0.020), total hospital stay time (t = 2.527, P = 0.015) were significantly less than the control group. Conclusion High-volume hemofiltration during daytime can improve respiratory index, reduce APACHEⅡscore, reduce ICU and total length of hospital stay, and reduce the number of hospitalizations and 28-day deaths.