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目的:急性肾功能衰竭是挤压综合征最常见的严重并发症,本文报道了连续性血液净化(CBP)辅助治疗3例挤压综合征伴多器官功能障碍综合征患者获得成功的救治过程。方法:3例患者均在20080512中国四川省汶川大地震中受伤,分别在受伤后11、11和18天时被送到我院。患者受压的时间分别为5.5、22.5和28h,均合并少尿性急性肾功能衰竭,在当地均接受了输液、清创、筋膜切开和肾脏替代治疗。转来我院时,例1和例2仍持续无尿,血肌红蛋白分别为765和829ng/ml;例3已进入多尿期(早期即行CBP治疗),血肌红蛋白正常。来院后患者均给予扩大清创、清除坏死肌肉组织、引流、换药和抗感染等治疗,并给予连续性高容量血液滤过治疗(置换量4000ml/h),采用枸橼酸置换液或联合低分子量肝素抗凝,AV600滤器(聚砜膜,面积1.6m2),开始为持续24h不间断,在病情稳定后改为日间间歇性治疗8～12h/d治疗,连续监测中心静脉压(CVP)以调控容量状况。同时给予输注全血、红细胞悬液以提升Hb,新鲜冰冻血浆以补充胶体;予胰岛素泵控制血糖;大剂量促红细胞生成素、虫草制剂促进肾小管修复,并给予肠内营养支持治疗。结果:治疗过程中患者血流动力学稳定,无出血等与抗凝剂相关的并发症,患者体温和WBC趋于正常,Hb、血浆白蛋白回升。血、尿肌红蛋白、磷酸肌酸激酶均恢复正常。在少尿期分别持续20和22天后,例1和例2尿量逐渐增多,肾功能逐渐恢复,且未出现明显的多尿期;例3(少尿期仅10天)则在经历16天多尿期后尿量逐渐恢复正常。3例患者的肾小管功能亦基本恢复正常。在设定置换量4L/h和2L/h的条件下,计算对肌红蛋白的清除率分别为9.5ml/min和5.9ml/min。3例患者伤口均愈合良好,无一例需要截肢。结论:CBP可有效辅助治疗挤压综合征多器官功能障碍综合征患者,保持容量平衡、清除肌红蛋白、避免出血并发症和感染是保证CBP成功治疗挤压综合征的关键。
OBJECTIVE: Acute renal failure is the most common complication of crush syndrome. We report the successful treatment of 3 patients with crush syndrome with multiple organ dysfunction syndrome treated with continuous blood purification (CBP). Methods: All three patients were injured at 20080512 Wenchuan Earthquake in Sichuan Province, China. They were delivered to our hospital at 11, 11 and 18 days after injury respectively. Patients underwent compression for 5.5, 22.5 and 28 h, respectively, with oliguric acute renal failure, receiving infusion, debridement, fasciotomy and renal replacement therapy in the area. When transferred to our hospital, cases 1 and 2 continued to be anuria, with hemoglobin of 765 and 829 ng / ml, respectively. Case 3 had entered the polyuria stage (early CBP treatment) and hemoglobin was normal. Patients were hospitalized to expand debridement, removal of necrotic muscle tissue, drainage, dressing and anti-infection treatment, and given continuous high-volume hemofiltration (replacement volume 4000ml / h), using citric acid replacement solution or combination Low molecular weight heparin anticoagulation, AV600 filter (polysulfone membrane, area 1.6m2), beginning for the uninterrupted 24h, changed to intermittent intermittent treatment 8 ~ 12h / d after treatment in stable condition, continuous monitoring of central venous pressure (CVP ) To regulate capacity status. At the same time give infusion of whole blood, red blood cell suspension to enhance Hb, fresh frozen plasma to supplement the colloid; to insulin pump to control blood sugar; high-dose of erythropoietin, Cordyceps preparations promote tubular repair, and give enteral nutrition support. Results: During the course of treatment, patients were hemodynamically stable and had no complications related to anticoagulant such as hemorrhage. Patients’ body temperature and WBC tended to be normal, and Hb and plasma albumin rose. Blood, urine myoglobin, creatine phosphokinase were returned to normal. In oliguric phase lasted for 20 and 22 days, respectively, cases 1 and 2, urine output gradually increased, renal function gradually recovered, and no significant polyuria; Example 3 (oliguria only 10 days) after 16 days Urine volume gradually returned to normal after polyuria. Tubular function in 3 patients returned to normal. The clearance rates for myoglobin were calculated to be 9.5 ml / min and 5.9 ml / min, respectively, at the set volume of 4 L / h and 2 L / h. The wounds of 3 patients healed well, and no case required amputation. Conclusion: CBP can effectively treat patients with crush syndrome with multiple organ dysfunction syndrome. To maintain volume balance, clear myoglobin, avoid bleeding complications and infection is the key to successful CBP treatment of crush syndrome.