连续静脉-静脉血滤治疗重症急性胰腺炎的临床观察

目的 观察连续静脉-静脉血液滤过(CVVH)治疗重症急性胰腺炎(SAP)临床疗效.方法 12例SAP患者在接受基础治疗的同时行CVVH治疗.每例次至少持续12 h;监测并计算血气分析、血生化、CRP及APACHEⅡ评分的变化.结果 所有患者经CVVH治疗后,血气分析、血生化、CRP及APACHEⅡ评分有显著改善(P<0.01).结论 早期、及时、合理地使用CVVH治疗SAP,能提高疗效,减少并发症,降低病死率.是一项的重要措施.     

连续性血液滤过治疗重症急性胰腺炎——附13例报告

目的 探讨连续性静脉-静脉血液滤过(CVVH)治疗重症急性胰腺炎(SAP)的疗效。方法 13例SAP患者均接受了CVVH治疗,平均治疗时间为62 h。观察治疗前、中、后患者的血液生化指标、血 常规、血气分析和细胞因子IL-1β、TNF-α、IL-6含量,并进行APACHEⅡ评分。结果 13例患者中,治愈 10例,死亡3例,死亡率为23.1％。CVVH治疗过程中血流动力学稳定。APACHEⅡ评分治疗前为(15.3 ±5.7)分,治疗后24 h、48 h及72 h分别降至(11.6±4.2)分、(9.1±3.8)分和(7.2±3.3)分,差异显著 (P<0.05)。CVVH治疗后12 h。血浆中细胞因子IL-1β、TNF-α、IL-6的水平均显著降低(P<0.05)。结 论SAP患者早期行CVVH治疗,可改善SAP预后,降低病死率。     

连续性血液滤过治疗重症急性胰腺炎--附13例报告

目的探讨连续性静脉-静脉血液滤过(CVVH)治疗重症急性胰腺炎(SAP)的疗效.方法13例SAP患者均接受了CVVH治疗,平均治疗时间为62 h.观察治疗前、中、后患者的血液生化指标、血常规、血气分析和细胞因子IL-1β、TNF-α、IL-6含量,并进行APACHEⅡ评分.结果13例患者中,治愈10例,死亡3例,死亡率为23.1%.CVVH治疗过程中血流动力学稳定.APACHEⅡ评分治疗前为(15.3±5.7)分,治疗后24 h、48 h及72 h分别降至(11.6±4.2)分、(9.1±3.8)分和(7.2±3.3)分,差异显著(P<0.05).CVVH治疗后12 h,血浆中细胞因子IL-1β、TNF-α、IL-6的水平均显著降低(P<0.05).结论SAP患者早期行CVVH治疗,可改善SAP预后,降低病死率.     

连续性静脉-静脉血液滤过对急性呼吸窘迫综合征的治疗作用研究

目的探讨应用连续性静脉-静脉血液滤过(CVVH)治疗急性呼吸窘迫综合征(ARDS)的疗效及机制。方法选择2002年5月至2005年11月重庆医科大学附属第一医院急诊ICU住院的76例ARDS患者,在接受常规治疗的同时,行CVVH治疗,每次治疗至少持续24h。CVVH治疗前后监测病情及动脉血气的变化,并测定血中内毒素。结果CVVH治疗后患者气促、发绀等症状明显缓解,低氧血症及酸中毒纠正,急性生理学与慢性健康状况评分(APACHEⅡ)下降。CVVH治疗6h后,血中的内毒素明显下降。结论在用常规治疗方法治疗ARDS的同时行CVVH治疗,有利于低氧血症的纠正和病情的缓解。     

应用CVVH治疗重症急性胰腺炎

目的研究连续性静脉-静脉血液滤过(CVVH)治疗重症急性胰腺炎(SAP)的疗效及机制.方法13例SAP患者诱因分别为酒精性胰腺炎2例,胆源性胰腺炎11例.CT扫描示2例患者33%胰腺组织坏死,3例坏死67%,其余8例为100%坏死,CT严重度评分为8.9±2.1.CVVH至少持续72h,距离起病平均间隔5.2±3.2天,中心静脉置管建立血管通路,使用AN69膜滤器,面积为1.2m2,每24h更换一次.结果CVVH治疗过程中,患者血流动力学状态稳定,ICU存活率为76.9%,13例患者中2例死于霉菌性败血症,1例死于颅内感染,另1例患者在出院前死于与SAP无关的原因,只有9例患者出院.CVVH后发热、心动过速、呼吸急促等症状明显缓解.CVVH前APACHEⅡ评分为15.2±6.5,CVVH 24h,48h和72h分别降至8.1±5.3,7.5±4.9和8.0±5.2,差异非常显著.ICU存活组行CVVH早于ICU死亡组,CVVH后临床缓解更明显.在CVVH过程中,外周血IL-1β和TNF-α浓度在使用每一新滤器后的第6h达到最低水平,第12h逐渐升高至CVVH前水平直到第24h.CVVH停止后,两种细胞因子水平均明显升高,与治疗前相比差异均十分显著.结论SAP合并多器官功能障碍综合征患者行CVVH时血流动力学稳定,并发症少,能有效缓解患者的临床症状,可能与外周血中IL-1β和TNF-α等炎症介质的清除有关.在病程早期行CVVH能改善急性胰腺炎的预后.     

间断性床旁静静脉血液滤过辅助治疗SAP28例

目的探讨间断性床旁静静脉血液滤过在重症急性胰腺炎（SAP）治疗中的效果。方法对28例SAP患者于接受传统治疗的同时行间断性床旁静静脉血液滤过,治疗前及治疗1、2、3d后行急性生理学及慢性健康状况评分（APACHEⅡ评分）。结果好转出院23例（82．14％）、死亡5例（17．86％）;治疗2d和3d后存活者APACHEⅡ评分显著下降,低于治疗前及死亡者（P〈0．05、0．01）。结论SAP早期（发病后72h内）行间断性床旁静静脉血液滤过治疗可改善患者预后。     

连续性静脉静脉血液滤过对多脏器功能障碍综合征患者脏器功能的影响

对ICU的多脏器功能障碍综合征（MODS）21例患者行床旁连续性静脉静脉血液滤过（CVVH），观察CVVH治疗前后MODS患者的临床指标、实验室检查结果及APACHEⅡ评分，对患者各脏器病理生理的影响进行评估。结果21例患者CVVH治疗后心率、平均动脉压、pH、氧合指数、血尿素氮、血肌酐、血钾、血钠、APACHEⅡ评分均有显著改善（P〈0．05），外周血白细胞、血小板、血红蛋白、血胆固醇及甘油三脂、血清总胆红素及谷丙转氨酶、心肌酶谱包括肌酸激酶及其同工酶、乳酸脱氢酶和α-羟丁酸脱氢酶、Glasgow昏迷评分均无变化（P〉0．05）。认为CVVH可使MODS患者循环稳定，提高肺氧合水平，改善肾功能，纠正酸中毒及电解质紊乱，而对肝、脑、心等重要脏器无不良影响。     

连续性静脉-静脉血液滤过联合血液灌流治疗严重脓毒症临床研究

目的探讨连续性静脉-静脉血液滤过(CVVH)联合血液灌流(HP)应用于严重脓毒症的临床意义。方法入选2011年12月至2014年8月收治梅州市人民医院重症医学一科的92例严重脓毒症存在血液净化治疗指征患者,随机分为CVVH组及CVVH+HP组,比较两组治疗过程中炎症介质C-反应蛋白(CRP)、补体3(C3)、内毒素;血流动力学指标平均动脉压(MAP)、中心静脉压(CVP);组织器官灌注指标血乳酸(Lac)、中心静脉血氧饱和度(Scv O2)、氧合指数(Pa O2/Fi O2);以及血小板、感染相关器官功能衰竭评分(SOFA)。结果 CVVH+HP组治疗72 h时CRP、C3及内毒素降至最低,且低于CVVH组;治疗12 h后CVVH+HP组Lac低于CVVH组(P0.05),Scv O2高于CVVH组(P0.05);MAP、CVP两组间差异无统计学意义(均P0.05);治疗24h CVVH+HP组Pa O2/Fi O2较CVVH组升高(P0.05),治疗12 h后,CVVH+HP组患者血小板水平较治疗前有所下降,且较CVVH组更低(均P0.05),治疗48h SOFA评分亦较CVVH组降低(P0.05)。结论 CVVH联合HP能够有效清除炎症介质,提高严重脓毒症患者氧合状态,改善组织器官灌注,改善器官功能,但对血小板有一定破坏。     

早期肠内营养支持治疗对重症急性胰腺炎自然病程的影响

目的探讨早期肠内营养（EEN）支持对重症急性胰腺炎（SAP）治疗的影响。方法将60例SAP患者随机分为2组,实验组在常规治疗基础上实施EEN持续至经口进食。观察治疗后血/尿淀粉酶、血常规、肝肾功能、血浆内毒素变化;比较治疗前后APACHEⅡ评分、Balthazar CT评分、住院费用及天数。结果 2组治疗后血/尿淀粉酶、血常规、肝肾功能等均无明显变化;实验组治疗后内毒素水平较治疗前及对照组治疗后降低（P〈0.05或〈0.01）。入院1周后2组APACHEⅡ评分无统计学差异,实验组Balthazar CT评分、住院天数及费用均高于对照组（P均〈0.01）。结论 EEN支持治疗能明显降低SAP患者感染、并发症的发生,缩短患者病程,减少住院费用。     

CVVH联合血必净治疗老年多脏器功能障碍综合征患者的临床疗效

目的探讨连续性静脉-静脉血液滤过(CVVH)联合血必净注射液治疗老年多脏器功能障碍综合征(MODS)患者的临床疗效。方法将66例老年MODS患者分为常规治疗组24例,常规治疗+CVVH组20例,常规治疗+CVVH+血必净组22例,观察各组治疗前及治疗后1、3、5 d急性生理与增性健康评分(APACHE)Ⅱ评分及各脏器功能的变化、呼吸支持时间、ICU住院时间。结果治疗后各组APACHEⅡ评分、各脏器功能均较治疗前有明显改善(P<0.05),三联组疗效更显著(P<0.01);两联、三联两组患者的呼吸机支持时间和ICU住院时间较常规组明显缩短,三联组更为显著(P<0.05,P<0.01)。结论 CVVH联合血必净治疗老年MODS患者可明显改善患者的各脏器功能,并缩短ICU住院时间。     

Continuous veno-venous haemofiltration in the treatment of severe acute pancreatitis: 6-year experience

Background. Continuous veno-venous haemofiltration (CVVH) could be reasonable for attenuation of systemic complications in severe acute pancreatitis (SAP). The aim of the study was implementation and feasibility assessment of the CVVH in the treatment protocol of SAP. Patients and methods. CVVH was applied to 111 SAP patients during 2000–2005. APACHE II, systemic inflammatory response syndrome (SIRS), multiple organ dysfunction syndrome (MODS), serum lipase, C-reactive protein (CRP), complication rate and main outcomes were analysed comparing two periods. Results. Overall, 39 patients corresponded to Balthazar grade E SAP and 72 patients to necrotizing SAP (NSAP), with an average APACHE II score of 7 and 8.5, respectively, on admission. CVVH was started within 48 h in 82% of patients. Duration of CVVH was significantly augmented in NSAP patients during the routine period, comprising 92 h (p=0.006). The clinical presentation of SIRS and MODS was similar in both periods, with more initial pulmonary dysfunctions in NSAP (p=0.048). Peripancreatic infection decreased in the routine period; surgical interventions were performed in 34.8% vs 72.4% of patients. Hospital stay comprised on average 15.9 days for grade E SAP and 29.4 days for NSAP in the routine period, with overall mortality of 10.26% and 30.5%, respectively. Discussion. Application of CVVH in the treatment protocol of SAP is obscure due to relative invasiveness, a poorly understood mechanism of action and scarce clinical experience. We conclude that early pre-emptive application of CVVH is safe and feasible in the treatment of SAP. Duration of the procedure seems to be essential. Randomized clinical trials are justified. Our results are in favour of clinical application of CVVH in the treatment of SAP.     

连续性血液滤过治疗急性重症胰腺炎的Meta分析

目的评价连续性静脉-静脉血液滤过(CVVH)治疗急性重症胰腺炎的有效性和安全性。方法应用计算机检索电子数据库:PubMed(1980～2011年)、中国期刊全文数据库(CNK:1990～2011年)、万方数据库(1980～2011年),并手工检索Cochrane图书馆。采用Cochrane系统评价员手册4.2.2推荐的方法纳入文献,并对其进行Meta分析。结果共有12篇文章纳入研究。共纳入383例患者,其中CVVH治疗者(CVVH组)208例,常规非手术治疗者(对照组)175例。对12个研究进行了Meta分析。结果显示:与常规非手术组相比,CVVH组明显提高了总体治愈率[OR=3.24,95%CI(1.69,6.22),P=0.0004],降低了总体病死率[OR=0.32,95%CI(0.15,0.68),P=0.003],缩短了腹痛、腹胀症状改善时间,降低了并发症发生率。结论根据目前证据,早CVVH治疗SAP患者可能是安全有效的。目前所获研究仅来自中国且方法学质量较低,需要进一步开展高质量大样本的RCT来评价CV-VH治疗SAP有效性和安全性。     

连续性静脉-静脉血液滤过治疗急性严重低钠血症六例

目的　观察连续性静脉 静脉血液滤过 (CVVH)治疗急性严重低钠血症的疗效。方法急性严重低钠血症 6例 ,基础病变分别为慢性肾功能衰竭 3例 ,急性肾功能衰竭、妊娠子痫及骨科手术后各 1例。所有患者血钠均低于 115mmol/L ,均为 4 8h内发生。采用中心静脉留置导管建立血管通路行CVVH。滤器为AN6 9及AV6 0 0各 2例 ,HF12 0 0及FH6 6各 1例 ,每 2 4h更换 1次 ,低分子肝素抗凝。结果　CVVH平均治疗时间为 5 9 7h。CVVH治疗中 ,患者血流动力学稳定 ,6例意识模糊者 ,5例治疗 12h后意识有所好转 ;3例嗜睡及谵妄者治疗 2 4h后症状消失 ;1例抽搐者治疗 2 4h后症状消失 ;1例昏迷者治疗 96h后神志完全恢复正常。CVVH治疗后 4 8h血钠上升至 (14 0 3± 1 6 )mmol/L ,纠正速度为 (0 82± 0 10 )mmol·L-1·h-1;血渗量水平为 (2 95 0± 4 2 )mOsm/kgH2 O ,纠正速度为 (1 6 3± 0 2 0 )mOsm·kgH2 O-1·h-1。CVVH开始置换液钠比血钠高 (16 0± 6 0 )mmol/L。CVVH治疗 4 8h后Glasgow评分较治疗前有显著升高 (P <0 0 5 ) ,APACHEⅡ评分较治疗前有显著降低 (P <0 0 5 )。 6例患者全部存活 ,3例转为维持性血液透析 ,3例完全康复。结论　CVVH治疗严重急性低钠血症是有效的 ,为严重急性低钠血症的救治提供了新的治疗     

Clinical Effects of Pulse High‐Volume Hemofiltration on Severe Acute Pancreatitis Complicated With Multiple Organ Dysfunction Syndrome

To evaluate the effects of pulse high‐volume hemofiltration (PHVHF) on severe acute pancreatitis (SAP) with multiple organ dysfunction syndrome (MODS). Thirty patients were divided into two groups: PHVHF group and continuous venovenous hemofiltration (CVVH) group. They were evaluated in terms of clinical symptoms, acute physiology and chronic health evaluation (APACHE) II score, sequential organ failure assessment (SOFA) score, simplified acute physiology (SAPS) II score and biochemical changes. The levels of IL‐6, IL‐10 and TNF‐α in plasma were assessed by ELISA before and after treatment. The doses of dopamine used in shock patients were also analyzed. In the two groups, symptoms were markedly improved after treatment. Body temperature (BT), breath rate (BR), heart rate (HR), APACHE II score, SOFA score, SAPS II score, serum amylase, white blood cell count and C‐reactive protein were decreased after hemofiltration (P < 0.05). The PHVHF group was superior to the CVVH group, especially in APACHE II score, CRP (P < 0.01), HR, temperature, SOFA score and SAPS II score (P < 0.05). The doses of dopamine for shock patients were also decreased in the two groups (P < 0.05), with more reduction in the PHVHF group than the CVVH group (P < 0.05). The levels of IL‐6, IL‐10 and TNF‐α decreased (P < 0.05) in the PHVHF group more significantly than the CVVH group (P < 0.01). PHVHF appears to be superior to CVVH in the treatment of SAP with MODS.     

Clinical effects of continuous high volume hemofiltration on severe acute pancreatitis complicated with multiple organ dysfunction syndrome

AIM: To investigate the efficiency of continuous high volume hemofiltration (HVHF) in the treatment of severe acute pancreatitis (SAP) complicated with multiple organ dysfunction syndrome (MODS).METHODS: A total of 28 SAP patients with an average of 14.36±3.96 APACHE Ⅱ score were involved. Diagnostic criteria for SAP standardized by the Chinese Medical Association and diagnostic criteria for MODS standardized by American College of Chest Physicians (ACCP) and Society of Critical Care Medicine (SCCM) were applied for inclusion. HVHF was started 6.0±6.1 (1-30) days after onset of the disease and sustained for at least 72 hours, AN69 hemofilter (1.2 m2)was changed every 24 hours. The ultrafiltration rate during HVHF was 4 000 mi/h, blood flow rate was 250-300 mi/min,and the substitute fluid was infused with pre-dilution. Low molecular weight heparin was used for anticoagulation.RESULTS: HVHF was well tolerated in all the patients, and lasted for 4.04±3.99 (3-24) days. 20 of the patients survived,6 patients died and 2 of the patients quited for financial reason.The ICU mortality was 21.4%. Body temperature, heart rate and breath rate decreased significantly after HVHF.APACHE Ⅱ score was 14.4±3.9 before HVHF, and 9.9±4.3after HVHF, which decreased significantly (P＜0.01). Partial pressure of oxygen in arterial blood before HVHF was 68.5±19.5 mmHg, and increased significantly after HVHF,which was 91.9±25 mmHg (P＜0.01). During HVHF the hemodynamics was stable, and serum potassium, sodium,chlorine, glucose and pH were at normal level.CONCLUSION: HVHF is technically possible in SAP patients complicated with MODS. It does not appear to have detrimental effects and may have beneficial effects.Continuous HVHF, which seldom disturbs the hemodynamics and causes few side-effects, is expected to become a beneficial adjunct therapy for SAP complicated with MODS.     

连续性血液净化治疗重症急性胰腺炎的临床观察

目的探讨应用连续性床旁血液净化(CBP)治疗重症急性胰腺炎的临床效果,以有效防止并发症的恶化及减少死亡率的发生。方法回顾性分析2007～2009年我院应用床旁连续性静脉-静脉血液滤过(CVVH)净化方法治疗重症急性胰腺炎或暴发性胰腺炎28例的临床资料。结果重症急性胰腺炎28例,其中暴发性胰腺炎21例。所有患者均在综合治疗的基础上进行CVVH净化治疗,病情好转26例,死亡2例。结论应用CBP治疗重症急性胰腺炎或暴发性胰腺炎,可阻断机体的炎症介质的瀑布式炎症反应,明显的改善了各脏器的功能,病死率显著降低,显示出了其独特的功效。     

维持性血液滤过治疗心脏手术后急性肾损伤

目的探讨持续性血液滤过（CVVH）对心脏手术后急性肾损伤（acute kidney injury，AKI）的治疗作用。方法回顾性分析12例心脏手术后AKI患者采用CVVH治疗的临床资料。结果11例存活，1例死亡。存活患者心率及平均动脉压在CVVH过程中波动于正常范围，血肌酐、尿素氮、血钾水平在治疗后显著下降，肾功能均恢复正常。结论CVVH是救治心脏手术后AKI患者的有效手段，此结果仍需扩大样本进一步研究。     

Conservative approach in the management of severe acute pancreatitis: eight-year experience in a single institution

Introduction. Recognition of severe acute pancreatitis (SAP), intensive care, shifting away from early surgical treatment, and monitoring of the intra-abdominal pressure (IAP) is important in the management of SAP. The aim of our study was retrospective evaluation and critical assessment of the experience with SAP management protocol involving new strategy in the university hospital. Methods. Protocols of 274 SAP patients treated in our institution during the last eight years were reassessed. APACHE II, CRP and SOFA score, IAP, pulmonary complications, ventilatory support and infection rate were evaluated. The success of the conservative treatment, surgical interventions and mortality was analysed comparing period 1 from 1999 to 2002 and period 2 from 2003 to 2006. Results. More patients with necrotising SAP were treated in period 2. The average CRP and SOFA score was higher in period 2, p=0.018; p=0.011. A total of 139 patients underwent continuous veno-venouse haemofiltration (CVVH) as a component of fluid resuscitation and IAP control. Application of CVVH increased in period 2, p<0.005. Only 5–8% of patients were managed with ventilatory support. The overall infection rate decreased in period 2 comprising 21%, p<0.005. Success rate of the conservative therapy reached 69% in period 2, p<0.01. Surgical treatment was performed in 41% of patients in period 1 vs. 19% in period 2, p<0.001. Overall mortality was 19%, with a reduction to 12% in year 2006. Conclusion. The conservative protocol-based approach is a rational treatment strategy for the management of SAP and can be successfully implemented in the setting of the university hospital.     

无肝素抗凝技术在连续性静脉-静脉血液滤过中的应用

目的对连续性静脉-静脉血液滤过治疗过程中无肝素抗凝技术进行综合评价。方法2005年1月至4月对四川大学华西医院的42例危重患者行连续性静脉-静脉血液滤过(CVVH)治疗,其中高危出血患者19例采用无肝素技术抗凝,设为观察组;23例采用低分子肝素抗凝,设为对照组(其中3例因故改用无肝素抗凝)。两组置换液速度均为3000mL/h,持续时间12h/d,碳酸氢盐置换液前稀释方式输入。计算溶质下降率,治疗前后检测电解质、酸碱指标、凝血指标;记录心率、平均动脉压、跨膜压及滤器寿命。结果两组治疗后血尿素氮、肌酐均显著下降,但组间比较溶质下降率差异并无显著性意义(P>0.05),对照组活化部分凝血时间(APTT)显著延长(P<0.05)。观察组跨膜压在7h明显升高,而对照组在9h明显升高;观察组滤器的平均寿命短于对照组(P<0.05)。结论CVVH中应用无肝素抗凝技术同样高效、稳定、安全,对于高危出血患者,是保障CVVH治疗持续进行的重要措施。     

酒精性重症急性胰腺炎的临床特征

目的 探讨酒精性重症急性胰腺炎(SAP)的临床特征.方法 回顾性分析2001年1月至2008年12月福建省立医院收治的重症急性胰腺炎(SAP)患者166例.根据发病前12～48h内有无大量饮酒分成酒精性SAP组(43例)和非酒精性SAP组(123例),分析两组年龄,性别,入院时CT评分、APACHEⅡ评分、血糖、血清三酰甘油、血钙、血清白蛋白、并发症及后期感染率、病死率的差异.结果 两组年龄无统计学差异,酒精性SAP组男性的构成比(39/43)明显高于非酒精性SAP组(58/123,P＜0.01).入院时两组CT评分、血糖及血钙无统计学差异.酒精性SAP组APACHEⅡ评分为19.16±5.38,血清三酰甘油水平为(5.06±4.03)mmol/L,均显著高于非酒精性SAP组的16.02±5.09和(3.12±2.95)mmol/L(P＜0.05),而血清白蛋白(25.23±7.12)g/L则明显低于非酒精性SAP组的(30.68±8.35)g/L(P＜0.01).酒精性SAP组急性呼吸窘迫综合征、上消化道出血发生率与非酒精性SAP组无统计学差异,但急性肾功能衰竭(44.2%)、肝功能衰竭(41.9%)、心功能衰竭(37.2%)、休克(39.5%)、感染的发生率(27.9%)及病死率(30.2%)明显高于非酒精性SAP组(分别为26.0%、30.9%、20.3%、16.3%、16.3%、7.3%,P＜0.05或＜0.01).结论 酒精性SAP患者以男性为主,并发症多,病死率高.改变酗酒的不良嗜好是预防酒精性SAP的有效措施.