连续性静脉-静脉血液滤过在老年多器官功能障碍中的应用

目的:观察连续性静脉-静脉血液滤过(CVVH)在一组老年多器官功能障碍(MODS)患者中应用的效果及安全性。方法:50例老年MODS患者患者分为A组和B组,A组27例接受CVVH治疗,B组23例接受普通透析,患者在治疗前后进行APACHE评分,并检测血钠、钾、氯、尿酸、碳酸氢盐、氧分压、二氧化碳分压和脑钠肽。结果:①治疗后,血电解质紊乱和酸碱失衡得到纠正,毒素明显下降,两组患者间无显著性差异。②与B组患者相比,A组患者治疗后,脑钠肽和二氧化碳分压明显下降,氧分压上升,APACHE评分明显降低。结论:与普通透析相比,CVVH除了能清除毒素和纠正电解质酸碱失衡以外,还能提高患者PO2、减轻CO2潴留,明显改善心肺功能效果,因此应用于老年MODS患者是安全有效的。     

连续性血液透析滤过对内毒素诱导急性肺损伤幼猪血流动力学影响

目的 探讨连续性血液透析滤过对稳定内毒素诱导急性肺损伤幼猪血流动力学的价值.方法 18头幼猪随机分为对照组、肝素组和干预组,每组6头.内毒素诱导肺损伤.于动物基础状态(B)、成模(A 0 h)、成模后2 h(A 2 h)、4 h(A 4 h)、6 h(A 6 h)记录心率(HR)、平均动脉压(MABP)、脉搏轮廓心输出量指数(PCCI)、全身血管阻力指数(SVRI)、心功能指数(CFI)、左心室收缩力指数(dPmx)、肺血管外肺水指数(EVLWI).结果 A 0 h各组PCCI、MABP、CFI、dPmx较B下降;HR、SVRI、EVLWI较B上升,组间比较无统计学意义.A 4 h各组EVLWI、SVRI、CFI、dPmx:干预组(15.0±1.9)ml/kg、(3073.0±685.0)dyns·cm-5·m2、(5.3±0.5)L/min、[(1883.0±466.0)mmHg/s,1 mm Hg=0.133 kPa];对照组(34.3±5.7)ml/kg、(4991.0±574.0)dyns·cm-5·m2、(3.6±0.4)L/min、(713.0±211.0)mm Hg/s;肝素组(34.3±5.1)ml/kg、(5445.0±576.0)dyns·cm-5m2、(3.3±0.2)L/min、(768.0±247.0)mm Hg/s.A 6 h各组HR、MABP、PCCI:干预组(154.2±12.4)/min、(97.2±10.3)mm Hg、(3.9±0.5)L/(min·m2);对照组(172.0±2.8)/min、(76.2±10.8)mm Hg、(2.7±0.5)L/(min·m2);肝素组(174.5±7.6)/min、(76.0±10.2)mm Hg、(2.8±0.4)L/(min·m2).干预组与对照组和肝素组比较差异有统计学意义(P<0.05),肝素组与对照组比较差异无统计学意义.结论 连续性血液透析滤过对稳定内毒素诱导急性肺损伤幼猪血流动力学状态有效.     

连续性血液净化救治心脏术后重症肾衰竭的疗效分析

目的探讨连续性血液净化（CBP）治疗心脏术后重症急性肾衰竭（ARF）的效果和时机选择。方法31例行CBP治疗的重症ARF患者分为生存组（A组）和死亡组（B纽）。观测两组治疗前后平均动脉压（MAP）、氧舍指数（PaO2／FiO2）、肾功能（Cr、BUN）、MODS评分和APACHEⅡ评分；比较2组CBP距ARF和尿量〈0．5ml／（Kg·h）时间。结果CBP前B组MODS评分、APACHEⅡ评分均明显高于A组；CBP后，仅A组MODS评分、APACHEⅡ评分下降；CBP后2组Cr、BUN降低，MAP、PaO2／FiO，升高；B组的CBP距ARF和尿量〈0．5ml／（Kg·h）时间长于A组（P均〈0．05）。结论CBP治疗心脏术后重症ARF是安全有效的，尽早行CBP有利于改善患者预后。     

Modified DALI LDL-apheresis using trisodium citrate anticoagulation plus bicarbonate or lactate-buffered hemofiltration substitution fluids as primers

BACKGROUND: DALI (direct adsorption of lipids) is the first LDL-apheresis technique able to adsorb low-density lipoprotein (LDL) and lipoproteina) directly from whole blood. In the standard procedure, acid citrate dextrose (ACD-A) is used as anticoagulation and the adsorber is rinsed with a specially manufactured priming solution (PS). Using neutral trisodium citrate (TSC) instead of ACD-A might improve the acid-base homeostasis during DALI apheresis; moreover, applying wholesale hemofiltration solutions instead of the special PS might avoid the use of two separate solutions for both priming before and reinfusion after the treatment, thus simplifiying the procedure. AIM: The present study was performed to test the effect of neutral (TSC) anticoagulation and of two different commercially available hemofiltration (HF) priming solutions on the efficacy and biocompatibility of DALI apheresis. MATERIALS AND METHODS: Five hypercholesterolemic chronic DALI patients were treated prospectively, on a weekly or biweekly basis, 3 times each by standard DALI-apheresis (A). by DALI using 4% TSC and bicarbonate-buffered HF BIC35-210 priming (B). as well as by DALI using 4% TSC and lactate-buffered HF 23 priming (C). After the sessions, the extracorporeal circuit (ECC) was rinsed with saline in study arm A and with the corresponding HF solutions in study arms B and C, respectively. RESULTS: Acute LDL-cholesterol reductions in the study arms A/B/C averaged 64/64/63%, for Lp(a) 62/64/62%, respectively (n=15). Clinically, all sessions were essentially uneventful and no clots were observed in the ECC. No major differences were found between the 3 study arms with respect to biocompatibility (elastase, C3a, thrombin-antithrombin, beta-thromboglobulin, bradykinin). CONCLUSION: DALI apheresis using TSC anticoagulation and HF solutions for both priming and reinfusion proved to be as safe and effective as the standard DALI apheresis. These modifications, however, further simplify the procedure.     

Customized bicarbonate buffered dialysate and replacement solutions for continuous renal replacement therapies: effect of crystallization on the measured levels of electrolytes and buffer

The aim of this study was to investigate the impact of the addition of calcium to bicarbonate solutions for continuous renal replacement therapy (CRRT). We tested single bag (bicarbonate and calcium mixed 24 h before testing) and double bag solutions (mixed immediately before) with and without the addition of 4 mEq/L of acetate. Prescribed calcium varied from 0 to 5 mEq/L. All test solutions containing calcium showed crystallization at light microscopy. The double bag solutions decreased but did not prevent crystallization. The addition of acetate did not interfere with crystallization. Crystallization, as measured by the weight of the crystals after filtration of the solutions, showed a significant positive correlation with the calcium deficit (prescribed minus measured) and with partial pressure of carbon dioxide. The measured level of calcium was lower than expected and correlated with crystallization. Our results suggest that the use of bicarbonate solutions containing calcium as replacement fluids for CRRT is a potentially unsafe procedure.     

Development of a New Antithrombogenic Continuous Ultrafiltration System

By interfacing a polyacrylonitrile (PAN)-polyethyleneoxide (PEO) membrane with an ionically heparin-bound catheter, tubing, and module header, a totally antithrombogenic continuous ultrafiltration system (ACUS) was developed and its performance, persistent antithrombogenicity, and well-maintained ultrafiltration level were confirmed through animal experiments. Although the amount of heparin released and accumulated in vitro from those heparinized parts was very low and stable (on the order of 1 x 10(-2) U/cm2/min), partial thromboplastin time evaluated in vivo was not elongated during passage through the ACUS. Extracorporeal circulation time with the ACUS in unheparinized dog model was 458 +/- 302 min (n = 24), whereas those of partially modified (antithrombogenic) system did not exceed 100 min. As compared with that in a conventional continuous arteriovenous hemofiltration system, an extracorporeal circulation with the ACUS in an unheparinized dog model revealed significantly less fluctuation of platelet count, and no adherent platelets were observed on the surface of the PAN-PEO membrane. An ACUS consisting of a PAN-PEO membrane and heparinized parts was thus demonstrated to have good platelet compatibility. An ACUS with a surface area of 0.25 m2 was applied to two patients with acute renal failure. Hemofiltration without systemic heparinization lasted for 44 h per hemofilter, and a stable level of ultrafiltration was maintained. This system seems to be applicable for the clinical management of volume overload, especially in patients with bleeding tendencies or postoperative bleeding.     

血液滤过对严重创伤后并发急性呼吸窘迫综合征患者氧合功能和血流动力学的影响

目的 研究血液滤过对严重创伤后并发ARDS患者氧合功能和血流动力学的影响。方法 选择严重创伤后ARDS患者12例，在呼吸机辅助或控制呼吸下行血液滤过治疗，于血液滤过后1－5d内用Swan-Ganz漂浮导管监测血流动力学和肺氧功能的变化。结果 与血液滤过前比较，滤过后第1天CVP、MPAP、SVRI、PVRI显著降低，整个血液滤过时间PaO2／FiO2升高非常显著，MAP、PCWP、HR、CI、DO2、VO2、ExtrO2、Qs/Qt无显著变化。结论 血液滤过对严重创伤后ARDS患者的血流动力学和氧合功能无明显影响，但可使氧合指数升高。     

以血浆作透析液的血液透析联合高容量血液滤过治疗高胆红素血症的机制研究

目的 前瞻性观察以人体新鲜冰冻血浆作透析液行血液透析（HD-PBD）后继续进行高容量血液滤过（HVHF）,评价其对高胆红素血症患者血清胆红素的清除机制.方法 选择第四军医大学第一附属医院15例肝衰竭患者行HD-PBD治疗6h后,应用同一滤器（AV600）继续行HVHF治疗24h.全部患者分别在HD-PBD治疗初始（0h）及开始后2h、4h和6h取滤器动脉端和静脉端血液、流入端和流出端透析液,HVHF治疗0h、6h、12h和24h取滤器前及滤器后血液,同时留取滤液.观察治疗前后胆红素水平的变化.结果 ①HD-PBD对胆红素的清除较HVHF明显（P＜0.05）.②HD-PBD治疗初始的TB溶质清除率（Kd）为（23.0±3.4）ml/min,滤器使用4～6h后弥散作用下降.③HD-PBD治疗初始通过弥散和吸附的体外清除量分别为（15.6±5.6）mmol/min和（10.3±3.2）mmol/min,滤器使用4～6 h后作用下降.④HVHF以吸附清除为主,其中治疗初始吸附清除量最大,12h以后吸附清除量而滤过清除量相对恒定.⑤HD-PBD治疗初始的体外清除总量高于HVHF[（25.9±8.2）mmol/min vs（7.17±3.34）mmol/min,P＜0.05.结论 HD-PBD联合HVHF治疗对血清胆红素有明显降低作用,其清除机制主要为弥散和吸附,对流作用较小.     

Effect of continuous hemofiltration on hemodynamics, lung inflammation and pulmonary edema in a canine model of acute lung injury

Objective This study examined whether continuous hemofiltration favorably affects cardiopulmonary variables, lung inflammation, and lung fluid balance in a canine model of oleic acid induced acute lung injury.Methods Eleven pentobarbital-anesthetized dogs were randomly divided into a control (mechanical ventilation, MV) group (n=6) and a MV plus hemofiltration (HF) group (n=5). All animals received an intravenous injection of oleic acid (0.09 ml/kg) to induce acute lung injury. Continuous arterial-venous hemofiltration (blood flow 100 ml/min, ultrafiltration rate at 50–65 ml kg^–1 h^–1) was started after establishment of oleic acid induced acute lung injury and continued for 4 h. Hemodynamics, lung mechanics, gas exchange, lung fluid balance, lung histology, and the level of plasma cytokines were assessed.Results After 240 min of HF treatment there was a significant increase in cardiac output, reduction in pulmonary arterial pressure, and improvement in both oxygenation and lung mechanics. Also, in the HF group the lung wet-to-dry weight ratio was significantly reduced. Histologically, HF reduced edema and inflammatory cell infiltration in the lung. There was also a significantly greater decrease in plasma IL-6 and IL-8 levels in the HF group than in group receiving MV alone.Conclusions In a canine model of acute lung injury continuous HF improved cardiopulmonary function, reduced pulmonary edema, decreased lung permeability and inflammation, and decreased the plasma concentration of proinflammatory cytokines.     

Plasmapheresis combined with continuous venovenous hemofiltration in surgical patients with sepsis

Objective: To examine the effect of continuous venovenous hemofiltration (CVVHF) combined with plasmapheresis (TPE) in critically ill surgical patients after treatment of the septic focus. Design: Observational pilot study. Setting: University teaching hospital intensive care unit. Interventions: TPE and CVVHF were administered 24 h after surgical and/or interventional treatment of septic focus. Arterial blood pressure, cardiac output, and systemic vascular resistance values were monitored. We examined the effect of the combined extracorporeal detoxification on outcome related to age, morbidity, organic failure rate, and initial APACHE II score. Measurements and results: Forty-three patients with sepsis were treated; 19 received TPE in combination with CVVHF, and 24 did not receive extracorporeal therapy. Overall mortality was 44.2 %. In the therapy group mortality was lower (42.1 vs. 45.8 %), but the primary organic failure rate was higher. The relationship between mortality and age was similar in the two groups. There was also no difference between the groups in the course of scores on APACHE II, multiple-organ failure, and sepsis severity. Only patients with an initial APACHE II score of 21–25 had a significant reduction in mortality after combined extracorporeal detoxification. Mortality of 17 % in TPE/CVVHF patients with single- (pulmonary) and double-organ failure (renal/pulmonary) was significantly lower (P < 0.0001) than in untreated patients. Conclusions: Reduction in mortality in single- and double-organ failure was as high as 28 % in septic patients with combined extracorporeal detoxification. A prospective randomized trial in sepsis and double-organ failure should be projected. Received: 28 May 1999 Final revision received: 29 February 2000 Accepted: 1 March 2000