不同连续性肾脏替代治疗模式溶质清除和体外循环通路抗凝效果的比较

目的比较连续性静脉-静脉血液滤过(CVVH)、连续性静脉-静脉血液透析(CVVHD)及连续性静脉-静脉血液透析滤过(CVVHDF)3种不同的连续性肾脏替代治疗模式对溶质的清除效率以及体外循环通路抗凝的效果。方法选取2017年3月至2017年10月在武汉市第五医院行连续性肾脏替代治疗的患者49例,分别接受CVVH、CVVHD及CVVHDF 3种模式治疗,同一患者CRRT治疗剂量、血流量、抗凝方式及抗凝剂用量相同。比较3种不同治疗模式对血肌酐、尿素氮、尿酸、血磷、β2微球蛋白的清除率,同时监测治疗过程中体外循环通路凝血的情况。结果在相同CRRT治疗剂量下,CVVHDF、CVVHD对血肌酐、尿素氮、尿酸、血磷的清除率高于CVVH,且有统计学差异(P0.01);CVVHDF、CVVH对β2微球蛋白的清除率高于CVVHD,且有统计学差异(P0.01)。在抗凝剂方式及抗凝剂用量相同的情况下,选取CVVHDF治疗模式体外循环通路凝血情况好于CVVH及CVVHD治疗模式,且有统计学差异(P0.05)。结论 CVVHDF、CVVHD对小分子溶质的清除率高于CVVH,而CVVHDF和CVVH对中大分子溶质的清除率高于CVVHD;在抗凝方式相同及抗凝剂用量相同的情况下,CVVHDF对体外循环通路的抗凝效果好于CVVH及CVVHD。因此,建议临床上行连续性肾脏替代治疗时可首选CVVHDF模式。     

血液灌流联合血液透析治疗尿毒症皮肤瘙痒患者的临床观察

目的 探讨血液透析和血液灌流联合治疗维持性血液透析尿毒症患者皮肤瘙痒的疗效.方法 将81例尿毒症皮肤瘙痒患者按皮肤瘙痒程度分为3组,每组按随机数字表法分为治疗组和对照组.治疗组和对照组采用营养支持及综合治疗,对照组在此基础上加用血液透析治疗;治疗组采用血液灌流+血液透析治疗.于治疗前、治疗3、6周后分别检测两组患者甲状旁腺激素、β2微球蛋白的水平变化以及皮肤瘙痒程度并进行比较.结果 治疗组患者经治疗后3、6周后甲状旁腺激素和β2微球蛋白水平与对照组比较差异有统计学意义(P＜0.05);治疗组患者经治疗3周后皮肤瘙痒症状较对照组改善,其中可视模拟评分法评为6～8分组改善最明显(P＜0.05).治疗组治疗6周后皮肤瘙痒症状较对照组改善,其中可视模拟评分法评分＞6分组改善最明显(P＜0.05).结论 血液灌流+血液透析联合治疗能显著降低尿毒症患者甲状旁腺激索和β2微球蛋白水平,减轻皮肤瘙痒症状.

Abstract：

Objective To explore the clinical efficacy of maintenance hemodialysis (HD) combined with hemoperfusion( HP) in treatment of uremic pruritis. Methods The 81 uremic patients with uremic pruritus were divided into 3 groups according to degree of skin itching. Each group was randomly divided into treatment group and control group. On the basis of nutrition support and comprehensive treatment, patients in treatment group were treated with combined HD + HP, while the patients in control group received HD treatment only. Parathyroid hormone (PTH), β2 microglobulin (β2-MG) levels and the degree of pruritus in patients were measured before treatment, treatment for 3 weeks and 6 weeks after in each group. Results effects were evaluated by comparing the PTH, β2 microglobulin (β2-MG) levels and the degree of pruritus of the experimental groups and control groups. Results 3 weeks and 6 weeks after treatment, the PTH and β2-MG levels in the experimental groups were markedly decreased (P ＜ 0.05). After 3 weeks treatment, compared with the control group the pruritus symptoms improved in the treatment group, and the visual analogue scales (VAS) score 6-8 group improved most significantly (P ＜ 0.05). After 6 weeks treatment, compared with the control group the pruritus symptoms improved in the treatment group, and the VAS score ＞ 6 group improved most significantly (P ＜ 0.05).Conclusion HP + HD combination therapy can significantly reduce PTH, β2-MG levels and skin itching in uremic patients.     

高容量血液滤过治疗多器官功能障碍综合征的分析

目的研究高容量血液滤过 (HVHF)在多器官功能障碍综合征 (MODS)治疗中的作用。方法 19例MODS患者 ,随机选择 10例行HVHF ,另 9例行常规连续性静脉 静脉血液滤过 (CVVH)。于治疗前和治疗开始后 2、4、8h动脉采血 ,检测血气、血肌酐 (Scr)、尿素氮 (BUN)、肿瘤坏死因子(TNFα)、白细胞介素 1(IL 1β)、白细胞介素 6 (IL 6 )的变化。 结果HVHF组与CVVH组于治疗开始后4h血Scr、BUN均显著下降 ,肾功能改善。HVHF组血TNFα、IL 1β、IL 6治疗前分别为 ( 1795± 5 0 6 )ng/L、( 96 4± 185 )ng/L、( 1332± 4 15 )ng/L ,治疗开始后 4h为 ( 12 6 5± 397)ng/L、( 5 11± 12 4 )ng/L、( 72 6±2 4 3)ng/L ,差异有显著意义 ,P <0 0 5。CVVH组血TNFα治疗前为 ( 1799± 5 11)ng/L ,治疗开始后 4h为 ( 132 7± 4 2 1)ng/L ,差异有显著意义 ,P <0 0 5。HVHF组死亡 3例 ( 3/ 10 ) ,CVVH组死亡 5例 ( 5 / 9) ,差异有显著意义 ,P <0 0 5。结论HVHF可通过对流和AN6 9膜的吸附作用清除大量炎症介质 ,改善MODS患者的预后     

Effect of hyperbaric oxygen on cytochrome C,Bcl-2 and bax expression after experimental traumatic brain inlury in rats

Objective： To explore the effects of hyperbaric oxygen （HBO） treatment on the neuronal apoptosis at an earlier stage and the expressions of Cytochrome C （Cyt C）, Bcl-2 （B-cell lymphoma-2 family） and Bax （Bcl-2 associated X protein） in rat brain tissues after traumatic brain injury （TBI）. Methods： Forty adult rats were divided into two groups, i.e. ,Group A （the rats with untreated TBI） and Group B （ rats with HBO treatment after TBI）. Sections of brain tissues of these two groups were then detected at 3,6, 12,24,72 hours after TBI by immunohistochemistry and Results： HBO treatment could up-regulate the expression of Bcl-2 within 72 hours, reduce the release of Cyt C from mitochondria, attenuate the formation of dimeric Bax and alleviate the mitochondrial edema within 24 hours after TBI. Conclusions： HBO treatment can alleviate neuronal apoptosis after TBI by reducing the release of Cyt C and the dimers of Bax and up-regulating the expression of Bcl-2.     

Effect of hyperbaric oxygen on cytochrome C, Bcl-2 and bax expression after experimental traumatic brain injury in rats

Objective: To explore the effects of hyperbaric oxygen (HBO) treatment on the neuronal apoptosis at an earlier stage and the expressions of Cytochrome C (Cyt C), Bcl-2 ( B-cell lymphoma-2 family) and Bax ( Bcl-2 associated X protein) in rat brain tissues after traumatic brain injury (TBI). Methods: Forty adult rats were divided into two groups, i.e. , Group A (the rats with untreated TBI) and Group B (rats with HBO treatment after TBI). Sections of brain tissues of these two groups were then detected at 3,6, 12,24, 72 hours after TBI by immunohistochemistry and electronmicroscope, respectively. Results: HBO treatment could up-regulate the expression of Bcl-2 within 72 hours, reduce the release of Cyt C from mitochondria, attenuate the formation of dimeric Bax and alleviate the mitochondrial edema within 24 hours after TBI. Conclusions: HBO treatment can alleviate neuronal apoptosis after TBI by reducing the release of Cyt C and the dimers of Bax and up-regulating the expression of Bcl-2.     

Clinical analysis of the syndrome of inappropriate antidiuretic hormone secretion after brain injury

Objective. To study the diagnosis and treatment of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) after brain injury. Methods: A retrospective analysis was conducted on 12 patients suffered from SIADH after brain injury. The clinical features of these patients were similar to those of common hyponatremia. Most of the hyponatremia were detected by routine examinations. Supplement of salt as the initial treatment was used in these patients. If natremia did not rise or descended 2-3 days after treatment, SIADH was considered or diagnosed. Treatment scheme should be adjusted to limit water and natrium instead of supplying salt. Frusemide and albumin were the first choice for dehydration therapy. Results: 24-48 hours after limiting water and natrium, 12 patient‘s natremia level was back to normal.Eight out of 12 patients were corrected completely in 1 week, 1 in 14 days, and 1 in 3 months after injury. Conclusions: Diagnosis of SIADH is difficult before treatment though effective treatment can be obtained if we adopt correct strategy. In these patients, the diagnosis of SIADH is confirmed in the course of treatment.     

Diagnosis and treatment of penetrating craniocerebral injury

Objective : To evaluate the clinical characteristics and present the experience in the treatment of patients with penetrating craniocerebral injury (PCCI). Methods: The data of 7 cases with PCCI by foreign body were retrospectively studied and compared with associated literatures. The strategies of diagnosis and treatment of PCCI were analyzed. In this series, 3 cases underwent emergency debridements and 4 cases underwent craniotomies. All patients received surgical intervention within 3 hours after admission. Results: Outcomes were good in 3 cases, moderate disability was in 2 cases, severe disability in 1 case and persistent vegetative state in 1 case. One case developed wound and intracranial infection, but made good recovery after treatment. During the follow-up period, one patient died one month after discharge and other six patients (range from 8 months to 3 years) recovered well and no epilepsy, leakage of cerebrospinal fluid (CSF), or traumatic vascular disease occurred. Conclusions : Early diagnosis and prompt debridement are the fundamental factors affecting theout come of PCCI. CT scans are the mainstay in evaluating PCCI and three dimensional (3D) images reconstructed from spiral CT scans provide more information. Efficient debridement should be performed as early as possible. Minimizing the degree of surgical management of PCCI is preferred when there is no indication for aggressive operation. It is important to stress the rapid and effective management of CSF leakage in early stage of PCCI. Use of prophylactic broad-spectrum antibiotics is recommended for patients with PCCI. Traumatic vascular injury should be paid attention to after PCCI.     

Early changes and rules of cardiac function and hemodynamics in rabbits with experimental myocardial contusion

Objective: To study changes and rules of the left ventricular functions in rabbits with myocardial contusion through parallel functional analysis by using echocardiography combined with cardiac catheter intervention. Methods : Thirty healthy rabbits were selected and impacted to make moderate or severe myocardial contusion by BIM-Ⅱ biomedical impact machine. The changes of bemodynamics and cardiac systolic and diastolic functions were respe~vely observed before injury and 1, 4, 8 and 24 hours after injury. Results: After myocardial contusion, the heart rate,systolic pressure, diastolic pressure and mean arterial pressure of rabbits decreased remarkably at 1-4 hours. The left ventricular end-systolic pressure ( LVESP ), the maximum increasing rate of the left intraventricular pressure ( dp/dtmax), isovolumic pressure (IP) and the maximum systolic vdocity of the left ventricle (Vmax) also decreased markedly. And then these parameters recovered to the levd of preinjury at 8-24 hours. The left ventricular end-diastolic pressure (LVEDP), the rate of the left intraventricular pressure ( - dp/dtmax ) and the decreasing time constant of the left intraventricular pressure (T) increased remarkably 1 hour after myocardial contusion,and did not decrease until 8 hours after myocardial contusion. Detection by echocardiography showed that ejection fraction of the left ventricle markedly decreased at 24 hours after myocardial contusion, while the systolic volume decreased obviously as early as 1 hour after myocardial contusion, at 4-8 hours it recovered a little and again decreased at 24 hours. The end systolic volume and end diastolic volume increased after myocardial contusion,but statistical sitmificance was only seen at 8 hours after myocardial contusion. Conclusions: Cardiac functions of the left and right ventricles are markedly injured after myocardial contusion with disorders of the left ventricle diabolic function and of the right ventricle systolic function as the dominant injury.While the systolic function of the left ventricle can recover.Echocardiography shows clinical importance in detection of early injuries of cardiac functions.     

Posterior fixation and fusion with atlas pedicle screw system for upper cervical diseases

Objective： To evaluate the feasibility, safety and efficacy of atlas pedicle screws system fixation and fusion for the treatment of upper cervical diseases.
Methods： Twenty-three consecutive patients with upper cervical disorders requiring stabilization, including 19 cases of atlantoaxial dislocation （4 congenital odontoid disconnections, 6 old odontoid fractures, 4 fresh odontoid fractures of Aderson Ⅱ C, 3 ruptures of the C1 transverse ligament, and 2 fractures of C1）, 2 cases of C2 tumor （instability after the resection of the tumors）, and 2 giant neurilemomas of C2-C3（instability after resection of the tumors）, were treated by posterior fixation and fusion with the atlas pedicle screw system, in which the screws were inserted through the posterior arch of C1. The operative time, bleeding volume and complications were reported. All patients were immobilized without external fixation or with rigid cervical collars for 1-3 months. All patients were followed up and evaluated with radiographs and CT.
Results： In the 23 patients, 46 C1 pedicle screws, 42 C2 pedicle screws and 6 lower cervical lateral mass screws and 2 lower cervical pedicle screws were placed. The mean operative time and bleeding volume was 2.7 hours and 490 ml respectively. No intraoperative complications were directly related to surgical technique. No neurological, vascular or infective complications were encountered. All patients were followed up for 3-36 months （average 15 months）. Firm bony fusion was documented in all patients after 3-6 months. One patient with atlas fracture showed anterior occipitocervical fusion. There was no implant failure. Conclusions： Posterior fixation and fusion of the atlas pedicle screw system is feasible and safe for the treatment of upper cervical diseases, and may be applicable to a larger number of patients.     

Comparison between sitagliptin and nateglinide on postprandial lipid levels: The STANDARD study

AIM: To assess the effects of sitagliptin and nateglinide on lipid metabolism. METHODS: In a parallel group comparative open trial, patients with type 2 diabetes mellitus under treatment at the Japanese Red Cross Medical Center were randomly assigned to receive either sitagliptin (50 mg once daily) or nateglinide (90 mg three times daily before meals). Eligible patients met the following criteria: age ≥ 20 years; hemoglobin A 1c (HbA 1c ) > 6.5% despite diet and exercise; HbA 1c between 6.5% and 8.0%; fasting glucose < 7.77 mmol/L; diet and exercise therapy for more than 3 mo; and ability to read and understand the information for written informed consent. Exclusion criteria were contraindications to sitagliptin, contraindications to nateglinide, pregnancy or possible pregnancy, and severe liver/renal failure. Patients who were considered to be unsuitable by the attending physician for other reasons were also excluded. Blood samples were collected at one and three hours after intake of a test meal. The primary outcome measure was the area under the curve (AUC) of apolipoprotein (Apo) B48 at three hours postprandially. RESULTS: Twenty patients were randomly assigned to the sitagliptin group and sixteen patients were randomized to the nateglinide group. All 36 patients took the medication as directed by the physician in both groups, and they all were analyzed. Apart from antidiabetic drugs, there was no difference between the two groups with respect to the frequency of combined use of lipid-lowering, antihypertensive, and/or antiplatelet drugs. The doses of these medications were maintained during 12 wk of treatment. Detailed dietary advice, together with adequate exercise therapy, was given to the patients so that other factors apart from the two test drugs were similar in the two groups. There were no significant differences of the baseline characteristics between the two groups, except for body mass index (the sitagliptin group: 25.14 ± 3.05 kg/m 2 ; the nateglinide group: 21.39 ± 2.24 kg/m 2 ). Fasting levels of HbA 1c , glycated albumin, 1.5-anhydroglucitol, and blood glucose, as well as the blood glucose levels at one and three hours postprandially, improved in both groups after 12 wk of treatment, and there were no significant differences between the two groups. However, the glucagon level at one hour postprandially (P = 0.040) and the diastolic blood pressure (P<0.01) only showed a significant decrease in the sitagliptin group. In the nateglinide group, there was no significant change in the AUC of Apo B48, the glucagon level at one hour postprandially, the fasting triglyceride level, or the diastolic blood pressure. Body weight was unchanged in both groups. However, the AUC of Apo B48 at three hours postprandially showed a significant decrease in the sitagliptin group from 2.48 ± 0.11 at baseline to 1.94 ± 0.78 g/L per hour after 12 wk (P=0.019). The fasting triglyceride level also decreased significantly in the sitagliptin group (P = 0.035). With regard to lipid-related markers other than Apo B48 and fasting triglycerides, no significant changes were observed with respect to Apo A1, Apo B, or Apo C3 in either group. No adverse events occurred in either group. CONCLUSION: Sitagliptin significantly improves some lipid parameters while having a comparable effect on blood glucose to nateglinide. A large-scale prospective study of sitagliptin therapy is warranted.     

不同剂量血液滤过对内毒素休克猪生存时间和细胞因子水平的影响

目的 探讨不同剂量连续性血液滤过（CVVH）对细胞因子的清除作用以及对血浆细胞因子水平的影响。 方法 采用静脉注射内毒素（E.coli O111: B4,15.7 μg/kg）的方法诱导内毒素休克猪模型。将内毒素休克猪按随机数字表法分为对照组(n=6)、 CVVH组 (n=6,前稀释法,等于后稀释法的45 ml·kg-1·h-1）和高容量血液滤过（HVHF）组 (n=6,前稀释法,等于后稀释法的70 ml·kg-1·h-1）。于造模前（基线）、成模时（T0）,成模后1 h（T1）、6 h（T6）、12 h（T12）、24 h（T24）分别测定血浆肿瘤坏死因子α（TNF-α）、白细胞介素（IL）6、IL-10和IL-18水平。 结果 对照组动物平均生存时间为（15.4±5.2） h;CVVH 组为(21.4±7.1) h;HVHF组为（22.4±6.7） h,CVVH组和HVHF组的生存时间显著高于对照组（均P < 0.05）。3组动物的心率（HR）、平均动脉压（MAP）、中心静脉压（CVP）和心排出量（CO）之间差异无统计学意义（P > 0.05）。内毒素休克猪成模后出现BUN和Scr的进行性升高,两治疗组的BUN和Scr水平显著低于对照组（P < 0.05）,但两者之间差异无统计学意义（P > 0.05）。对照组TNF-α和IL-6水平在T1时达高峰,IL-10水平在T0时最高,随后不断下降。IL-18水平在成模后上升,后无明显变化。CVVH组血浆IL-10（T6、T12、T24）水平低于对照组（P < 0.05）。HVHF组TNF-α（T6）和IL-10（T6、T12、T24）水平低于对照组和CVVH组（P < 0.05）,3组的IL-6和IL-18水平差异无统计学意义,IL-6（T6、T12）水平和动物生存时间呈负相关（P < 0.05）。 结论 CVVH和HVHF治疗均能显著延长内毒素休克猪的生存时间。CVVH能有效清除IL-10;HVHF治疗能清除TNF-α和IL-10;但CVVH和HVHF对IL-6和IL-18水平无明显影响;CVVH和HVHF均能有效清除BUN和Scr。IL-6水平是预测内毒素休克预后的独立指标。     

高容量血液滤过联合机械通气对犬海水型呼吸窘迫综合征的作用

目的 建立稳定的海水型呼吸窘迫综合征（SW-RDS）犬模型,探讨高容量血液滤过（HVHF）联合机械通气（MV）对海水淹溺后发生SW-RDS的疗效。 方法 采用健康杂种犬10只,随机分为2组：（1）单纯MV组（n=5）：实验犬在模型成功后行MV;（2）HVHF+MV组（n=5）：模型成功后在MV的基础上联合HVHF。两组均连续观察4 h。在气管插管成功稳定15 min后（基础状态）、成模、治疗60 min、120 min、180 min、240 min时记录平均动脉血压（MAP）、心率（HR）、中心静脉压（CVP）,进行动脉血气分析,采集静脉血标本以测血浆渗透浓度;另于基础状态、成模、治疗120 min、240 min采集静脉血标本以测炎性介质（IL-8、IL-6、TNF-α）;实验结束后取肺组织标本行光镜及电镜检查。 结果 （1）在治疗4 h后两组实验犬均存活。（2）血氧分压（PaO2）及氧饱和度（SaO2）均有所上升,HVHF+MV组较MV组改善更明显（P < 0.05）;HVHF+MV组pH、实际碳酸氢根 (AB)、剩余碱（BE）较MV组显著改善（P < 0.05）,恢复至基础状态水平。（3）两组在治疗4 h过程中MAP、HR、CVP均保持稳定,治疗240 min后MAP、HR、CVP与成模时比较差异无统计学意义;两组间相同时间点比较差异亦无统计学意义。（4）MV组在治疗4 h过程中,血浆渗透浓度保持稳定,与成模时比较差异无统计学意义。HVHF+MV组在治疗240 min后血浆渗透浓度较MV组同时间点显著升高（P < 0.05）,较同组成模及治疗180 min时亦显著升高（P < 0.01）。（5）HVHF+MV组血浆炎性介质（IL-8、IL-6、TNF-?琢）在治疗240 min后与MV组同时间点比较显著减少（P < 0.01）;MV组治疗240 min后IL-8、TNF-?琢较成模型时比较明显升高（P < 0.05）。（6）肺组织病理提示,HVHF+MV组肺组织炎性反应、水肿、肺泡上皮损伤等情况较MV组有所改善。 结论 HVHF+MV能明显改善犬SW-RD的低氧血症及纠正酸中毒。HVHF可有效清除循环血炎性介质及多余的水分,从而改善肺组织病理。HVHF对犬SW-RD的mABP、HR、CVP无显著影响。     

Haemostatic changes in systemic inflammatory response syndrome during continuous renal replacement therapy

BACKGROUND: Endothelial damage and hemostatic imbalance play an important role in the evolution of the Systemic Inflammatory Response Syndrome (SIRS) into the Multiple Organ Dysfunction Syndrome (MODS). In Acute Renal Failure associated with SIRS, different types of Continuous Renal Replacement Therapies (CRRT) may give non-renal benefits by modifying the levels of some factors related to those disturbances. METHODS: Forty patients with SIRS-associated ARF were randomised to receive either continuous venovenous hemofiltration (CVVH) or continuous venovenous hemodiafiltration (CVVHDF) for the first 24 h. Afterwards the CRRT method was reversed. The group treated with CVVH moved to CVVHDF and that treated with CVVHDF to CVVH for the next 24 h. Plasma levels of: von Willebrand Factor (vWF), thrombomodulin, plasminogen activity inhibitor type 1 (PAI-1: antigen and activity), tissue type plasminogen activator (t-PA: antigen), prothrombin fragment 1+2 (F1+2) and thrombin-antithrombin complexes (TAT) were measured previously to CRRT (base-line), and after 24 and 48 hours of therapy. Multivariate ANOVA was the statistical method used. RESULTS: In the MANOVA study a significant decrease in PAI-1 activity during the treatment procedure was observed (horizontality p <0.05). PAI-1 antigen showed a tendency to decrease although without statististical significance. There were no significantly different changes in the other factors analysed during either CRRT (parallelism p >0.05). At the base-line point, all the factors were higher than normal values in healthy adults. CONCLUSIONS: The present study suggests that CRRT, in patients with SIRS, may promote a decrease in PAI-1 and consequently, a better outcome. There were no differences between the CVVH and the CVVHDF methods regarding the factors analysed. The present data confirms that there is an important endothelial and hemostatic dysfunction in SIRS from the early phases.     

高通量血液滤过治疗脓毒症的疗效分析

目的 分析脓毒症预后的影响因素,以及探讨高通量血液滤过（HVHF）治疗脓毒症的疗效和治疗脓毒症并发急性肾损伤（AKI）的开始时机。 方法 回顾性分析接受HVHF治疗的152例脓毒症患者的临床资料。对治疗前和治疗后24、48、72 h进行急性生理与慢性健康状况评分（APACHE）Ⅱ、APACHEⅢ、简化急性生理学评分（SAPS）。根据第28天存活情况,将患者分为存活组和死亡组,组内比较治疗前、治疗后24、48、72 h临床指标变化;组间比较治疗前临床资料差异。多元回归分析影响患者预后的危险因素。分析AKI不同分期对患者预后的影响。 结果 肺部和消化道是脓毒症常见感染部位。HVHF治疗后第28天,152例患者中存活74例(48.68%),死亡78例(51.32%),其中4例(2.63%)需继续肾脏替代治疗。第28天病死率明显低于根据APACHEⅢ预测的病死率（88.78±17.72）%。HVHF治疗24 h后APACHEⅡ、APACHEⅢ、SAPSⅡ评分显著降低（均P < 0.01）。年龄、衰竭器官数目、APACHEⅡ、APACHEⅢ、SAPSⅡ评分、基础疾病、休克、AKI、急性重症胰腺炎、消化道出血、昏迷及使用升压药物与28 d存活率密切相关,其中基础疾病、APACHEⅢ是独立危险因素。AKI 1期的肾功能恢复率高于AKI 2、3期（均P < 0.05）;无AKI患者28 d病死率低于AKI 1、2、3期（均P < 0.05）,但AKI 1、2、3期间28 d病死率差异无统计学意义。 结论 脓毒症患者预后差。HVHF能有效改善脓毒症的临床和生化指标,减轻病情,提高存活率。基础疾病、APACHEⅢ是影响脓毒症患者28 d死亡的独立危险因素。无AKI患者的28 d病死率显著低于AKI 1、2、3期的患者。AKI分期与28 d肾功能恢复率相关,与28 d病死率无相关。     

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（continuous venc-venous blood hemofihrition，CVVH）治疗老年多器官功能障碍的疗效，探讨其应用价值。方法回顾性分析2005年5月至2007年11月期间在我院住院发生多器官功能障碍并接受CVVH治疗的危重患者32例。观察治疗过程中血压、血气分析、毒素清除、电解质的波动及APACHEⅡ评分的变化情况。结果治疗开始时APACHEⅡ评分为（20．7±4．30），存活时间超过2周者16例，临床痊愈12例。死亡组患者APACHEⅡ评分为（27．0±4．37），存活组评分为（13．8±3．86）。存活的患者，治疗过程中血压、血气分析等指标逐渐好转，治疗前后比较差异具有统计学意义。8例治疗前休克需要升压药维持血压者，治疗后5例升压药物逐渐减量、停药；合并心衰者治疗过程中心功能稳定；合并急性肾衰竭者17例，其中13例为肺部感染诱发多器官功能障碍综合征（MODS），治疗过程中内环境稳定，治疗后尿量均有不同程度好转，最终因病原菌耐药8例死亡、1例肾功能未恢复转变为慢性肾功能不全；治疗过程中未发生血液净化治疗相关的严重并发症。结论连续性静脉-静脉血液滤过是老年多器官障碍治疗中有效的辅助手段，可明显改善患者预后。     

Serum IL-6 and IL-1-ra with sequential organ failure assessment scores in septic patients receiving high-volume haemofiltration and continuous venovenous haemofiltration

AIM: Sepsis is characterized by an uncontrolled release of pro-inflammatory and anti-inflammatory mediators leading to immunoparalysis, cellular and humoral dysfunction, multiorgan dysfunction and death. This study evaluated the efficacy of high-volume haemofiltration (HVHF) compared with continuous venovenous haemofiltration (CVVH) in removing these inflammatory mediators. Clinical responses were assessed with the sequential organ failure assessment (SOFA) score. METHODS: Septic patients with an end-organ dysfunction or septic shock were randomized to receive 6 h of CVVH (ultrafiltration dose of 2 L/h equivalent to about 35 mL/kg per hour or HVHF (ultrafiltration dose of 100 mL/kg per hour or 6 L/h, whichever was higher). The sequential organ failures were scored for the 24 hours preceding recruitment; at day 1, day 7, at discharge from the intensive care unit and at hospital discharge. RESULTS: Thirty-three patients were enrolled. Fifteen received HVHF and 18 received CVVH. The serum IL-6 levels (pg/mL) at baseline were similarly elevated in both groups (P = 0.745). The HVHF group showed a significant reduction after 6 h of treatment with a median interquartile range (IQR) of 20.62 (49.21) pg/mL (P = 0.025) with no similar result in the CVVH group. Non-survivors showed a higher baseline serum IL-6 compared with the survivors (median (IQR) 172.31 (261.34) vs 58.9 (104.21), P = 0.044). In the HVHF group there was a positive association between the IL-6 levels at 6 h with the SOFA scores at day 1 (r = 0.392, P = 0.001) but not at day 7. After 6 h of treatment in the HVHF group there was a direct correlation between the IL-6 levels and number of hospital days (r = 0.90, P = 0.040). The maximum SOFA scores were persistently recorded before treatment. The SOFA scores reduced in both groups from baseline to day 7 (HVHF P = 0.048; CVVH P = 0.006). The SOFA scores at day 1 is significantly higher in the non-survivors compared with the survivors (P = 0.038). CONCLUSIONS: High-volume haemofiltration at 6 L/h may seem to successfully remove some inflammatory cytokines in septic patients. The improvement in the SOFA scores at day 7 promises benefit of continuous renal replacement therapy in septic patients, but after 20 days this effect may be lost. In addition, the baseline serum IL-6 and IL-1-ra were independent predictors of a poor outcome as reflected by the higher SOFA scores at day 1.     

疝补片修补及开腹减压术在腹腔间室综合征伴腹腔感染治疗中的应用

目的探讨疝补片修补及开腹减压术对腹腔间室综合征（abdominal compartment syndrome,ACS）伴腹腔感染患者的临床疗效,分析其应用价值。 方法回顾性分析2011年4月至2018年4月,解放军第九六〇医院淄博院区收治的ACS伴腹腔感染42例患者的临床资料,根据患者及家属意愿分为2组。试验组患者18例,采用疝补片修补术;对照组患者24例,采用开腹减压修补术。比较2组患者治疗后的总有效率,治疗前后的急性生理与慢性健康状况（acute physiology and chronic health evaluation,APACHE）Ⅱ评分,并对比分析治疗前后患者的血清炎性因子C反应蛋白（C-reactive protein,CRP）、白细胞介素6（interleukin-6,IL-6）和肿瘤坏死因子α（tumor necrosis factor-α,TNF-α）水平。 结果2组患者治疗病情好转,试验组总有效率（83.33%）高于对照组患者（79.17%）,但差异无统计学意义（P=0.773）;2组患者治疗后APACHEⅡ评分均下降,但试验组患者下降程度大于对照组,差异有统计学意义（P<0.01）;治疗后,患者炎症反应明显减轻,CRP、IL-6、TNF-α均下降,治疗前后差异均有统计学意义（P<0.01）,且试验组患者炎症缓解程度显著大于对照组,差异有统计学意义（P<0.01）。 结论疝补片修补应用于临床治疗ACS伴腹腔感染能有效改善患者血清炎性因子水平,缓解患者临床症状,有效改善患者健康状况,降低患者腹内压,为临床治疗提供新选择。     

早期肠屏障功能保护在重症急性胰腺炎治疗中的重要性

目的 观察早期保护肠屏障功能对重症急性胰腺炎(SAP)患者的影响.方法 分析56例SAP患者的治疗方法和预后.随机数字表法将患者分为常规治疗组(A组)和肠屏障保护组(B组),比较两组患者不同时间的APACHEⅡ评分、Ranson评分、Marshall评分、CT严重指数(CTSI)、胃肠功能评分、尿乳果糖/甘露醇(L/M)比值、血浆内毒素和二胺氧化酶(DAO)、血清C反应蛋白(CRP)和肿瘤坏死因子α(TNF-α)、胰腺感染和多器官功能障碍综合征(MODS)发生率、住院病死率.结果 治疗后第7天,B组APACHEⅡ评分、胃肠功能评分、尿L/M比值、血浆内毒素和DAO、血清CRP和TNF-α较A组显著降低,差异有统计学意义(P<0.05).入院2周内,两组患者CTSI比较,差异无统计学意义(P>0.05);B组患者胰腺感染和MODS发生率明显低于A组,差异有统计学意义(P<0.05);两组住院病死率比较,差异无统计学意义(P>0.05).结论 早期保护肠屏障功能,能明显减轻SAP患者的全身炎症反应,降低胰腺感染和MODS发生率,从而改善其预后.

Abstract：

Objective To observe the influence of early intestinal barrier protection in patients with severe acute pancreatitis(SAP). Methods To analyze the therapeutic methods and prognosis of 56 patients with SAP. The patients were randomly divided into the conventional therapy group (A) and the intestinal barrier protection group (B). The APACHE Ⅱ score, Ranson score, Marshall score, CT severity index (CTSI), gastrointestinal functions score (GFS), the ratio of Lactulose to Mannitol (L/M), plasma Endotoxin and Diamine Oxidase (DAO), serum C-reactive protein (CRP) and TNF-α, incidence of pancreatic infection and multiorgan dysfunction syndrome (MODS), and the hospitalization mortality were compared between the two groups. Results On the 7th day after admission, the APACHE Ⅱ score, GFS, L/M, Endotoxin, DAO, CRP and TNF-α were significantly less in group B than in group A (P<0. 05). There was no significant difference in the CTSI (P>0. 05)between the two groups at 2nd week after admission. The incidence of pancreatic infection and MODS in group B were significantly lower than in group A (P<0. 05). The hospitalization mortality was not significantly different (P>0. 05) between the two groups. Conclusion Early intestinal barrier protection in SAP alleviated systemic inflammatory response, and reduced the incidences of pancreatic infection and MODS, thus improved the prognosis.     

Superior mesenteric vein thrombosis – unusual management of unusual complication of Whipple procedure

INTRODUCTION

Pancreatoduodenectomy is an extensive procedure carrying risk of a number of postoperative complications. Of these the most common are surgical site infections (SSI), bleeding, delayed gastric emptying, and anastomotic leakage. However, the most serious complications are ones, that are rare, clinically hardly diagnosed, and if untreated, leading to the death of a patient. Among the latter complications is thrombosis of superior mesenteric vein. Its clinical signs are unspecific and diagnostics complicated. Treatment requires aggressive approach. If this is absent, intestinal necrosis with septic state, Multiple Organ Dysfunction Syndrome (MODS) and Multiple Organ Failure (MOF) lead to a death of a patient.

PRESENTATION OF CASE

Authors present a case of a patient after pancreatoduodenectomy, complicated by the thrombosis of superior mesenteric vein. Patient was managed by resection of the necrotic bowel, venous decompression by venous bypass from superior mesenteric vein to the right ovarian vein, and open abdomen with negative pressure wound therapy (NPWT). Patient suffered severe abdominal sepsis with need for intensive organ support. Abdomen was definitely closed on fourth NPWT redress. Patient healed without any further complications, is well and was released to the ambulatory setting.

DISCUSSION

Superior mesenteric vein (VMS) thrombosis is a rare complication. It diagnosis requires high level of vigilance and once diagnosed, aggressive therapy is essential. Two goals of surgical treatment exist: resection of the necrotic bowel and facilitation of the blood outflow.

CONCLUSION

Mesenteroovarian anastomosis is one of the options in treatment of thrombosis of VMS if thrombectomy is not feasible.Abbreviations: CRP, C-reactive protein; CT, Computer Tomography; ERCP, Endoscopic Retrograde Cholangiopancreaticography; IPP, Proton Pump Inhibitor; IU, International Units; LMWH, Low molecular weight heparin; MODS, Multiple Organ Dysfunction Syndrome; MOF, Multiple Organ Failure; NPWT, Negative Pressure Wound Therapy; PCT, Procalcitonine; SSI, Surgical Site Infection; SMV, Superior mesenteric vein; UFH, Unfractioned heparin; WBC, White blood cell count     

血必净联合连续肾脏替代治疗对外科术后脓毒症患者炎性因子及凝血功能的影响

目的:探讨血必净联合连续肾脏替代治疗(CRRT)对外科术后脓毒症患者炎性因子与凝血功能的影响。方法:将2016年3月1日2018年12月1日本院ICU科所收治的术后脓毒症患者158例纳入此次研究,依据治疗方案的不同,分成对照组52例、血必净组53例与联合组(血必净+血液净化)53例,比较治疗前与治疗后48 h三组的血清炎性因子(CRP、LPS、PCT及IL-10、IL-6、IL-1b)、凝血功能(APTT、PT、FIB)、肾功能(血Scr与BUN)、氧合指数及APACHEⅡ评分。结果:治疗后,各组凝血功能相关指标、血清相关炎性因子、肾功能指标、氧合指数及APACHEⅡ评分与治疗前相比均有所改善(P<0.05),血必净组和联合组均比对照组改善明显,且联合组比血必净组更加显著(P<0.05)。结论:血必净与CRTT联合用于外科术后脓毒症的患者,能够有效降低患者机体发生的炎性反应,对患者的凝血功能与APACHEⅡ评分起到改善作用,有一定的临床推广价值。