连续性静脉静脉血液滤过治疗多器官功能障碍综合征的临床研究

目的　研究连续性静脉静脉血液滤过治疗多脏器功能衰竭的疗效。方法　1999 -12 ~2003 -12大连医科大学附属第一医院64例多器官功能障碍综合征(MODS)病人分为CVVH(静脉静脉血液滤过)治疗组34例和IHD(间歇性血液透析)治疗组30例,记录发生低血压、心律失常的次数,计算尿素清除指数(KT/V)值,治疗前后计算APACHE Ⅱ评分并记录转归情况。结果　CVVH治疗组血流动力学稳定性好于IHD治疗组;CVVH组KT/V值高于IHD组;CVVH组治疗后APACHE Ⅱ评分好于IHD组,分别为(17 .23±6 .86)分, (20. 91±5 .77)分(P<0 .05)。结论　CVVH治疗在血流动力学稳定性,溶质清除率及预后方面优于IHD。     

连续性静脉-静脉血液滤过治疗急性肾功能衰竭

为了评价连续性肾脏替代治疗对急性肾功能衰竭(ARF)的治疗效果,2年来对14例ARF患者行连续性静脉-静脉血液滤过(CVVH)治疗.10例(71.4%)患者恢复正常肾功能,4例死亡.治疗过程中血流动力学稳定,没有观察到明显不良反应.因此,CVVH是治疗重症ARF的有效手段.     

连续静脉-静脉血液滤过治疗难治性心力衰竭临床疗效观察

目的 观察连续静脉-静脉血液滤过（CVVH）治疗难治性充血性心力衰竭（CHF）的疗效及安全性.方法 21例难治性心力衰竭患者,行床边CVVH治疗,观察治疗前、后心衰症状改善情况、血流动力学和实验室检测指标变化情况.结果 经CVVH治疗后,所有患者心衰症状均有不同程度改善,血流动力学及电解质稳定,尿素氮（BUN）、肌酐（Cr）、血尿酸、NT-proBNP较治疗前降低（P＜0.05）,且无严重并发症.结论 CVVH治疗充血性心力衰竭患者水钠潴留的近期疗效是有效和安全的.     

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。     

连续血液净化对MODS患者的多器官支持治疗效果研究

目的探讨连续血液净化（continuous blood purification，CBP）对严重脓毒症（severe sepsis），特别是多器官功能障碍综合征（multiple organ dysfunction syndrome，MODS）患者的多器官支持治疗作用（multiple organ support therapy，MOST）效果。方法采用连续静脉-静脉血液滤过（CVVH）方法，对21例MODS患者（2002年10月-2004年12月）治疗前后内环境变化、血流动力学参数、氧合指数、肝、肾功能指标以及APACHE-Ⅱ评分的变化。结果CVVH治疗可纠正水电解质及酸碱紊乱，改善内环境，提高氧合指数，稳定血压及减少血管活性药用量。并且能够滤过炎症介质。治疗后总体APACHE-Ⅱ评分较治疗前明显降低。结论对危重症患者，特别是存在多器官功能不全者，连续血液净化通过对内环境的精细调节，可对多器官功能起到支持治疗作用，改善预后。     

连续性静脉-静脉血液滤过透析和连续静脉-静脉血液滤过对危重心肾综合征患者的临床疗效比较

危重心肾综合征( SCRS)患者均呈现重度心力衰竭和肾衰竭,临床上常出现少尿、无尿、高度浮肿、端坐呼吸、心律失常或电解质紊乱,常规的利尿剂和正性肌力药物往往难以奏效,连续性血液净化(CBP)在治疗中起到了关键作用危重心肾综合征临床上尚无统一的诊断标准[1],我们对连续性静脉-静脉血液滤过透析( CVVHDF)和连续静脉静脉血液滤过(CVVH)对27例SCRS患者的临床疗效进行比较.     

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。     

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。     

早期连续静脉-静脉血液滤过治疗重症急性胰腺炎4例报道

目的探讨早期应用连续静脉-静脉血液滤过(CVVH)治疗重症急性胰腺炎(SAP)对病情改善的作用.     

连续性静脉-静脉血液滤过治疗八十岁以上老年多器官功能衰竭患者的经验

目的:观察连续性静脉静脉血液滤过(continuousvenovenoushemofiltration,CVVH)用于老年多器官功能衰竭(multipleorganfailureintheelderly,MOFE)患者救治的临床疗效,以及治疗中并发症的情况。方法:2000年至2004年在本中心接受CVVH治疗的35例MOFE患者,年龄80～94(84.1±4.08)岁。观察CVVH疗效及治疗过程中患者血压、心率、体温、呼吸等生命体征变化,监测其肝、肾功能,同时观察CVVH治疗中并发症情况。结果:35例患者中存活时间超过15天的有23例(65.7%),最终存活率为42.9%(15/35),13例肾功能恢复正常。存活组年龄明显低于死亡组[(85.1±4.11)岁vs(82.3±3.41)岁,P<0.05],同时呼吸衰竭及肝功能衰竭的发生率均明显低于死亡组,所有患者对CVVH治疗均耐受良好,治疗过程中血压、心律平稳,血流动力学稳定,存活组患者APACHEⅡ积分在治疗过程中明显下降。治疗中并发症发生率低,其中4例出现导管继发的感染,9例患者并发出血,4例患者体温不升,经积极处理后好转。结论:CVVH治疗用于MOFE患者的救治,可有效缓解患者病情,保护脏器功能,提高患者存活率,治疗过程中患者耐受良好,血流动力学稳定,并发症少,是MOFE患者救治中重要的治疗手段之一。     

连续肾脏替代治疗在肝移植中的应用

目的探讨连续肾脏替代治疗(CRRT)在肝移植术后急性肾功能衰竭(ARF)合并多器官功能不全(MODS)治疗中的应用价值。方法分析连续静脉静脉血液滤过(CVVH)治疗7例肝移植术后ARF、成人呼吸窘迫综合征(ARDS)、急性心衰、全身炎症反应综合征(SIRS)等患者。3例合并ARDS患者同时进行呼吸机辅助呼吸治疗。结果4例治愈,另3例ARF合并MODS患者死亡。经CVVH治疗后,患者血清中的肌酐、尿素氮、血钾较治疗前降低(P<0.05),凝血酶原时间变化无意义。结论CVVH能有效控制氮质血症和高血钾等高分解状态,而不影响凝血功能。早期应用可以改善肝移植术后ARF、ARDS、充血性心力衰竭、SIRS等MODS患者的预后。     

连续性静脉-静脉血液滤过在48例难治性心力衰竭患者中的治疗作用

目的探讨连续性静脉-静脉血液滤过(CVVH)对难治性心力衰竭患者的治疗作用及安全性。方法48例难治性心力衰竭患者经常规强心、利尿等治疗效果不佳后接受CVVH治疗共167例次。观察治疗前后心率、血压、呼吸频率、肺部罗音、肝颈静脉回流征和水肿等的变化,并判断心功能的改变;测定治疗前、后左心室射血分数、肾功能及电解质等。结果经CVVH治疗后大部份患者(77.1%)呼吸困难缓解,心率逐渐恢复,血压维持正常,肺部罗音减少,肝颈静脉回流征转为阴性,水肿消退,左心室射血分数增加,心功能从Ⅳ级提高到Ⅱ~Ⅲ级;38例合并肾功能不全的患者经CVVH治疗后血尿素氮、肌酐降低;28例合并电解质紊乱者经治疗后高钾血症和低钠血症得到纠正。9例合并严重心律失常的患者有6例经CVVH治疗后心率、心律恢复正常。结论CVVH能平稳地清除水分及溶质并保持血流动力学的稳定,可以安全有效地应用于难治性心力衰竭的治疗。     

连续性血液净化在ICU多器官功能障碍综合征合并急性肾衰竭患者的应用及预后分析

目的探讨连续性血液净化治疗（CBPT）在ICU多器官功能障碍综合征（MODS）合并急性肾衰竭（APF）患者的疗效及影响预后的相关因素。方法回顾性分析2004年1月至2008年2月该院ICU中行连续性静-静脉血液滤过（CVVH）治疗的245例MODS合并ARF患者一般资料、血液生化检查、疾病严重程度评分等，对比分析CVVH治疗前后临床参数的变化及影响预后的因素。结果CVVH对容量负荷、溶质清除效果明显；反映疾病严重程度如氧合指数、APACHEⅡ评分、MODS评分、SOFA评分CVVH治疗前后比较无明显差异；全部患者死亡率为64．9％，病死率随着衰竭器官数目的增加而显著升高。多因素回归分析显示，患者CVVH治疗前衰竭器官数、医院获得性ARF、CVVH前APACHEⅡ评分、平均动脉压是独立危险因素。结论对于MODS合并ARF患者，CVVH治疗前患者疾病的严重程度是影响预后的重要因素，依据患者临床病情早期积极CBPT可能改善MODS合并ARF患者的预后。     

Amelioration of hemodynamics and oxygen metabolism by continuous venovenous hemofiltration in experimental porcine pancreatitis

AIM: To investigate the potential role of continuous venovenous hemofiltration (CVVH) in hemodynamics and oxygen metabolism in pigs with severe acute pancreatitis (SAP). METHODS: SAP model was produced by intraductal injection of sodium taurocholate [4%, 1 mL/kg body weight (BW)] and trypsin (2 U/kg BW). Animals were allocated either to untreated controls as group 1 or to one of two treatment groups as group 2 receiving a low-volume CVVH [20 mL/(kg·h)], and group 3 receiving a high-volume CVVH [100 (mL/kg·h)]. Swan-Ganz catheter was inserted during the operation. Heart rate, arterial blood pressure, cardiac output, mean pulmonary arterial pressure, pulmonary arterial wedge pressure, central venous pressure, systemic vascular resistance, oxygen delivery, oxygen consumption, oxygen extraction ratio, as well as survival of pigs were evaluated in the study. RESULTS: Survival time was significantly prolonged by low-volume and high-volume CVVHs, which was more pronounced in the latter. High-volume CVVH was significantly superior compared with less intensive treatment modalities (low-volume CVVH) in systemic inflammatory reaction protection. The major hemodynamic finding was that pancreatitis-induced hypotension was significantly attenuated by intensive CVVH (87.4±12.5 kPa vs116.3±7.8 kPa,P＜0.01). The development of hyperdynamic circulatory failure was simultaneously attenuated, as reflected by a limited increase in cardiac output, an attenuated decrease in systemic vascular resistance and an elevation in oxygen extraction ratio. CONCLUSION: CVVH blunts the pancreatitis-induced cardiovascular response and increases tissue oxygen extraction. The high-volume CVVH is distinctly superior in preventing sepsis-related hemodynamic impairment.     

血液净化治疗急性中毒并发多器官功能障碍综合征82例临床观察

目的探讨血液净化治疗急性中毒并发多器官功能障碍综合征（MODS）的临床价值。方法治疗组82例在综合治疗的基础上,40例给予血液灌注（HP组）,42例用HP＋连续性静脉-静脉血液滤过（CVVH）治疗（HP＋CVVH组）。对照组86例仅给予综合治疗。结粜（1）治疗组机械通气时间（46．5±8．5）h,住院时间（10．5±3．5）d,治愈好转率91．5％（75／82）,病死率8．5％（5／82）;对照组分别为（59．5±11．5）h、（15．5±4．5）d、72．1％（62／86）及27．9％（24／86）。两组比较差异有统计学意义（P均〈0．01）。（2）HP＋CVVH组72h的肝功能、肾功能、炎性因子、APACHEⅡ评分指标比单纯HP组治疗明显改善（P均〈0．05）。（3）HP＋CVVH组的机械通气时间为（42．5±8．5）h,住院时间为（9．5±2．5）d,治愈好转率为97．6％（41／42）,病死率为2．4％（1／42）;HP组的机械通气时间为（50．5±9．5）h,住院时间为（11．5±3．5）d,治愈好转率为85．0％（34／40）,病死率为15％（6／40）,两组比较差异有统计学意义（P均〈0．05）。结论血液净化治疗急性中毒并发MODS,能从血液中直接、迅速地清除内外源性有害物质,疗效肯定,尤其HP＋CVVH治疗的疗效更为显著。     

The effect of intensive plasma water exchange by hemofiltration on hemodynamics and soluble mediators in canine endotoxemia

High volume hemofiltration (HVHF) (200 ml/kg/h) improves hemodynamics in experimental septic shock but is difficult to apply clinically. Accordingly, we studied whether less intensive HVHF (80 ml/kg/h) can still improve hemodynamics in experimental septic shock. We also investigated its effect on the serum concentrations of several inflammatory mediators, including endothelin (ET-1), endotoxin (LPS), tumor necrosis factor-alpha (TNF-alpha), and 6-keto prostaglandin F(1alpha) (6-kepto PGF(1alpha)). Sixteen anesthetized dogs were connected to a continuous veno-venous hemofiltration (CVVH) (filtration: 80 ml/kg/h) or sham circuit and endotoxin (0.5 mg/kg) was infused intravenously over 5 min. Hemodynamic variables were measured at baseline and at 15, 45, 90, and 180 min. The major hemodynamic finding was that endotoxin-induced hypotension was significantly attenuated by intensive CVVH (p < 0.04). Changes in cardiac output and right ventricular ejection fraction were equal in both groups. ET-1 levels, but not LPS, TNF-alpha, or 6-keto PGF(1alpha), were lower during CVVH (p = 0.042). Endotoxin or TNF-alpha were not found in the ultrafiltrate. Median clearances of ET-1 and 6-keto PGF(1alpha) during intensive CVVH were 8.8 and 25.9 ml/m, respectively. We conclude that intensive CVVH attenuates the early component of endotoxin-induced hypotension and reduces serum concentrations of endothelin-1. The effect of CVVH on blood pressure is not explained by convective clearance of the mediators in question.     

连续性静脉-静脉血液滤过在重症胰腺炎治疗中的价值

目的 观察在传统治疗重症急性胰腺炎(SAP)的同时行连续性静脉-静脉血液滤过(CVVH)的疗效。方法 53例SAP患者在接受传统治疗的同时行CVVH,每次至少持续24h。监测CVVH前后病情及血清淀粉酶、脂肪酶的变化,行动脉血气分析和APACHlE Ⅱ评分,测血中内毒素水平。结果 CVVH治疗后患者心动过速、呼吸窘迫、腹痛、腹胀等症状明显缓解,APACHEⅡ评分明显降低,淀粉酶、脂肪酶、尿素氮、肌酐明显降低,酸中毒、低氧血症纠正。CVVH治疗6h后,血中内毒素水平下降,24h后又恢复至治疗前的水平。53例患者中38例痊愈出院,存活率为71．7％。结论 在传统治疗SAP的同时行CVVH,能提高抢救的成功率,降低病死率。     

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.     

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.     

连续静脉血液滤过治疗对血浆NT-proBNP水平的影响及其意义

目的:研究连续静脉血液滤过(CVVH)对N端脑钠尿肽原(NT-proBNP)的影响,以及此类患者CVVH治疗前后NT-proBNP的水平和心功能的相关性。方法: 对50例接受CVVH治疗患者的临床资料进行回顾性分析,收集CVVH治疗前后的血样,采用电化学发光免疫技术检测血浆NT-proBNP的水平,并比较NT-proBNP水平在血液净化治疗前后的变化及其与左室射血分数(LVEF)的相关性。结果: 血浆NT-proBNP的水平在CVVH治疗前明显高于治疗后（P<0.01）。CVVH治疗前NT-proBNP的水平与LVEF呈负相关性（Pearson系数为-0.783）,治疗结束后此种相关性消失。CVVH治疗前,死亡组患者NT-proBNP的水平高于存活组患者（P<0.01）。治疗结束后,两组患者血浆NT-proBNP的水平无统计学差异。结论: CVVH治疗可以使血浆NT-proBNP的水平显著下降,且NT-proBNP水平下降的程度与CVVH治疗的时间及脱水量呈正相关。对于接受CVVH治疗及肾功能不全的患者,需慎重以NT-proBNP的水平作为评价心功能的血清学指标。