腹腔感染合并急性肾功能衰竭患者连续静脉-静脉血液滤过治疗前后血浆氨基酸水平变化

目的 探讨腹腔感染合并急性肾功能衰竭患者连续静脉-静脉血液滤过(CVVH)治疗前后血浆氨基酸水平变化和氨基酸丢失量.方法 回顾性分析2008年9月至2009年9月南京军区南京总医院收治的10例腹腔感染合并急性肾功能衰竭患者的临床资料.采用AV600S聚砜膜行24 h CVVH治疗,分别采集CVVH治疗前、治疗12 h和24 h血浆,连续收集24 h滤液.高压液相色谱测定血浆和滤液氨基酸浓度,并计算滤液氨基酸丢失量.采用配对t检验或Wilcoxon秩和检验,一元线性回归分析变量之间的关系.结果 10例患者中死亡6例,其中3例死于脓毒性休克,3例死于MODS.CVVH治疗24 h后血浆各种氨基酸水平显著下降,其中组氨酸、异亮氨酸、半胱氨酸和谷氨酰胺分别由(22.1±10.3)、(20.0±7.6)、(10.3±4.7)、(122.3±72.2)μmoL/L下降至(5.6±3.4)、(6.4±2.5)、(2.9±2.4)、(42.5±33.6)μmol/L.血浆总氨基酸水平呈下降趋势,CVVH治疗12 h和24 h分别下降52%和59%.滤液氨基酸24 h平均丢失量为(9631±1089)mg/d,其中非必需氨基酸和必需氨基酸丢失量分别为(5072±618)mg/d和(3747±654)mg/d,两者比较,差异有统计学意义(t=4.52,P＜0.05).CVVH治疗12 h后滤液氨基酸丢失量和血浆氨基酸水平之间呈正相关(r=0.68,P＜0.05).结论 腹腔感染患者接受CVVH治疗时,氨基酸可以经滤液丢失,因此,为CVVH患者制定营养方案时,滤液额外丢失的氨基酸需要考虑在内,尤其要适当增加非必需氨基酸的含量.     

连续性静脉-静脉血液滤过对内毒素休克羊血液动力学和炎性介质的影响

目的观察连续性静脉.静脉血液滤过(CVVH)对内毒素休克血液动力学和炎性介质的影响。方法 雄性绵羊12只,随机分为两组。对照组(A组,n=6),内毒素以1 mg·kg-1静脉泵注,30min内完成,同时静脉输注林格液15 ml·kg-1·h-1,持续6 h;血滤组(B组,n=6),于开始泵注内毒素后1 h给予CVVH治疗5 h,其余处理同A组。所有动物均给予气管插管、镇静、肌松、控制呼吸,行有创血液动力学监测;两组分别于内毒素泵注前(T0)、开始泵注后30、60、90、120、210、360 min(T1～T6)采静脉血及超滤液4ml,测定血浆及超滤液中内毒素、TNF-α、IL-6、IL-10的浓度。结果 血滤组CVVH治疗后(T1-T6)平均动脉压及体循环阻力指数明显上升、心率显著性下降。TNF-α于泵注内毒素后(T1-T6)两组均显著性增高,血滤组于CVVH治疗60 min(T4)时较治疗前(T2)虽无明显改变,但明显低于同时点对照组(P<0.01),CVVH治疗150～300 min(T5-T6)时TNF-α浓度较对照组及治疗前(T2)均显著性降低(P<0.05);IL-10虽呈增高趋势,但较治疗前和对照组无显著性变化;而两组IL-6水平则无明显差异。超滤液中可检测到TNF-α、IL-6、IL-10。结论 血滤治疗有利于纠正促炎细胞因子过度释放和抗炎细胞因子失衡,改善内毒素休克血液动力学。     

无抗凝血液滤过用于不同原因高危出血倾向患者的研究

目的:研究不同原因的高危出血倾向患者在实施无抗凝连续性静脉-静脉血液滤过(continuous veno-venous hemofiltration,CVVH)时,滤器使用寿命和溶质清除效果的差异。方法:按照高危出血倾向的不同原因,将无抗凝CVVH治疗的118例次患者分为低凝组(n=58)和出血组(n=60),比较CVVH治疗前后两组间血ΔScr、ΔBUN和滤器使用寿命的差异。结果:出血组滤器使用寿命(17.5±11.2)h,低于低凝组(35.8±15.8)h,差异具有统计学意义。滤器使用寿命12 h的比例在低凝组、出血组分别是72.4%、38.3%,滤器使用寿命24 h的比例在低凝组、出血组分别是43.1%、16.7%,其差异均具有统计学意义。出血组ΔScr(74.5±32.2)μmol/L、ΔBUN(7.0±2.8)mmol/L,低于低凝组(167.0±100.5)μmol/L、(11.1±4.9)mmol/L,其差异均具有统计学意义。结论:无抗凝CVVH可应用于因凝血功能障碍或血小板减少导致的高危出血倾向患者,不建议用于活动性出血或外科术后的高危出血倾向患者。     

局部枸椽酸抗凝在血液净化中应用的临床观察及护理

【摘要】 目的 探讨局部枸椽酸抗凝在连续性静脉血液滤过(CVVH)中应用的临床效果及护理体会。方法〓选取52例行静脉血液滤过的患者,按应用抗凝剂的不同分成A组和B组,A 组即局部枸椽酸抗凝组26例,B组即全身低分子肝素抗凝组26例。监测两组患者CVVH治疗前及治疗72小时后肾功能及出凝血情况、滤器及管道情况、护士工作时间。结果〓两组患者72小时后肌酐(238.6±81.2 vs. 245.0±75.4 umol/L, t=-0.295,P=0.769)、尿素氮(13.8±4.8 vs. 13.5±5.2 umol/L, t=0.257, P=0.798)、APACHEII评分(17.7±3.4 vs. 16.0±4.1, t=1.608 P=0.114)间差异均无统计学意义;出凝血功能(TT:18.8±4.1 vs. 19.6±4.3秒,t=-0.654、P=0.516,APTT:45.4±11.6 vs. 40.5±11.7秒,t=1.498、P=0.140,PLT:108.9±49.7 vs. 113.2±48.4×109/L,t=-0.312、P=0.756)、气道/各穿刺点出血人次(1 vs. 3人次,Χ2=1.083,P=0.298)的差异无统计学意义。但对于滤器及管道寿命,B组明显长于A组(48.78±12.83 vs. 17.67±6.49小时,t=-11.029,P=0),护士工作时间,前者亦明显少于后者(401.7±54.7 vs. 459.4±74.1分钟,t=3.195,P<0.05)。结论〓局部枸椽酸抗凝在血液净化中对肾脏功能影响、凝血功能变化与低分子肝素无差异,说明其安全、有效,但管道及滤器使用时间明显延长,明显减少管道及滤器更换次数,大大提高经济性同时大大减轻护士工作量。     

血浆置换联合连续性血液滤过治疗重症医学科患者的应用观察

目的 探讨血浆置换联合连续性血液滤过治疗重症医学科患者的应用观察.方法 所有患者均采用股静脉留置单针双腔导管建立体外循环.血浆置换、连续性血液滤过采用GAMBRO-PRISMA血液净化机,血浆置换采用Prisma TPE 2000膜式血浆分离器,流速为50～ 150ml/min,每次以30 ～40ml/kg体重计算置换量;连续性血液滤过采用Prisma M 100血液滤过器(AN69HF),滤器面积为0.9m2,流速为180 ml/min.在体外循环连接前采用肝素100 mg加入0.9％氯化钠溶液500ml中预冲洗血液滤过器及通路30 min;置换液配方按照南京军区总医院的配方,并结合患者情况适当调整.结果 7例患者中抢救成功5例.共行血浆置换治疗12次,每次血浆置换、连续性血液滤过后行生化、肝功能、血脂检查.妊娠合并高脂血症性急性胰腺炎患者治疗前血清甘油三酯为21.29 mmol/L,总胆固醇为33.79 mmol/L,血浆置换出乳糜样物,治疗后血清甘油三酯为7.98 mmol/L,总胆固醇为5.73 mmol/L,淀粉酶恢复正常,肾脏功能及其他脏器功能恢复.自身免疫性溶血性贫血并急性肾功能衰竭患者治疗前血红蛋白为35 g/L,血肌酐为296 μmol/L,尿潜血(+++～++++),经治疗后血红蛋白为105 g/L,血肌酐恢复正常,尿潜血消失;产后弥漫性血管内凝血并急性肝脏功能衰竭患者治疗前总胆红素为236.72μmol/L,直接胆红素为135.25μmol/L,纤维蛋白原为1.78g/L,治疗后总胆红素为62.91μmol/L,直接胆红素为39.76μmol/L,纤维蛋白原为3.83 g/L;肝肾综合征和系统性红斑狼疮患者经过治疗,患者临床症状明显改善;其他患者治疗后意识转清,肾脏、各器官功能恢复,治疗前,急性生理学及慢性健康状况Ⅱ评分为(57±11)分,治疗后,急性生理学及慢性健康状况Ⅱ评分为(8±6)分,治疗前,C反应蛋白为(98±26) mg/L,治疗后,C反应蛋白为(15±9)mg/L,治疗前、后比较差异有统计学意义(P＜0.01).结论 采用血浆置换联合连续性血液滤过治疗具有以下优点:(1)能有效地将大、中、小分子的毒性物质清除,补充凝血因子等生物活性物质,实现优势互补,改善患者的中毒症状、生化指标,预防多器官功能障碍综合征发生;(2)不良反应少见,术中均未出现严重并发症,证明联合应用血浆置换和连续性血液滤过治疗重症医学科患者较为安全.     

肿瘤坏死因子-α对人脐静脉血管内皮细胞结构和功能的影响

目的 观察人肿瘤坏死因子-α(TNF-α)对人脐静脉血管内皮细胞EA.hy926结构和功能的影响,并探讨其作用机制.方法 培养人脐静脉血管内皮细胞EA.hy926,分组加入1、10、100 μg/L TNF-α培养24 h,或加入100 μg/L TNF-α培养3、8、12、24 h,Western blot检测细胞中血管扩张刺激磷蛋白(VASP)的表达水平;实时定量聚合酶链反应(Real-time PCR)检测细胞中VASPmRNA的表达水平,流式细胞仪检测细胞凋亡,透射电子显微镜观察细胞超微结构的变化.结果 TNF-α干预24h不同浓度组VASP mRNA水平分别为0.993±0.045(对照组)、0.801±0.022(1 μg/L)、0.626 ±0.018(10 μg/L)、0.529±0.017(100 μg/L);蛋白水平分别为0.849±0.021(对照组)、0.788±0.028(1μg/L)、0.364 ±0.018(10 μg/L)、0.317±0.023(100 μg/L);细胞凋亡率分别为(2.5±1.0)％(对照组)、(14.0±1.1)％(1 μg/L)、(24.4±3.8)％(10 μg/L)、(36.0±2.5)％(100 μg/L).100 μg/L TNF-α干预不同时间组VASP mRNA表达分别为0.829 ±0.051(3 h)、0.741±0.029(8 h)、0.669 ±0.026(12 h)、0.528 ±0.017(24 h),蛋白水平分别为0.528±0.201(3 h)、0.470±0.016(8 h)、0.299±0.015(12 h)、0.298±0.016(24 h);细胞凋亡率分别为(5.4±0.9)％(3 h)、(11.4±1.2)％(8 h)、(21.2±1.4)％(12 h)、(36.3±2.1)％(24 h).VASPmRNA及蛋白水平均呈时间及剂量依赖表达降低(P＜0.05),细胞凋亡率呈时间及剂量依赖升高(P＜0.05).结论 TNF-α通过破坏血管内皮细胞结构和功能导致血管内皮细胞通透性增高,呈时间与剂量依赖性.     

连续性静-静脉血液滤过治疗多器官功能障碍综合征伴高血钾患者的护理

目的 探讨无钾置换液用于连续性静一静脉血液滤过(CVVH)治疗多器官功能障碍综合征(MODS)伴高血钾的护理要点.方法 对10例MODS伴高血钾患者采用无钾置换液行CVVH治疗,治疗期间加强血管通路的护理、液体平衡的管理、监测生命体征等护理.结果 患者接受CVVH治疗5～6次,平均治疗时间6～12 h.10例均在首次治疗2 h后血清钾浓度下降,6 h后血清钾降至(4.76±0.41)mmol/L;且心律失常消失,恢复正常窦性心律.治疗后9例预后良好,1例死亡.结论 应用无钾置换液行CV-VH治疗MODS伴高血钾患者疗效较好,治疗中密切观察病情变化并做好相应护理,可保障治疗顺利有效地进行.     

不同稀释方式对无抗凝连续静脉-静脉血液滤过治疗的影响

在进行连续静脉-静脉血液滤过(CVVH)治疗(特别是无抗凝治疗)时,不同的置换液稀释方式对滤器寿命和溶质清除效率有显著的影响.本研究通过观察不同稀释方式对无抗凝CVVH治疗滤器寿命的影响以探索最佳稀释方式.     

连续性血浆滤过联合血浆吸附治疗脓毒症急性肾损伤的临床研究

目的探讨连续性血浆滤过联合血浆吸附治疗脓毒症急性肾损伤(acute kidney injury,AKI)的治疗效果。方法根据纳入排除标准,124例脓毒症AKI患者作为研究对象,随机分为观察组和对照组,每组62例。对照组予连续性血液滤过治疗,治疗时间24~72 h,血流速度150~180ml/min;观察组予连续性血浆滤过联合血浆吸附治疗,治疗时间血浆吸附每天3 h,血浆滤过24~72h,血流速度150~180 ml/min,比较2组患者28 d生存率、ICU入住时间、依赖呼吸机时间以及治疗前、后生命体征、氧合指数、IL-6、肿瘤坏死因子α(tumor necrosis factor-α,TNF-α)、白细胞介素1β、白细胞介素10、血肌酐、尿素氮、白细胞及急性生理学与慢性健康情况评价系统Ⅱ(acute physiology and chronic health evaluationⅡ,APACHEⅡ)。结果 2组患者治疗后生命体征、白细胞介素6、TNF-α、白细胞介素1β、白细胞介素10、氧合指数、血肌酐、尿素氮、白细胞及APACHE II评分等均明显改善(P0.05)。与对照组相比,观察组患者28 d生存率显著提高(72.58%比46.77%,P0.05),治疗后氧合指数改善更明显[(362.56±98.25)比(82.84±105.38),P0.05],血肌酐[(61.47±10.65)比(79.30±11.75)μmol/L,P0.05]、尿素氮[(8.69±3.61)比(14.06±3.76)mmol/L]、白细胞[(11.80±4.51)×10~9/L比(14.53±5.09)×10~9/L,P0.05]、白细胞介素6[(62.63±45.25)ng/ml比(112.38±66.23)ng/ml]、TNF-α[(23.62±4.27)ng/ml比(34.82±5.29)ng/ml]、白细胞介素1β[(32.52±8.32)ng/ml比(46.15±9.52)ng/ml]、白细胞介素10[(295.21±106.28)ng/ml比(361.78±102.03)ng/ml],生命体征改善明显(P0.05),APACHE II评分(11.62±3.71)比(14.36±3.52)、ICU入住时间[(15.69±3.51)比(18.92±3.27)d]及依赖呼吸机时间[(4.68±3.10)比(6.83±3.21)d]明显减少(P0.05)。结论连续性血浆滤过联合血浆吸附治疗可有效降低脓毒症AKI患者细胞炎性因子水平,改善患者预后。     

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     

Rapid removal of vancomycin by continuous veno-venous hemofiltration

We describe a 14-year-old girl with staphylococcal (coagulase-negative) ventriculo-peritoneal shunt infection, who developed oliguric acute renal failure and was found to have a serum vancomycin concentration of 250 microg/ml. Since only about 10%-50% of vancomycin is bound to protein in blood, we employed continuous veno-venous hemofiltration (CVVH) with a high ultrafiltration rate (1,800 ml/h) for increased convective clearance to remove vancomycin, which may have contributed to the acute renal failure. At the end of 38 h of CVVH, the vancomycin concentration had decreased in an exponential manner to 27 microg/ml. Over the subsequent 3-4 days, her renal function improved and the vancomycin concentration decreased further to <5 microg/ml. In conclusion, we believe that a high serum vancomycin concentration may be nephrotoxic and demonstrate that CVVH can be used effectively to remove vancomycin in children with acute renal failure.     

Reduced Protein Loss During Hemofiltration Using Cuprophan Membranes

In a study of four patients treated with one hour of hemofiltration using Cuprophan membranes, followed by three hours of hemodialysis, it was found that protein loss during hemofiltration was minimal. Losses ranged from 0.013 mg/mg at a transmembrane pressure (TMP) of 300 mmHg to 0.012 mg/ml at a TMP of 600 mmHg. Protein loss was not dependent on TMP and varied from dialyzer to dialyzer. Protein levels in serum remained unchanged during the period of hemofiltration in these patients and no evidence of protein wastage was evident.     

特利加压素对肝硬化患者肝部分切除术后肝肾功能保护作用的效果分析

目的 探讨特利加压素对肝硬化患者肝部分切除术后肝肾功能保护作用的临床疗效.方法 通过对57例行非规则性肝切除术的原发性肝癌合并肝硬化患者的临床资料进行分析,按照其手术后是否应用特利加压素,将其分为试验组(A组)27例和对照组(B组)30例,试验组术后当天开始应用特利加压素,对照组术后不使用特利加压素,观察两组手术前后肝功能指标(ALT、AST、TB)、腹腔引流液、尿量及肾功能指标(Cr、BUN)的变化.结果 与术后第1天比较,两组患者术后第3、5、7天血ALT、AST及腹腔引流液均有显著降低(P＜0.05),尿量均有显著增加(P＜0.05),术后第7天肌酐均显著降低(P＜0.05),但对照组上述观察指标改善不如试验组明显.组间比较,试验组患者的血ALT于术后第5天、第7大明显低于对照组,分别为(144.9±76.3)U/L、(100.5±61.5) U/L和(267.2 ±91.2) U/L、(199.3 ±70.5) U/L,差异均有统计学意义(P＜0.05),试验组术后第3、5、7天AST(211.1 ±99.8) U/L、(80.4±54.6) U/L、(50.6±46.5) U/L、尿素氮(6.6±1.9) mmol/L、(6.5±1.7) mmol/L、(6.3 ±2.1)mmol/L、肌酐(74.3±10.9) μmol/L、(71.5±8.9)μmol/L、(58.7±4.1) μmol/L、腹腔引流液(247.6±60.3) ml、(58.8±54.3) ml、(40.2±31.8) ml低于对照组AST(298.7±131.2) U/L、(201.1 ±93.4) U/L、(114.7±70.3) U/L、尿素氮(7.3±1.9) mmol/L、(7.2±1.8) mmol/L、(7.1±1.7) mmol/L、肌酐(79.5 ±15.1)μmol/L、(76.9±16.2) μmol/L、(69.4 ±11.4) μmol/L、腹腔引流液(275.2±88.1) ml、(191.7±71.6) ml、(93.2±50.2) ml,尿量(2232.3±409.8) ml、(2270.5±395.8)ml、(2179.0 ±301.4)ml多于对照组尿量(1921 ±510.4) ml、(2019.1±411.2) ml、(1978.7±323.7) ml,两组之间差异均有统计学意义(P＜0.05).试验组有2例(7.4％)患者并发肝肾功能不全、肝肾综合征等并发症,而对照组有11例(36.7％).结论 应用特利加压素对肝硬化肝部分切除术患者的肝肾功能有一定的保护作用,并可减少术后腹腔积液及预防肝肾综合征的发生.     

Tumor necrosis factor-alpha during continuous high-flux hemodialysis in sepsis with acute renal failure

Suppressed ex vivo endotoxin (ET)-induced production of the proinflammatory cytokine, tumor necrosis factor-alpha (TNF-alpha), in isolated mononuclear cells (PBMCs) is associated with fatal outcome in severe sepsis. PBMCs from surviving patients, but not those from nonsurviving patients, recover their capacity to produce normal amounts of TNF-alpha. We tested the influence of two modalities of continuous renal replacement therapy (CRRT) on ex vivo-induced whole-blood production of TNF-alpha and inhibitory TNF-soluble receptor type I (TNFsRI) in 12 patients with acute renal failure and sepsis (APACHE II score 22 to 30). METHODS: Standard continuous venovenous hemofiltration (CVVH; 36 liters of bicarbonate substitution fluid per day) was performed in 7 patients using polyamid hemofilters (FH66; Gambro). In an additional five patients, we performed daily 18 hours of high-flux hemodialysis (CHFD) using polysulfon F60S dialyzers (Fresenius) and 75 liters of bicarbonate dialysate using the GENIUS single-pass batch dialysis system. Samples were separated from the blood circuit as well as from the ultrafiltrate/spent dialysate lines at the start, during, and end of treatment. Whole-blood samples were incubated with 1 ng/ml of ET for three hours at 37 degrees C. Ultrafiltrate or dialysate samples were incubated with donor whole blood in the presence of ET to measure suppressing activity in ultrafiltrate and spent dialysate. RESULTS: At the start of CRRT, ET-induced whole-blood TNF-alpha production was suppressed to approximately 10% of that in normal controls. During CVVH, median ET-induced TNF-alpha production increased from 0.35 ng/ml at the start to 1.2 ng/ml at three hours, but decreased to pre-CVVH levels at the end of a 24-hour period. In contrast, in patients on CHFD, the median ET-induced TNF-alpha production was 0.5 ng/ml at the start, 1.1 ng/ml at 3 hours, 1.6 ng/ml at six hours, and 1.5 ng/ml at the end of 18 hours of treatment. The ultrafiltrate obtained after three hours of CVVH did not contain suppressing activity. In CHFD, the spent dialysate as compared with fresh dialysate suppressed ET-induced TNF-alpha production in donor blood by 33% throughout the 18 hours of treatment. Whole-blood production of TNFsRI did not change significantly at any time point during CVVH or CHFD. CONCLUSION: These data suggest that high-volume CHFD is superior to standard CVVH in removing a suppressing factor of proinflammatory cytokine production. As CVVH only transiently improves TNF-alpha production, it is most likely that the putative suppressing factor is removed because of saturable membrane adsorption in CVVH. In CHFD, there is a combination of adsorption and detectable diffusion into the dialysate. It remains to be shown whether a further increase in the volume of dialysate per day is able to not only improve but normalize the cytokine response and improve outcome in septic patients with acute renal failure.     

Cytokine removal during continuous hemofiltration in septic patients

A potential application of the continuous renal replacement therapies is the extracorporeal removal of inflammatory mediators in septic patients. Cytokine elimination with continuous renal replacement therapies has been demonstrated in several clinical studies, but so far without important effects on their serum concentrations. Improved knowledge of the cytokine removal mechanisms could lead to the development of more efficient treatment strategies. In the present study, 15 patients with septic shock and acute renal failure were observed during the first 24 h of treatment with continuous venovenous hemofiltration (CVVH) with an AN69 membrane. After 12 h, the hemofilter was replaced and the blood flow rate (QB) was switched from 100 ml/min to 200 ml/min or vice versa. Pre- and postfilter plasma and ultrafiltrate concentrations of selected inflammatory and anti-inflammatory cytokines were measured at several time points allowing the calculation of a mass balance. Cytokine removal was highest 1 h after the start of CVVH and after the change of the membrane (ranging from 25 to 43% of the prefilter amount), corresponding with a significant fall in the serum concentration of all cytokines. The inhibitors of inflammation were removed to the same extent as the inflammatory cytokines. Adsorption to the AN69 membrane appeared to be the main clearance mechanism, being most pronounced immediately after installation of a new membrane and decreasing steadily thereafter, indicating rapid saturation of the membrane. A QB of 200 ml/min was associated with a 75% increase of the ultrafiltration rate and a significantly higher convective elimination and membrane adsorption than at a QB of 100 ml/min. The results indicate that optimal cytokine removal with CVVH with an AN69 membrane could be achieved with a combination of a high QB/ultrafiltration rate and frequent membrane changes.     

Continuous venovenous hemofiltration: an alternative to continuous arteriovenous hemofiltration and hemodiafiltration in acute renal failure

Continuous venovenous hemofiltration (CVVH) has been used as an alternative to continuous arteriovenous hemofiltration (CAVH) and hemodiafiltration (CAVHD) in the management of critically ill patients with acute renal failure. This report describes our experience with the first 25 patients treated with CVVH at our institution. Vascular access was obtained through a single dual-lumen venous catheter. A blood pump was used to provide ultrafiltration pressure. An ultrafiltrate pump was incorporated to ensure predictable ultrafiltrate production rates. Safety features in the extracorporeal circuit included a venous drip chamber with bubble detector and an in-line pressure monitor. CVVH was initiated by a nephrologist and dialysis nurse and was maintained by the intensive care unit (ICU) nursing staff. Fifteen females and 10 males received CVVH therapy for a total of 193.5 days (average, 7.7 +/- 10.3 days; range, 0.5 to 48 days). Four of the 25 patients (16%) survived and were discharged from the hospital. Four additional patients (16%) survived the acute phase of their illness, but died from complications of their primary disease before discharge from the hospital. The mean weight change during CVVH was -7.9 +/- 7.0 kg (range, -26.5 to +2.9 kg). Metabolic waste products and electrolytes were adequately controlled by CVVH in all but one hypercatabolic patient. The mean heparin dose required was 6.5 +/- 4.2 U/kg/h and was adjusted to prevent filter clotting rather than to achieve a predetermined activated partial thromboplastin time (PTT). The median PTT was 35.8 seconds (range, 22.0 to 100; control, 19.5 to 29.5 seconds). Four episodes of volume-responsive hypotension occurred during the 193.5 treatment days. Only one patient experienced a hemorrhagic complication during CVVH. No patient experienced a complication related to vascular access. Twelve of 111 total hemofilters were changed because of clot formation. CVVH was well tolerated by patients and managed efficiently by the ICU nursing staff.(ABSTRACT TRUNCATED AT 250 WORDS)     

不同血液净化方式对尿毒症透析患者血中细胞因子清除的临床应用

目的 研究不同血液净化方式对尿毒症透析患者血中细胞因子的清除效果.方法 将2006年4月至2009年2月在我院血液净化中心透析的45例患者按随机数字表法分为(1)血液透析联合血液灌流组;(2)血液透析滤过组;(3)HD组,血液透析组,每组15例.血液透析联合血液灌流组、血液透析滤过组每周治疗1次,每组患者治疗3次,中间间隔1周,第1次及第3次治疗前、后各从动脉端采血5 ml,并留取正常健康对照组血液,整批送检.测定治疗前、后血清细胞因子的浓度.结果 血液灌流联合血液透析组、血液透析滤过组及血液透析组治疗前、后白细胞介素1β、白细胞介素6、肿瘤坏死因子α浓度与健康对照组比较差异有统计学意义(P＜0.01);血液透析组患者血肿瘤坏死因子α、白细胞介素1β、白细胞介素6水平分别为(3±10)ng/L、(4±9)ng/L、(4±9)ng/L,治疗前、后差值比较分别为176.0%、141.0%、187.0%,血液透析滤过组血肿瘤坏死因子α、白细胞介素1β、白细胞介素6水平分别为(39±15)ng/L、(36±14)ng/L、(45±16)ng/L,治疗前后差值比较分别为24.6%、22.1%、29.8%,血液灌流联合血液透析组血肿瘤坏死因子α、白细胞介素1β、白细胞介素6水平分别为(48±16)ng/L、(38±15)ng/L、(50±14)ng/L,治疗前差值比较分别为27.8%、23.9%、32.3%,3组患者血肿瘤坏死因子α、白细胞介素1β、白细胞介素6水平间比较差异有统计学意义(t分别=17.39、11.24、21.89,P均＜0.01).结论 不同的血液净化方式对各类细胞因子的清除效果不同,其中液灌流联合血液透析组及血液透析滤过组治疗埘细胞因子清除有效,血液透析组治疗对细胞因子清除基本无效,液灌流联合血液透析组及血液透析滤过组细胞因子清除效果与血液透析滤过组比较差异无统计学意义(P＞0.05).     

Comparison of a Lactate- Versus Acetate-Based Hemofiltration Replacement Fluid in Patients with Acute Renal Failure

The objective of the study was to determine the impact of a lactate- and an acetate-based hemofiltration replacement fluid (HF) on the acid–base status in patients with acute renal failure (ARF) and continuous venovenous hemofiltration (CVVH). The prospective, cohort study was carried out in the intensive care unit of the Heinrich-Heine University Hospital, Düsseldorf, FRG. Subjects were 84 critically ill patients with ARF and CVVH. Fifty-two patients were subjected to lactate-based (group 1) and 32 to acetate-based hemofiltration (group 2). Thirty-eight patients had a septic, 46 a cardiovascular origin of the ARF. Creatinine, BUN, serum bicarbonate, arterial pH, lactate and APACHE II score were noted daily. Mean CVVH duration was 9.8 ± 8.1 days; mortality was 65%. The groups did not differ with regard to the main clinical parameters. Lacate-based hemofiltration led to significantly higher serum bicarbonate and arterial pH values as compared to the acetate-based hemofiltration. Baseline serum bicarbonate values were 23.3 ± 8.3 mmol/L in group 1 and 21.6 ± 4.3 mmol/L in group 2 (NS); values at 48 h after initiating CVVH treatment were 25.7 ± 3.8 mmol/L and 20.6 ± 3.1 mmol/L, respectively (p < 0.001). Arterial pH prior to CVVH treatment was 7.36 ± 0.1 in group 1 and 7.34 ± 0.1 in group 2 (NS), and 7.43 ± 0.07 versus 7.37 ± 0.06 (p < 0.001) on day 2. These findings were maintained throughout therapy. While a lack of increase in serum bicarbonate and arterial pH was correlated to a poor prognosis in lactate-based hemofiltration, no such observation could be made in acetate-based hemofiltration. Septic patients did not differ in their acid–base status from nonseptic patients. Lactic acidosis occurred in 8 septic patients irrespective of the substitution fluid. All 8 patients died. There was a significant increase in HCO₃ and arterial pH values in lactate-based as compared to acetate-based HF.     

右美托咪定联合尼卡地平对老年脊柱手术患者控制性降压及炎症因子的影响

目的 探讨右美托咪定联合尼卡地平对老年脊柱手术患者控制性降压及炎症因子的影响.方法 前瞻性收集大连市第二人民医院2017年6月至2019年6月收治的老年脊柱手术患者100例(ASA分级Ⅰ～Ⅱ级),男56例,女44例,平均(70±6)岁.依据随机数字表法分为右美托咪定复合尼卡地平组(D+N组)和单用尼卡地平组(N组),每...