连续性肾替代疗法治疗患者50例的护理体会

目的探讨连续性肾替代疗法(continuous renal replacement therapy,CRRT)过程中的正确护理方法。方法采用动-静脉内瘘或深静脉置管术建立体外循环通路,ACCURA血液净化机,置换液配方选用南京军区总医院配方,分别对50例患者行CRRT治疗,每次6~24h,效果满意。结果43例患者平稳过渡到血液透析治疗,2例患者痊愈,1例患者死亡,4例患者放弃治疗。     

持续性血液净化加灌流对腹部外伤海水浸泡犬血浆炎性细胞因子的影响

目的探讨持续性血液净化（CRRT）加灌流对腹部外伤合并海水浸泡实验犬血浆内毒素（ETX）、白介素6（IL-6）、肿瘤坏死因子-α（TNF-α）水平的影响。方法16只实验犬致伤后随机分为治疗组和对照组。对照组伤后给予生理盐水持续静脉滴注维持，治疗组给予持续性血液净化加用树脂罐灌流。分别于致伤前及伤后3、6、9、12、18h取血测定血浆ETX、IL-6、TNF-α平。结果对照组和治疗组在伤后6hETX开始明显升高，IL-6和TNF-α在伤后12h升高显著。但治疗组在伤后ETX、IL-6和TNF—α水平明显低于对照组。对照组在12h以后血浆肌酐、尿素氮水平升高明显．同炎性因子的变化相一致，而治疗组则无明显变化。对照组动物死亡率明显高于治疗组。结论持续性血液净化加灌流技术可以明显减轻实验犬血浆炎性因子水平，有利于稳定内环境。     

Artificial organ treatment for multiple organ failure,acute renal failure,and sepsis: recent new trends

Sepsis remains the major cause of mortality worldwide, claiming millions of lives each year. The past decade has seen major advances in the understanding of the biological mechanisms involved in this complex process. Unfortunately, no definitive therapy yet exists that can successfully treat sepsis and its complications. At variance with targeting single mediators, therapeutic intervention aimed at the nonselective removal of pro- and anti-inflammatory mediators seems a rational concept and a possible key to successful extracorporeal therapies. A further advantage may lie in the continuous nature of such therapy. With such continuous therapy, sequentially appearing peaks of systemic mediator overflow may be attenuated and persistently high plasma levels reduced. This theoretical framework is proposed as the underlying biological rationale for a series of innovative modalities in sepsis. In this editorial, we will review recent animal and human trials that lend support to this concept. We will also review the importance of treatment dose during continuous renal replacement therapy as a major factor affecting survival in critically ill patients with acute renal failure. Additionally, we will review novel information related to other blood purification techniques using large pore membranes or plasma filtration with adsorbent perfusion. Although these approaches are still in the early stages of clinical testing, they are conceptually promising and might represent an important advance.     

Bioethical issues related to continuous renal replacement therapy in intensive care patients

Objective: To examine the ethical approach of intensivists and nephrologists to continuous renal replacement therapy (CRRT).¶Design: A questionnaire.¶Setting: The First International Course on Critical Care Nephrology.¶Participants: The participants in the course (around 500).¶Results: Most participants think that establishing ethical criteria for managing CRRT is a medical task, as clinicians have adequate criteria for defining futility. However, many responders would grant the request of starting futile CRRT or would maintain it if requested by the family. Only 55 % believe that informed consent is necessary for initiating CRRT; one out of four would start or maintain unwanted life-saving CRRT. In case of lack of equipment, the majority would select the patients, excluding the worst one or on a “first-come, first-served” basis. Withholding and withdrawing are regarded differently by most responders. Again, most think that every vital support should be withdrawn when futile, but practical and psychological aspects still influence the final decision. Responders think that ethics critical care committees can help in the management of ethical problems in ICU.¶Conclusions: Our results show that several ethical questions are still unsolved and that practical and psychological aspects of the treatment process can be stronger than bioethical principles.     

Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

Hemorrhagic complications have been reported in up to 30% of critically ill patients with AKI undergoing RRT with systemic anticoagulation. Because bleeding is associated with significantly increased mortality risk, strategies aimed at reducing hemorrhagic complications while maintaining extracorporeal circulation should be implemented. Among the alternatives to systemic anticoagulation, regional citrate anticoagulation has been shown to prolong circuit life while reducing the incidence of hemorrhagic complications and lowering transfusion needs. For these reasons, the recently published Kidney Disease Improving Global Outcomes Clinical Practice Guidelines for Acute Kidney Injury have recommended regional citrate anticoagulation as the preferred anticoagulation modality for continuous RRT in critically ill patients in whom it is not contraindicated. However, the use of regional citrate anticoagulation is still limited because of concerns related to the risk of metabolic complications, the complexity of the proposed protocols, and the need for customized solutions. The introduction of simplified anticoagulation protocols based on citrate and the development of dialysis monitors with integrated infusion systems and dedicated software could lead to the wider use of regional citrate anticoagulation in upcoming years.     

CRRT联合白蛋白治疗危重症合并急性肾衰竭的疗效观察

目的:探讨CRRT联合白蛋白治疗危重症合并急性肾衰竭的临床疗效。方法:选择我院2016年8月~2018年7月间收治的危重症合并急性肾衰竭患者84例,随机分为对照组和观察组,各42例。观察组采用24h CRRT联合人血白蛋白治疗,对照组采用CRRT治疗,比较两组治疗前后ALB、BUN、SCr、IL-6、K+变化及并发症发生率情况。结果:治疗前,两组ALB、BUN、SCr、IL-6及K+水平比较差异无统计学意义(P>0.05);治疗后,两组ALB水平均升高,BUN、SCr、IL-6及K+水平均降低(P<0.05);观察组治疗后ALB水平高于对照组,BUN、SCr、K+水平低于对照组(P<0.05),两组IL-6水平比较无明显差异(P>0.05);观察组急性ARDS、多器官出血、渗出性肺炎发生率明显低于对照组(P<0.05)。结论:CRRT联合白蛋白对维持危重症并急性肾衰竭患者水电解质平衡、改善肾功能及降低临床并发症方面的疗效显著,可临床推广应用。     

连续性肾脏替代疗法治疗乳酸酸中毒患者的疗效与护理

目的 观察连续性肾脏替代疗法(CRRT)对乳酸酸中毒(LA)患者的疗效并总结护理经验.方法 对20例LA患者行CRRT治疗,观察动脉血气及生化指标变化.结果 经CRRT治疗及严密监测生命体征,加强血管通路、液体平衡管理,监测出凝血时间,预防并发症等综合护理后,患者血乳酸水平、PH值、Cr、Bun、HCO3-、MAP均改善,与治疗前比较差异有统计学意义.结论 CRRT治疗能有效纠正LA患者内环境紊乱,提高救治成活率.     

术前合并肾功能不全对心脏移植受者预后的影响分析

目的  评估心脏移植术前合并肾功能不全对围手术期死亡和并发症发生及长期生存的影响,并比较术前血清肌酐（Scr）和估测肾小球滤过率（eGFR）在术前风险评估中的差异。方法  回顾性分析1 095例心脏移植受者的临床资料,根据术前Scr分为Scr < 133 μmol/L组（980例）、Scr 133~176 μmol/L组（83例）和Scr≥177 μmol/L组（32例）;根据术前eGFR分为eGFR≥90 mL/（min·1.73 m²）组（436例）、eGFR 60~89 mL/（min·1.73 m²）组（418例）和eGFR < 60 mL/（min·1.73 m²）组（241例）。分析不同分组受者术后肾功能的转归情况及围手术期和远期结局。评价eGFR和Scr对心脏移植术后肾功能损伤和远期生存的影响。结果  随着术前Scr升高,受者术后使用连续性肾脏替代治疗（CRRT）的比例增加,术后机械循环辅助的比例增加,术后并发症发生率增加,机械通气时间和重症监护室（ICU）入住时间延长,院内病死率增加,3组间差异均有统计学意义（均为P < 0.05）。随着术前eGFR的下降,受者术后使用CRRT辅助的比例增加,术后使用主动脉内球囊反搏（IABP）的比例增加,机械通气时间和ICU入住时间延长,院内病死率增加,3组间差异均有统计学意义（均为P < 0.05）。Scr≥177 μmol/L是受者术后死亡的独立危险因素[校正风险比（HR）3.64,95%可信区间（CI）1.89~6.99,P < 0.01]。以Scr及以eGFR为指标的分组中,3组间的术后肾功能损伤累积发生率和远期生存率差异均有统计学意义（均为P < 0.05）。术前Scr < 133 μmol/L的受者中,术后远期肾功能损伤随时间的累积发生率随术前eGFR降低而升高（P < 0.01）,而不同eGFR分层的患者术后远期生存率差异无统计学意义（P > 0.05）。结论  心脏移植术前合并肾功能不全与围手术期和远期预后不良相关。心脏移植术前Scr和eGFR均是术后肾功能损伤发生的独立危险因素。Scr对于术前肾功能评估的灵敏度较低,但预测围手术期死亡风险的准确性更高。eGFR是术前评估肾功能更为敏感的指标,可以早期发现肾功能异常,早期采取有效措施从而减少对预后的不良影响。     

急性肾功能衰竭治疗的研究近况

急性肾功能衰竭是临床常见的危重症，其主要特征是肾功能的急剧下降，并且病死率也较高。近年来，国内外多采用连续肾脏替代疗法、营养疗法、生长因子及利尿剂、多巴胺等药物治疗，取得了较好的临床疗效。     

CRRT治疗尿毒症伴心、肺功能衰竭的疗效观察

目的 观察连续性肾脏替代疗法(CRRT)治疗慢性肾功能衰竭(CRF)伴心、肺功能衰竭的疗效。方法 18例CRF伴心、肺功能衰竭不能进行常规血液透析与腹膜透析治疗的患接受CRRT治疗，其中连续性静-静脉血液透析滤过(CVVHDF)10例，连续性静-静脉血液透析(CVVHD)2例，连续性静-静脉血液滤过(CVVH)3例，单纯性超滤(SCUF)3例。结果 均能满意控制水、电解质和酸碱平衡，显降低尿毒症毒素。本组死亡4例，占23．5％。死亡原因中，CRF同时合并心力衰竭、慢性呼吸衰竭的患死亡率高达75％。结论 CRRT是CRF患合并心、肺功能衰竭时不能进行常规血液透析与腹膜透析治疗时的有效方法，且患耐受性好。