床旁血液净化在危重烧伤患者中的应用

目的 探讨床旁血液净化在危重烧伤患者中的应用.方法 回顾分析我院血液净化中心2005年～2009年应用床旁血液净化方法,对20例伴有急性肾功能衰竭(ARF)的危重烧伤患者实行间断性CRRT治疗的资料.患者平均年龄42.2岁±10岁,平均烧伤面积为63.8%TBsA±13.7%TBSA;所有患者都需要机械式呼吸支持,大部分患者并发脓毒症,甚至是多器官功能障碍综合征(MODS),平均ARF出现的时间是10.8 d±9 d.20例患者均与脓毒症相关,其中:低血压14例,需用血管加压药者6例;4例患者属于非少尿型肾功能衰竭.接受CRRT治疗的主要原因包括:氮血症(20/20)、液体过载(12/20)、高钾血症(6/20)、高钠血症(18/20)和/或酸中毒(2/20).使用Prisma系统Muhiflow-100滤器、前稀释,先后行100余次CRRT治疗(包括病情平稳后接受间断性滤过透析治疗).14例患者使用了肝素1.25 mg/h～5.00 mg/h,6例患者未用抗凝剂.患者在刚收进烧伤科时,血清尿素氮和肌酐浓度分别为7.1 mmol/L±2.3 mmol/L和116.1 tunol/L±38.2 Izmol/L,当CRRT治疗开始时,血清尿素氮和肌酐浓度已上升至34.8 mmol/L±9.2 mmol/L和398.24 μmol/L±286.3μmol/L.16例患者同时接受肠内和肠外营养支持,4例患者只接受肠外营养支持.结果 8例生还者肾功能全都恢复正常,在出院时,血清肌酐浓度是80.1 μmol/L±11.1 μmol/L.在CRRT治疗期间,20例患者均没有发生明显并发症.结论 CRRT有如下优势:(1)维持体内水、电解质和酸碱平衡,有效地保证了内环境的稳定;(2)保证营养支持及其它药物治疗的实施;(3)对血流动力学影响很小,且在低血压时也可应用;(4)对发热患者还可以起到降温作用;(5)有效地清除毒素并降低氧耗.连续性血液净化是抢救危重烧伤患者的重要治疗手段之一,虽然危重患者病死率高,但是它能够延长危重患者的生命却是公认的.功能上由替代转化为支持,是一种概念上的突破.随着血液净化技术的不断完善,它将成为危重病医学的发展趋势.

The Application of Bed-side Hemodialysis in Patients with Severe Burn Injuries

Objective To investigate the application of bedside blood purification in patients with severe bums. Methods Retrospectively analyze the data of 20 severe burn patients with acute renal failure （ARF） treated by intermittent continuous renal replacement therapy （CRRT） using bedside blood purification between 2005 and 2009 in the blood purification center of our hospital. The average age of patients is 42. 2 ± 10.0 years old; the average bum area is 63.8± 13.7% of the total body surface area （TBSA） . All the patients needed mechanical respiratory support ; most of them had septic complications or even multiple organ dysfunction syndromes （MODS） . The average time of ARF occurrence was 10. 8 ± 9. 0 days, 20 cases were associated with sepsis, among which 14 cases were hypotension and 6 cases were administered with vasopressin, 4 cases were nonoliguric ARF. The main causes of giving CRRT included hyperazotemia （20/20）, liquid overload （ 12/20）, hyperkalemia （6/20）, hypernatremia （ 18/20 ） and/or metabolic acidosis （2/20） . All 20 patients received totally 100 times of pre- dilution CRRT （including intermittent filtration dialysis after the condition was steady） using the Prisma Pump system Muhiflow - 100 Filter. 14 patients were administered with heparin （1.25 - 5.00mg/h） and 6 were not treated with any anticoagulant. Central venous catheter were used to establish vascular access. The BUN and Scr were 7. 1 ± 2. 3 mmol/L and 116. 1 ±38. 2 umol/L respectively at admission, which increased to 34. 8 ±9. 2 mmol/L and 398.2 ± 286. 3 umol/L respectively at the beginning of CRRT. 16 patients received enteral and parenteral nutrition infusion, 4 patients received only parenteral nutrition infusion. Results All of the eight survivors restored their renal functions, and the Scr was 80. 1 ± 11.1 umol/L at discharge. All 20 patients had no significant complications during the treatments of CRRT. Conclusion CRRT used in severe burn patients with ARF has the following advantages： （1） Ensure the stability of the internal environment by maintaining the water, electrolyte and acid -base balances in vivo; （2） Guarantee the implementations of nutritiona/support and other drug therapies ; （3） Have little impact on hemodynamics and can be used even in the case of hypotension; （4） Reduce the body temperature of high fever patients; （5） Effectively remove burn toxins and reduce oxygen consumption. CRRT is one of the important treatments in rescuing critical burn patients and is commonly accepted to be able to extend their lives although the mortality of critical burn patients is high. The functionally transferring from substitution to support is a conceptual breakthrough. Blood purification technology is going to be a trend in the development of critical medicine as the technology improves constantly.