连续性血液净化治疗重症脓毒症合并ARDS的临床研究

目的探讨连续性高容量血液滤过（continuous high-volume haemofiltration,CHVHF）对重症脓毒症合并急性呼吸窘迫综合征（acute respiratory distress syndrome,ARDS）血流动力学及存活率的影响。方法应用前瞻性的分组干预研究选择2009年10月至2012年10月由各种病因导致的60例重症脓毒症合并ARDS患者,其中30例接受连续性高容量血液滤过治疗作为CRRT治疗组,余为对照组,所有患者均给予PiCCO监测血流动力学。在连续性高容量血液滤过治疗开始及治疗后24、48、72、96 h,分别同时监测两组患者血流动力学参数及急性生理指标。同时对血管外肺水指数（extravascular lung water index,EVLWI）与PaO2/FiO2进行相关性研究。结果两组患者入组开始治疗时心指数（cardiac index,CI）正常,胸腔内血容量指数（intrathoracic blood volume index,ITBVI）及EVLWI均高于正常范围,差异无统计学意义。CHVHF组治疗24 h后患者即出现ITBVI及EVLWI下降,48 h PVPI降低,PaO2/FiO2改善显著（P〈0.05）;对照组也出现不同程度的改善,ITBVI及EVLW、PVPI 72 h下降,PaO2/FiO296 h上升。住院总死亡率为33.3%,而预测死亡率分别为61%（基于APACHEⅡ评分）和68%（基于SAPSⅡ评分）;两组患者住院死亡率（CRRT组为30%,对照组为36.7%）差异无统计学意义（P=0.584）。EVLWI与PaO2/FiO2呈明显负相关（r=-0.52,P〈0.01）。当EVLWI≤14 ml/kg时,两者无明显相关性（r=0.20,P=0.3）;当EVLWI〉14 ml/kg时,两者呈明显负相关（r=-0.54,P〈0.01）。结论 CHVHF能更快地改善重症脓毒症合并ARDS患者的血流动力学状况,提高患者的氧合指数。

Continuous high-volume haemofiltration in treatment of severe sepsis with acute respiratory distress syndrome

Objective To evaluate the efficacy of continuous high-volume hemofiltration（ CHVHF） in treatment of severe sepsis w ith acute respiratory distress syndrome（ ARDS）. Methods Sixty critical patients w ith severe sepsis and ARDS in admitted from October 2009 to October 2012 w ere enrolled in the study. Patients w ere divided in to tw o groups： 30 patients received CHVHF（ CHVHF group） and another 30 patients received conventional treatment（ control group）. PiCCO hemodynamic monitoring w as performed in all patients. Hemodynamic parameters and acute physiological data w ere collected before and 24,48,72,96 h after treatment. Extravascular lung w ater index（ EVLWI） and PaO2/ FiO2w ere also analyzed. Results Patients in both group had normal cardiac index（ CI） at enrollment. Intrathoracic blood volume index（ ITBVI） and EVLWI w ere higher than the normal range. ITBVI and EVLWI in CHVHF group w as decreased at 24 h after treatment; PVPI w as decreased and PaO2/ FiO2w as increased significantly（ P ＆lt; 0. 05） at 48 h after treatment. ITBVI and EVLWI,PVPI in control group w ere decreased at 72 h,PaO2/ FiO2increased at 96 h after treatment（ P ＆lt; 0. 05）. The overall fatality rate w as 33. 3 %,w hich w as low er than the predicted fatality（ 61%,based on APACHE Ⅱ score or 68%,based on SAPS Ⅱ score）. There w as no significant difference in hospital fatality rate betw een tw o groups（ 30. 0 % vs 36. 7%,P = 0. 584）. EVLW I w as negatively correlated w ith PaO2/ FiO2（ r =- 0. 52,P ＆lt; 0. 01）. Stratification analysis show ed that w hen EVLWI ≤ 14 ml / kg there w as no significant correlation betw een EVLWI and PaO2/ FiO2（ r = 0. 20,P = 0. 3）; when EVLWI ＆gt; 14 ml / kg EVLWI was negatively correlated w ith PaO2/ FiO2（ r =-0. 54,P ＆lt;0. 01）. Conclusion CHVHF can improve hemodynamic status and PaO2/ FiO2in patients w ith severe sepsis and ARDS earlier than conventional treatment.