早期持续肾脏替代治疗在急性呼吸窘迫综合症患者中的应用价值探索

目的 观察急性呼吸窘迫综合症（ARDS）患者血管外肺水指数（EVLWI）、动脉血乳酸（Lac）等指标变化,以及早期行持续肾脏替代治疗（CRRT）对其的影响和临床意义.方法 36例ARDS患者随机分为A组（常规治疗组,18例）和B组（常规治疗＋CRRT组,18例）.B组患者明确诊断后即行CRRT治疗.通过脉搏指示连续心排监测仪（PICCO）监测确诊即刻、治疗后2h、1d、3d、7d EVLWI变化,在相同时间点监测Lac、氧合指数（PaO2 /FiO2）及pH值,并进行比较.比较两组患者机械通气时间、呼吸机相关性肺炎（VAP）发生率和死亡率.结果 B组患者pH值、PaO2/FiO2在治疗后2h较治疗前即开始出现显著上升,EVLWI、Lac则在治疗后1d开始出现显著下降;而A组患者pH值、PaO 2/FiO2显著上升及EVLWI、Lac显著下降的时间点分别为治疗后1d和治疗后3d,均晚于B组,且在相同时间点两组之间上述指标存在显著差异.A、B两组机械通气时间分别为14.5±1.0d和9.2±0.8d（P＜ 0.05）;VAP发生率分别为50%和17%（P＜0.05）;死亡率分别为38.9 %和22.2%（P＞0.05）.结论 对ARDS患者进行常规治疗的同时早期进行CRRT治疗能有效降低EVLWI、Lac水平,改善氧合状态,缩短机械通气时间,降低VAP的发生率.

Application of Continuous Renal Replacement Therapy in Patients with Acute Respiratory Distress Syndrome

Objective To investigate the changes of extra vascular lung water index （ EVLWI ）and arterial lactate （ Lac ） in patients with acute respiratory distress syndrome（ARDS）,and the effects of early continuous renal replacement therapy（CRRT） on EVLWI,Lac and other indicators, and its clinical significance. Methods 36 ARDS patients were randomly divided into two groups：group A undergoing conventional treatment and group B receiving conventional treatment plus CRRT immediately at onset of ARDS.The changes of EVLWI were observed by pulse indicator continuous cardiac output（PICCO） at the time points of 0h,2h later, l day later,2 days later and 7 days later. Lac,PaO2/FiO2 and pH were measured at the same time points.Duration of total mechanical ventilation, the incidence of ventilator-associated pneumonia and mortality rate were assessed. Results There was statistically increasing in pH and PaO2/FiO2 from 2h later,and statistically decreasing in EVLWI and Lac from l d later in patients of group B.While the time points of statistically increasing in pH and PaO2/FiO2 and statistically decreasing in EVLWI and Lac in group A were l d later and 3d later respectively,both later than those in group B.Further more, there were significantly differences in those indicators between two groups at the same time points.The duration of total mechanical ventilation of the group B patients was 9.2 ± 0.Sd,significantly shorter than that of group A patients （ 14.5 ± 1.0 d,p〈0.05].The incidence of VAP in group B patients was 17%,significantly lower than that in group A （50%,P〈0.05）,but the mortality rate didn＇ t differ between the two groups （ 22.2% vs 38.9%,P 〉 0.05 ）. Conclusion In the early phase of ARDS,CRRT combined conventional treatment in patients with ARDS can decrease EVLWI and the level of Lac,improve oxygenation,shorten the duration of mechanical ventilation and decrease the incidence of VAP.