不同液体治疗方案对脓毒性休克致急性肾损伤患者的防治研究

目的探讨脓毒性休克致急性肾损伤患者不同时期较理想的液体治疗方案。 方法本研究为回顾性研究，选择2013年1月至2017年6月衢州市第三医院重症医学科收治的脓毒性休克致急性肾损伤患者122例，根据其28 d生存情况分为生存组（66例）和死亡组（56例）。比较两组患者的一般资料，脓毒性休克发生时的心率、呼吸频率、平均动脉压、中心静脉压、中心静脉血氧饱和度（ScvO₂）、血乳酸水平，患者发生脓毒性休克当日的血肌酐和尿素氮水平以及脓毒性休克发生后的首个7 d（D1~D7）的每天液体治疗情况，计算每日液体净平衡量及累积7 d液体净平衡量。根据是否实行早期积极液体复苏（AIFR）及后期保守液体治疗（CLFM）方案将患者分成均接受AIFR及CLFM组（39例），仅接受AIFR组（35例），仅接受CLFM组（23例）及均未接受AIFR和CLFM组（25例）四个亚组，比较各亚组间28 d生存情况。采用多变量Cox比例风险回归分析，筛选影响28 d生存情况的相关因素；绘制Kaplan-Meier生存曲线，比较各亚组间28 d生存情况。 结果生存组患者实施AIFR方案（47/66 vs. 27/56，χ²=6.718，P=0.010）和CLFM方案（47/66 vs. 15/56，χ²=23.924，P < 0.001）以及使用CRRT（41/66 vs. 23/56，χ²=5.382，P=0.020）的比例均明显高于死亡组；而APACHEⅡ评分（23.1 ± 6.6）vs.（25.2 ± 4.0），t=2.192，P=0.031]及AKIN Ⅲ期所占比例（13/66 vs. 22/56，χ²=5.682，P=0.017）均显著低于死亡组。多变量COX回归分析结果显示，未接受AIFR方案HR=3.151，95%CI（1.749，5.676），P < 0.001]、未接受CLFM方案HR=3.278，95%CI（1.794，5.987），P < 0.001]、未行CRRT治疗HR=1.947，95%CI（1.111，3.409），P=0.020]及AKIN分期（Ⅲ期）HR=2.237，95%CI（1.186，4.604），P=0.014]均是脓毒性休克致AKI患者28 d生存情况的影响因素。四个亚组脓毒性休克致急性肾损伤患者28 d生存情况比较，差异有统计学意义（χ²=30.233，P < 0.001）。进一步两两比较发现，同时接受AIFR及CLFM的患者28 d生存情况（34/39）均明显优于仅接受AIFR（13/35）、仅接受CLFM（13/23）及均未接受AIFR和CLFM（6/25）的患者（P均< 0.008）。 结论AIFR联合CLFM的方案可以改善脓毒性休克致急性肾损伤患者的28 d生存情况，或许是理想的液体治疗方案。

Application of different liquid treatment in patients with acute kidney injury induced by septic shock

ObjectiveTo explore the ideal liquid therapy for patients with acute kidney injury (AKI) caused by septic shock at different stages. MethodsA total of 122 patients with AKI caused by septic shock were selected from January 2013 to June 2017 in the Department of Critical Care Medicine, Quzhou No.3 Hospital in this retrospective study. According to the 28-day survival condition, 122 cases were divided into the survival group (66 cases) and death group (56 cases). The general data, heart rate, respiratory frequency, mean arterial pressure, central venous pressure, central venous oxygen saturation, blood lactate level at the time of septic shock, blood creatinine and urea nitrogen levels on the day of septic shock, and the daily fluid therapy for the first 7 d (D1~D7) after septic shock of patients in two groups were compared; then daily net liquid balance and cumulative 7 d liquid net equilibrium were calculated. According to whether or not to implement the early active fluid resuscitation (AIFR) and later conservative fluid therapy (CLFM), patients were divided into four subgroups: AIFR and CLFM received (39 cases), AIFR received (35 cases), CLFM received (23 cases) and AIFR and CLFM unreceived (25 cases) subgroups. The survival of each subgroup for 28 days was compared. Multivariate Cox proportional risk regression analysis was used to screen the related factors affecting the survival of 28 days and the Kaplan-Meier survival curves were drawn to compare 28-day survival among subgroups. ResultsThe proportions of AIFR regimen (47/66 vs. 27/56; χ²=6.718, P=0.010), CLFM regimen (47/66 vs. 15/56; χ²=23.924, P < 0.001) and CRRT (41/66 vs. 23/56; χ²=5.382, P=0.020) in the survival group were significantly higher than those in the death group, while the APACHEⅡ score (23.1 ± 6.6) vs. (25.2 ± 4.0); t=2.192, P=0.031] and proportion of AKIN Ⅲ stage (23.1 ± 6.6) vs. (25.2 ± 4.0); t=5.682, P=0.017] were significantly lower than those in the death group. Multivariate COX regression analysis showed that unaccepted AIFR regimen HR=3.151, 95%CI (1.749, 5.676), P < 0.001], unaccepted CLFM regimen HR=3.278, 95%CI (1.794, 5.987), P < 0.001], untreated CRRT HR=1.947, 95%CI (1.111, 3.409), P=0.020] and AKIN staging HR=2.237, 95%CI (1.186, 4.604), P=0.014] were independent influencing factors of survival in patients with AKI induced by septic shock on the 28th day. In the four subgroups, the survival conditions of patients with AKI induced by septic shock were significantly different in 28 days (χ²=30.233, P < 0.001). Further comparison showed 28-day survival of patients receiving both AIFR and CLFM (34/39) was significantly better than that of patients who received AIFR (13/35), CLFM (13/23) and who received neither AIFR nor CLFM (6/25) (all P < 0.008). ConclusionThe combination of AIFR and CLFM can improve the survival of patients with AKI induced by septic shock, and it may be an ideal liquid therapy.