高容量血液滤过改善重型颅脑损伤患者脑功能的多中心随机对照研究

doi:10.3877/cma.j.issn.1674-6880.2019.02.005

中华危重症医学杂志(电子版) ›› 2019, Vol. 12 ›› Issue (02) : 98 -103. doi: 10.3877/cma.j.issn.1674-6880.2019.02.005

所属专题：文献；

论著

高容量血液滤过改善重型颅脑损伤患者脑功能的多中心随机对照研究

胡马洪¹, 赖志珍¹, 孟建标¹, 陆军², 唐卫东³, 张赟华⁴, 明自强⁵, 刘连升⁶, 金心⁷, 许秀娟¹, 季春莲¹, 代沐华¹, 张微¹, 庞丽莎¹, 张庚¹^,^†(

)

^1. 310012　杭州，浙江省立同德医院重症医学科
^2. 310005　杭州，浙江省新华医院重症医学科
^3. 311400　杭州，杭州市富阳区第一人民医院重症医学科
^4. 318000　浙江绍兴，诸暨市中医院重症医学科
^5. 312500　浙江绍兴，新昌县人民医院重症医学科
^6. 310012　杭州，浙江省立同德医院血液净化中心
^7. 310012　杭州，浙江省立同德医院神经外科

收稿日期:2018-12-12 出版日期:2019-04-01
通信作者: 张庚
基金资助:
浙江省公益技术研究社会发展项目(2013C33198)

High volume hemofiltration to improve brain function in patients with severe craniocerebral injury: a multicenter randomized controlled trial

Mahong Hu¹, Zhizhen Lai¹, Jianbiao Meng¹, Jun Lu², Weidong Tang³, Yunhua Zhang⁴, Ziqiang Ming⁵, Liansheng Liu⁶, Xin Jin⁷, Xiujuan Xu¹, Chunlian Ji¹, Muhua Dai¹, Wei Zhang¹, Lisha Pang¹, Geng Zhang¹^,^†()

^1. Department of Critical Care Medicine, Tongde Hospital of Zhejiang Province, Hangzhou 310012, China
^2. Department of Critical Care Medicine, Xinhua Hospital of Zhejiang Province, Hangzhou 310005, China
^3. Department of Critical Care Medicine, the First People's Hospital of Fuyang Hangzhou, Hangzhou 311400, China
^4. Department of Critical Care Medicine, Traditional Chinese Medical Hospital of Zhuji, Shaoxing 318000, China
^5. Department of Critical Care Medicine, the People's Hospital of Xinchang, Shaoxing 312500, China
^6. Department of Blood Purification Center, Tongde Hospital of Zhejiang Province, Hangzhou 310012, China
^7. Department of Neurosurgery, Tongde Hospital of Zhejiang Province, Hangzhou 310012, China

Received:2018-12-12 Published:2019-04-01
Corresponding author: Geng Zhang
About author:
Corresponding author: Zhang Geng, Email: zjzxyicu@126.com

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引用本文：

胡马洪, 赖志珍, 孟建标, 陆军, 唐卫东, 张赟华, 明自强, 刘连升, 金心, 许秀娟, 季春莲, 代沐华, 张微, 庞丽莎, 张庚. 高容量血液滤过改善重型颅脑损伤患者脑功能的多中心随机对照研究[J]. 中华危重症医学杂志(电子版), 2019, 12(02): 98-103.

Mahong Hu, Zhizhen Lai, Jianbiao Meng, Jun Lu, Weidong Tang, Yunhua Zhang, Ziqiang Ming, Liansheng Liu, Xin Jin, Xiujuan Xu, Chunlian Ji, Muhua Dai, Wei Zhang, Lisha Pang, Geng Zhang. High volume hemofiltration to improve brain function in patients with severe craniocerebral injury: a multicenter randomized controlled trial[J]. Chinese Journal of Critical Care Medicine(Electronic Edition), 2019, 12(02): 98-103.

目的

探讨高容量血液滤过（HVHF）对重型颅脑损伤患者颅内压、内环境、脑氧代谢及脑保护作用的影响。

方法

采用随机数字表法将114例重型颅脑损伤患者分为常规组和HVHF组，每组各57例。常规组予以甘露醇0.5 g/kg静脉滴注，每6小时1次，连续治疗7 d；HVHF组在常规组的基础上72 h内予以超滤量为60 mL·kg^-1·h^-1的HVHF治疗，持续72 h。记录两组患者的一般资料，治疗前及治疗24 h、72 h、7 d后的颅内压，颈内静脉血氧饱和度（SjvO₂），血清Na⁺浓度，平均动脉压，机械通气时间及ICU住院时间。

结果

两组患者各时间点颅内压、血清Na⁺及SjvO₂表达水平比较，差异均有统计学意义（F= 8.159、3.770、2.787，P < 0.001、= 0.011、0.040）；而平均动脉压比较，差异无统计学意义（F= 0.755，P= 0.520）。进一步两两比较发现，常规组患者治疗7 d后颅内压较同组治疗前显著降低（P < 0.05）；HVHF组患者治疗72 h及7 d后颅内压均较同组治疗前和常规组同时间点显著降低（P均< 0.05）；常规组患者治疗72 h及7 d后血清Na⁺和SjvO₂表达水平均较同组治疗前显著升高（P均< 0.05）；HVHF组患者治疗24 h、72 h及7 d后血清Na⁺表达水平均较常规组同时间点显著降低（P均< 0.05），治疗72 h及7 d后SjvO₂表达水平均较同组治疗前和常规组同时间点显著升高（P均< 0.05）。两组患者机械通气时间[（13.5 ± 3.3）d vs.（12.5 ± 2.6）d]和住ICU时间[（18 ± 6）d vs.（16 ± 5）d]比较，差异均无统计学意义（t = 1.797、1.599，P = 0.075、0.113）。

结论

HVHF可有效改善重型颅脑损伤患者颅内压及脑代谢水平，具有脑保护和稳定内环境的作用。

关键词: 颅内压, 高容量血液滤过, 重型颅脑损伤, 脑氧代谢

Objective

To investigate the effects of high volume hemofiltration (HVHF) on intracranial pressure, internal environment, cerebral oxygen metabolism and brain protection in patients with severe craniocerebral injury.

Methods

Totally 114 patients with severe craniocerebral injury were divided into the routine group (57 cases) and HVHF group (57 cases) by the random number table method. The routine group was treated with 0.5 g/kg mannitol intravenously once every 6 hours for 7 days. The HVHF group was treated with HVHF with an ultrafiltration dose of 60 mL·kg^-1·h^-1 for 72 h on the basis of the routine group. The intracranial pressure, internal jugular venous oxygen saturation (SjvO₂), serum Na⁺ concentration, mean arterial pressure, mechanical ventilation time and hospitalization time of ICU were recorded before and 24 h, 72 h, 7 d after treatment in these two groups.

Results

There were significant differences in intracranial pressure, serum Na⁺ and SjvO₂ levels between these two groups (F = 8.159, 3.770, 2.787; P < 0.001, = 0.011, 0.040) and there was no significant difference in mean arterial pressure (F = 0.755, P = 0.520). Further pairwise comparison showed that the intracranial pressure in the routine group on 7 days after treatment was significantly lower than that in the same group before treatment (P < 0.05), while the intracranial pressure in the HVHF group decreased significantly at 72 h and 7 d after treatment compared with that in the same group before treatment and at the same time point in the routine group (all P < 0.05). The levels of serum Na⁺ and SjvO₂ at 72 h and 7 d after treatment in the routine group were all significantly higher than those in the same group before treatment (all P < 0.05). The level of serum Na⁺ in the HVHF group was significantly lower than that in the routine group at 24 h, 72 h and 7 d after treatment (all P < 0.05). The expression of SjvO₂ at 72 h and 7 d after treatment was significantly higher than that in the same group before treatment and at the same time point in the routine group (all P < 0.05). There were no significant differences between these two groups in mechanical ventilation time [(13.5 ± 3.3) d vs. (12.5 ± 2.6) d] and hospitalization time of ICU [(18 ± 6) d vs. (16 ± 5) d] (t = 1.797, 1.599; P = 0.075, 0.113).

Conclusion

HVHF can effectively improve intracranial pressure and brain metabolism in patients with severe craniocerebral injury, which can protect the brain and stabilize the internal environment.

Key words: Intracranial pressure, High volume hemofiltration, Severe craniocerebral injury, Cerebral metabolism

表1 两组重症颅脑损伤患者各时间点颅内压和血清Na⁺表达水平比较（±s）

组别	例数	颅内压（mmHg）				Na⁺（mmol/L）
组别	例数	治疗前	治疗24 h	治疗72 h	治疗7 d	治疗前	治疗24 h	治疗72 h	治疗7 d
常规组	57	22.7 ± 4.5	21.4 ± 6.3	24.0 ± 7.2	18.4 ± 5.2^a	138.8 ± 14.6	144.5 ± 28.3	157.4 ± 16.7^a	151.5 ± 14.2^a
HVHF组	57	23.1 ± 3.8	22.5 ± 5.4	19.1 ± 2.6^ab	16.6 ± 3.8^ab	135.1 ± 11.2	134.7 ± 12.8^b	139.1 ± 15.3^b	137.3 ± 18.6^b
F值	?	8.159				3.770
P值	?	< 0.001				0.011

表1 两组重症颅脑损伤患者各时间点颅内压和血清Na⁺表达水平比较（±s）

组别	例数	颅内压（mmHg）				Na⁺（mmol/L）
组别	例数	治疗前	治疗24 h	治疗72 h	治疗7 d	治疗前	治疗24 h	治疗72 h	治疗7 d
常规组	57	22.7 ± 4.5	21.4 ± 6.3	24.0 ± 7.2	18.4 ± 5.2^a	138.8 ± 14.6	144.5 ± 28.3	157.4 ± 16.7^a	151.5 ± 14.2^a
HVHF组	57	23.1 ± 3.8	22.5 ± 5.4	19.1 ± 2.6^ab	16.6 ± 3.8^ab	135.1 ± 11.2	134.7 ± 12.8^b	139.1 ± 15.3^b	137.3 ± 18.6^b
F值	?	8.159				3.770
P值	?	< 0.001				0.011

表2 两组重症颅脑损伤患者各时间点SjvO₂和平均动脉压表达水平比较（±s）

组别	例数	SjvO₂（%）				平均动脉压（mmHg）
组别	例数	治疗前	治疗24 h	治疗72 h	治疗7 d	治疗前	治疗24 h	治疗72 h	治疗7 d
常规组	57	65 ± 11	63 ± 16	70 ± 16^a	75 ± 12^a	85 ± 9	83 ± 9	87 ± 8	86 ± 9
HVHF组	57	63 ± 12	63 ± 17	75 ± 11^ab	82 ± 12^ab	85 ± 10	83 ± 10	84 ± 9	83 ± 7
F值	?	2.787				0.755
P值	?	0.040				0.520

表2 两组重症颅脑损伤患者各时间点SjvO₂和平均动脉压表达水平比较（±s）

组别	例数	SjvO₂（%）				平均动脉压（mmHg）
组别	例数	治疗前	治疗24 h	治疗72 h	治疗7 d	治疗前	治疗24 h	治疗72 h	治疗7 d
常规组	57	65 ± 11	63 ± 16	70 ± 16^a	75 ± 12^a	85 ± 9	83 ± 9	87 ± 8	86 ± 9
HVHF组	57	63 ± 12	63 ± 17	75 ± 11^ab	82 ± 12^ab	85 ± 10	83 ± 10	84 ± 9	83 ± 7
F值	?	2.787				0.755
P值	?	0.040				0.520

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