切换至 "中华医学电子期刊资源库"

中华危重症医学杂志(电子版) ›› 2020, Vol. 13 ›› Issue (05) : 334 -338. doi: 10.3877/cma.j.issn.1674-6880.2020.05.003

所属专题: 文献

论著

连续性肾脏替代疗法叠加全血吸附改善脓毒性休克患者心肌抑制的疗效研究
吕铁1, 应利君1,(), 席小龙1   
  1. 1. 312000 浙江绍兴,绍兴市人民医院重症医学科
  • 收稿日期:2020-08-21 出版日期:2020-10-31
  • 通信作者: 应利君
  • 基金资助:
    浙江省医药卫生平台重点资助计划项目(2015ZDA030、2018ZD046); 浙江省医药卫生科技计划项目(2020KY975)

Clinical effects of continuous renal replacement therapy combined with hemadsorption on myocardial inhibition in patients with septic shock

Tie Lyu1, Lijun Ying1,(), Xiaolong Xi1   

  1. 1. Department of Critical Care Medicine, Shaoxing People's Hospital, Shaoxing 312000, China
  • Received:2020-08-21 Published:2020-10-31
  • Corresponding author: Lijun Ying
  • About author:
    Corresponding author: Ying Lijun, Email:
引用本文:

吕铁, 应利君, 席小龙. 连续性肾脏替代疗法叠加全血吸附改善脓毒性休克患者心肌抑制的疗效研究[J/OL]. 中华危重症医学杂志(电子版), 2020, 13(05): 334-338.

Tie Lyu, Lijun Ying, Xiaolong Xi. Clinical effects of continuous renal replacement therapy combined with hemadsorption on myocardial inhibition in patients with septic shock[J/OL]. Chinese Journal of Critical Care Medicine(Electronic Edition), 2020, 13(05): 334-338.

目的

探讨连续性肾脏替代疗法(CRRT)叠加全血吸附对脓毒性休克患者心肌抑制的改善效果。

方法

选择2016年5月至2019年6月收治于绍兴市人民医院重症医学科、心脏指数(CI)< 3.0 L·min-1·m-2的60例脓毒性休克患者,按随机区组法分为对照组(30例)与试验组(30例),两组患者按照脓毒症/脓毒性休克标准化操作程序治疗,试验组在标准治疗基础上加用CRRT +全血吸附,连续治疗3 d。所有入选病例均应用脉波指示剂连续心排出量监测进行血流动力学监测,记录并评价两组患者入组时及治疗后第3、5天的CI、中心静脉压(CVP)、血管外肺水指数(EVLWI)、日去甲肾上腺素剂量、日液体总量及急性病生理学和长期健康评价(APACHE)Ⅱ评分。

结果

两组脓毒性休克患者在不同时间点CI、CVP、EVLWI、日去甲肾上腺素剂量、日液体总量和APACHEⅡ评分的比较,差异均有统计学意义(F = 12.543、10.213、12.840、9.765、10.821、19.466,P均< 0.05)。两组患者入组时上述各指标的比较,差异均无统计学意义(P均> 0.05);治疗后CI均有不同程度改善,试验组第3、5天CI均高于对照组[(3.0 ± 1.7)L·min-1·m-2 vs.(2.6 ± 1.6)L·min-1·m-2,(3.2 ± 1.8)L·min-1·m-2 vs.(2.7 ± 1.8)L·min-1·m-2P均< 0.05];两组患者的CVP治疗后均呈现下降趋势,且试验组第3、5天CVP值均显著低于对照组[(11.9 ± 5.9)cmH2O vs.(13.5 ± 3.1)cmH2O,(10.6 ± 3.7)cmH2O vs.(12.6 ± 2.6)cmH2O,P均< 0.05];两组患者EVLWI在治疗后第3、5天回落至正常水平,且治疗后第3天试验组EVLWI显著低于对照组[(9.8 ± 2.4)mL/kg vs.(11.4 ± 3.3)mL/kg,P < 0.05];治疗后第3、5天试验组日去甲肾上腺素剂量[(11.4 ± 3.4)mg vs.(18.9 ± 5.3)mg,(7.5 ± 2.1)mg vs.(13.2 ± 3.2)mg,P均< 0.05]和日液体总量[(2 954 ± 537)mL vs.(3 624 ± 453)mL,(2 446 ± 484)mL vs.(3 243 ± 675)mL,P均< 0.05]均少于对照组。两组患者APACHEⅡ评分治疗后呈下降趋势,试验组第3、5天APACHEⅡ评分均显著低于对照组[(13 ± 4)分vs.(18 ± 4)分,(11 ± 3)分vs.(13 ± 4)分,P均< 0.05]。

结论

CRRT叠加全血吸附可在早期改善脓毒性休克患者心肌抑制状态,一定程度上改善患者预后。

Objective

To observe the clinical effects of continuous renal replacement therapy (CRRT) combined with hemadsorption on myocardial inhibition in patients with septic shock.

Methods

Totally 60 patients with septic shock [cardiac index (CI) < 3.0 L·min-1·m-2] were selected from Department of Critical Care Medicine in Shaoxing People's Hospital between May 2016 and June 2019. They were randomly divided into a control group (n = 30) and an experimental group (n = 30). The two groups were both treated with a standardized procedure for sepsis, and the patients in the experimental group received additional treatment of CRRT combined with hemadsorption for 3 days. All selected cases were monitored by pulse-indicated continuous cardiac output to record hemodynamic indexes. The CI, central venous pressure (CVP) and extravascular lung water index (EVLWI) of these two groups were recorded on admission, the 3rd and 5th days after treatment. The daily norepinephrine dose, total daily fluid volume and acute physiology and chronic health evaluation (APACHE) Ⅱ scores were also recorded and evaluated.

Results

The differences of CI, CVP, EVLWI, daily norepinephrine dose, total daily fluid volume and APACHEⅡ scores between the two groups were all statistically significant at different time points (F = 12.543, 10.213, 12.840, 9.765, 10.821, 19.466; all P < 0.05). The differences of these indicators between the two groups were not statistically significant on admission (all P > 0.05). The CI of these two groups both improved after treatment. The CI in the experimental group was better than that in the control group on the 3rd and 5th days [(3.0 ± 1.7) L·min-1·m-2 vs. (2.6 ± 1.6) L·min-1·m-2, (3.2 ± 1.8) L·min-1·m-2 vs. (2.7 ± 1.8) L·min-1·m-2, both P < 0.05]. The CVP values decreased in both groups, and the CVP values in the experimental group were lower than those in the control group on the 3rd and 5th days after treatment [(11.9 ± 5.9) cmH2O vs. (13.5 ± 3.1) cmH2O, (10.6 ± 3.7) cmH2O vs. (12.6 ± 2.6) cmH2O, both P < 0.05]. The EVLWI of both groups gradually fell to normal levels on the 3rd and 5th days. The EVLWI was lower in the experimental group than in the control group on the 3rd day [(9.8 ± 2.4) mL/kg vs. (11.4 ± 3.3) mL/kg, P < 0.05]. The daily norepinephrine dose [(11.4 ± 3.4) mg vs. (18.9 ± 5.3) mg, (7.5 ± 2.1) mg vs. (13.2 ± 3.2) mg, both P < 0.05] and total daily fluid volume [(2 954 ± 537) mL vs. (3 624 ± 453) mL, (2 446 ± 484) mL vs. (3 243 ± 675) mL, both P < 0.05] of the experimental group were less than those of the control group on the 3rd and 5th days. The APACHEⅡ scores decreased in both groups after treatment. The APACHEⅡ scores in the experimental group were lower than those in the control group on the 3rd and 5th days[(13 ± 4) vs. (18 ± 4), (11 ± 3) vs. (13 ± 4), both P < 0.05].

Conclusion

CRRT combined with hemadsorption therapy can significantly improve myocardial inhibition in patients with septic shock, and improve their prognosis.

表1 两组脓毒性休克患者一般资料的比较
表2 两组脓毒性休克患者治疗前后血流动力学指标的比较( ± s
1
Artigas A, Niederman MS, Torres A, et al. What is next in sepsis: current trials in sepsis [J]. Expert Rev Anti Infect Ther, 2012, 10 (8): 859-862.
2
陈文秀,沈骁,宋晓春,等. 联合检测中性粒细胞与白蛋白比值和乳酸对脓毒性休克患者早期预后的评估价值[J/CD]. 中华危重症医学杂志(电子版),2020,13(2): 100-105.
3
Flierl MA, Rittirsch D, Huber-Lang MS, et al. Mole-cular events in the cardiomyopathy of sepsis[J]. Mol Med, 2008, 14 (5-6): 327-336.
4
高戈,冯喆,常志刚,等. 2012国际严重脓毒症及脓毒性休克诊疗指南[J]. 中华危重病急救医学,2013,8(25): 501-503.
5
Waisbren BA. Bacteremia due to gram-negative bacilli other than the Salmonella; a clinical and therapeutic study[J]. AMA Arch Intern Med, 1951, 88 (4): 467-488.
6
Tavener SA, Kubes P. Is there a role for cardiomyocyte toll-like receptor 4 in endotoxemia?[J]. Trends Cardiovasc Med, 2005, 15 (5): 153-157.
7
Hussein MH, Kato T, Sugiura T, et al. Effect of hemopefusion using polymyxin B-immobilized fiber on IL-6, HMGB-1 and IFN gamma in a neonatal sepsis model[J]. Pediatr Res, 2005, 58 (2): 309-314.
8
Ruberto F, Pugliese F, D'Alio A, et al. Clinical effects of direct hemoperfusion using a polymyxin-B immobilized column in solid organ transplanted patients with signs of severe sepsis and septic shock. A pilot study[J]. Int J Artif Organs, 2007, 30 (10): 915-922.
9
Sakamoto Y, Mashiko K, Matsumoto H, et al. Relationship between effect of polymyxin B-immobilized fiber and high-mobility group box-1 protein in septic shock patients[J]. ASOAIO J, 2007, 53 (3): 324-328.
10
Kushi H, Miki T, Nakahara J, et al. Hemoperfusion with an immobilized polymyxin B column reduces the blood level of neutrophil elastase[J]. Blood Purif, 2006, 24 (2): 212-217.
11
Kojika M, Sato N, Yaegashi Y, et al. Endoxin adsorption therapy for septic shock using polymyxin Bimmobilized fibers (PMX): evaluation by high-sensitivity assay and measurement of cytokine production capacity[J]. Ther Apher Dial, 2006, 10 (1): 12-18.
12
Cruz DN, Bellomo R, Ronco C. Clinical effects of polymyxin B-immobilized fiber column in septic patients[J]. Contrib Nephrol, 2007 (156): 444-451.
[1] 庄燕, 戴林峰, 张海东, 陈秋华, 聂清芳. 脓毒症患者早期生存影响因素及Cox 风险预测模型构建[J/OL]. 中华危重症医学杂志(电子版), 2024, 17(05): 372-378.
[2] 杨瑾, 刘雪克, 张媛媛, 金钧, 韦瑶. 肠道微生物来源石胆酸对脓毒症相关肝损伤的保护作用[J/OL]. 中华危重症医学杂志(电子版), 2024, 17(04): 265-274.
[3] 张霞, 张瑞, 郑志波, 张勤. 紫草素调控乳酸化修饰和线粒体功能改善脓毒症心肌病小鼠的预后[J/OL]. 中华危重症医学杂志(电子版), 2024, 17(04): 275-284.
[4] 张婧琦, 江洋, 孙佳璐, 唐兴喆, 赵宇飞, 崔颖, 李信响, 戴景月, 傅琳, 彭新桂. 基于肾周CT特征结合血清肌酐水平探讨脓毒症伴急性肾损伤的早期识别[J/OL]. 中华危重症医学杂志(电子版), 2024, 17(04): 285-292.
[5] 李振翮, 魏长青, 甄国栋, 李振富. 脓毒症并发急性呼吸窘迫综合征患者血清S1P、Wnt5a变化及其临床意义[J/OL]. 中华危重症医学杂志(电子版), 2024, 17(04): 293-300.
[6] 王杰, 袁泉, 王玥琦, 乔佳君, 谭春丽, 夏仲元, 刘守尧. 溃疡油在糖尿病足溃疡治疗中的应用效果及安全性观察[J/OL]. 中华损伤与修复杂志(电子版), 2024, 19(06): 480-484.
[7] 聂生军, 王钰, 王毅, 鲜小庆, 马生成. 复方倍他米松局部注射联合光动力疗法治疗小型瘢痕疙瘩的临床疗效观察[J/OL]. 中华损伤与修复杂志(电子版), 2024, 19(05): 404-410.
[8] 李义亮, 苏拉依曼·牙库甫, 麦麦提艾力·麦麦提明, 克力木·阿不都热依木. 机器人与腹腔镜食管裂孔疝修补术联合Nissen 胃底折叠术短期疗效分析[J/OL]. 中华疝和腹壁外科杂志(电子版), 2024, 18(05): 512-517.
[9] 杨万荣, 任治坤, 时新颍. 沙丁胺醇雾化吸入脾多肽治疗AECOPD的疗效分析[J/OL]. 中华肺部疾病杂志(电子版), 2024, 17(04): 609-612.
[10] 危用洋, 黄俊甫, 辛万鹏, 易思清, 涂书举, 方康, 李勇, 肖卫东. 三种术式治疗胰腺颈体部良性或低度恶性肿瘤的临床疗效分析[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(04): 515-519.
[11] 陈曦, 吴宗盛, 郑明珠, 邱海波. 胸腺萎缩在脓毒症免疫紊乱中的研究进展[J/OL]. 中华重症医学电子杂志, 2024, 10(04): 379-383.
[12] 韩俊岭, 王刚, 马厉英, 连颖, 徐慧. 维生素D 联合匹维溴铵治疗腹泻型肠易激综合征患者疗效及对肠道屏障功能指标的影响研究[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(06): 560-564.
[13] 陈惠英, 邱敏珊, 邵汉权. 脓毒症诱发肠黏膜屏障功能损伤的风险因素模型构建与应用效果[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(05): 448-452.
[14] 黄福秀, 张宁宁, 李晨阳, 李淑玲, 陈超. 单纯电切、单纯电凝与电凝电切术对扁平肠息肉疗效及不良事件发生率的影响[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(04): 310-314.
[15] 王楠钧, 马燕, 李隆松, 牛晓彤, 刘圣圳, 毕雅维, 苏松, 柴宁莉, 令狐恩强. 不同年龄段胃低级别上皮内瘤变患者内镜下射频消融术的疗效对比分析[J/OL]. 中华胃肠内镜电子杂志, 2024, 11(04): 238-242.
阅读次数
全文


摘要