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

doi:10.3877/cma.j.issn.1674-6880.2020.05.003

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^-2，P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。

关键词: 连续性肾脏替代疗法, 全血吸附, 脓毒症, 心肌抑制, 临床疗效

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.

Key words: Continuous renal replacement therapy, Hemoadsorption, Sepsis, Myocardial inhibition, Clinical efficacy

表1 两组脓毒性休克患者一般资料的比较

组别	例数	（性别例，男/女）	年龄（岁， ± s）	APACHEⅡ评分（分， ± s）	感染类型（例）
组别	例数	（性别例，男/女）	年龄（岁， ± s）	APACHEⅡ评分（分， ± s）	重症肺炎	腹膜炎	AOSC	皮肤软组织感染	胸腹腔感染
对照组	30	21/9	61 ± 9	21 ± 6	13	1	7	1	8
试验组	30	18/12	56 ± 10	21 ± 6	12	2	9	0	7
t/χ²值		0.121	1.213	2.426	1.690
P值		0.961	0.241	0.220	0.725

表1 两组脓毒性休克患者一般资料的比较

组别	例数	（性别例，男/女）	年龄（岁， ± s）	APACHEⅡ评分（分， ± s）	感染类型（例）
组别	例数	（性别例，男/女）	年龄（岁， ± s）	APACHEⅡ评分（分， ± s）	重症肺炎	腹膜炎	AOSC	皮肤软组织感染	胸腹腔感染
对照组	30	21/9	61 ± 9	21 ± 6	13	1	7	1	8
试验组	30	18/12	56 ± 10	21 ± 6	12	2	9	0	7
t/χ²值		0.121	1.213	2.426	1.690
P值		0.961	0.241	0.220	0.725

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）

组别	时间	例数	CI（L·min^-1·m^-2）	CVP（cmH₂O）	EVLWI（mL/kg）	日去甲肾上腺素剂量（mg）	日液体总量（mL）
对照组	入组时	30	2.4 ± 1.3	16.9 ± 3.9	14.9 ± 3.8	34.1 ± 6.8	4 513 ± 853
	治疗后第3天	30	2.6 ± 1.6^a	13.5 ± 3.1^a	11.4 ± 3.3^a	18.9 ± 5.3^a	3 624 ± 453^a
	治疗后第5天	30	2.7 ± 1.8^ab	12.6 ± 2.6^ab	9.5 ± 2.2^ab	13.2 ± 3.2^ab	3 243 ± 675^ab
试验组	入组时	30	2.5 ± 1.4	16.1 ± 4.3	14.3 ± 3.1	32.8 ± 9.5	4 352 ± 732
	治疗后第3天	30	3.0 ± 1.7^ac	11.9 ± 5.9^ac	9.8 ± 2.4^ac	11.4 ± 3.4^ac	2 954 ± 537^ac
	治疗后第5天	30	3.2 ± 1.8^abc	10.6 ± 3.7^abc	8.9 ± 3.7^ab	7.5 ± 2.1^abc	2 446 ± 484^abc
F值			12.543	10.213	12.840	9.765	10.821
P值			0.021	0.008	0.015	0.031	0.039

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）

组别	时间	例数	CI（L·min^-1·m^-2）	CVP（cmH₂O）	EVLWI（mL/kg）	日去甲肾上腺素剂量（mg）	日液体总量（mL）
对照组	入组时	30	2.4 ± 1.3	16.9 ± 3.9	14.9 ± 3.8	34.1 ± 6.8	4 513 ± 853
	治疗后第3天	30	2.6 ± 1.6^a	13.5 ± 3.1^a	11.4 ± 3.3^a	18.9 ± 5.3^a	3 624 ± 453^a
	治疗后第5天	30	2.7 ± 1.8^ab	12.6 ± 2.6^ab	9.5 ± 2.2^ab	13.2 ± 3.2^ab	3 243 ± 675^ab
试验组	入组时	30	2.5 ± 1.4	16.1 ± 4.3	14.3 ± 3.1	32.8 ± 9.5	4 352 ± 732
	治疗后第3天	30	3.0 ± 1.7^ac	11.9 ± 5.9^ac	9.8 ± 2.4^ac	11.4 ± 3.4^ac	2 954 ± 537^ac
	治疗后第5天	30	3.2 ± 1.8^abc	10.6 ± 3.7^abc	8.9 ± 3.7^ab	7.5 ± 2.1^abc	2 446 ± 484^abc
F值			12.543	10.213	12.840	9.765	10.821
P值			0.021	0.008	0.015	0.031	0.039

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

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