高容量血液滤过对感染性休克患者血管外肺水和肺泡-动脉间氧交换影响的研究  

Study of the effects of high volume hemofiltration on extra vascular lung water and alveolar-arterial oxygen exchange in patients with septic shock

作　　者：任宏生[1] 蒋进皎[1] 楚玉峰[1] 丁敏[1] 郄国强[1] 曾娟[1] 王鹏[1] 朱文瑛[1] 孟玫[1] 王春亭[1] 

机构地区：[1]山东大学附属省立医院ICU,济南250021

出　　处：《中华危重病急救医学》2014年第9期609-614,共6页Chinese Critical Care Medicine

基　　金：山东省自然科学基金（ZR2013HM062,Y2006C77）;国家自然科学基金青年基金（81200238）;山东省优秀中青年科学家科研奖励基金（BS2011YY043）

摘　　要：目的 探讨高容量血液滤过（HVHF）对感染性休克患者炎症因子、血管外肺水及肺泡-动脉间氧交换能力的影响.方法 回顾性分析2011年1月至2013年12月山东大学附属省立医院重症监护病房（ICU）87例感染性休克并行容量复苏患者的临床资料.根据是否实施HVHF将患者分为容量复苏组（41例）和HVHF组（46例）.HVHF组在容量复苏基础上行床旁高容量连续性静-静脉血液滤过,至少3d.比较两组患者治疗前后炎症因子、心功能指标、脉搏指示连续心排血量（PiCCO）监测的血流动力学参数、氧交换指标、病情严重程度评分以及28 d病死率,并分析血管外肺水指数（EVLWI）与肺泡-动脉血氧分压差（PA-aDO2）的相关性.结果 ①两组治疗后血清白细胞介素-6（IL-6）、降钙素原（PCT）、N末端B型脑钠肽前体（NT-proBNP）均逐渐下降,HVHF组治疗后3d时IL-6、PCT、NT-proBNP均较容量复苏组明显降低[IL-6（μg/L）：34.8±15.8比63.3±21.2,PCT（μg/L）：7.5±6.4比17.3±11.2,NT-proBNP（μg/L）：561.8±23.7比584.3±56.7,P＜0.05或P＜0.01].②两组治疗后血流动力学参数均有所改善;HVHF组治疗后3d时胸腔内血容量指数（ITBVI）、EVLWI、肺血管通透性指数（PVPI）均明显低于容量复苏组[ITBVI（mL/m2）：634.2±125.8比963.8±321.0,EVLWI（mL/kg）：7.5±2.4比12.3±4.2,PVPI：2.2±1.2比4.2±2.0,均P＜0.01].③两组治疗后PA-aDO2、乳酸（Lac）逐渐下降,氧合指数（PaO2/FiO2）逐渐升高.与容量复苏组比较,HVHF组治疗后3d、7d时PA-aDO2、Lac均明显降低[PA-aDO2（mmHg,1 mmHg=0.133kPa）3 d：252.37±29.45比270.82±38.07,7 d：181.08±21.81比221.02±29.13; Lac（mmol/L）3 d：3.17±2.03比4.07±2.43,7 d：1.95±0.97比2.45±1.07,P＜0.05或P＜0.01],治疗后7d时PaO2/FiO2明显升高（mmHg：258±41比178±34,P＜0.01）.④EVLWI与PA-aDO2呈显著正相关（r=0.693,P=0.001）,95％可信区间为0.617 ～ 0.773.⑤两组治疗后病情均有所改�Objective To explore the effects of high volume hemofiltration （HVHF） on inflammatory factors,extra vascular lung water and alveolar-arterial oxygen exchange in patients with septic shock.Methods The data of 87 patients with septic shock underwent fluid resuscitation admitted to intensive care unit （ICU） of Shandong Provincial Hospital Affiliated to Shandong University were retrospectively analyzed.According to whether HVHF was used or not,all the patients were divided into fluid resuscitation group （n=41） and HVHF group （n=46）.The patients in HVHF group received bedside high volume continuous vein-vein hemofihration for at least 3 days on the basis of fluid resuscitation.The inflammatory factors,indexes of heart function,hemodynamics monitored by pulse-indicated continuous cardiac output （PiCCO）,oxygen exchange,the severity of the disease before and after treatment,and 28-day mortality were compared between the two groups.The relationship between extra-vascular lung water index （EVLWI） and alveolar-arterial oxygen pressure difference （PA-aDO2） was analyzed.Results ①） After treatment,the serum levels of interleukin-6 （IL-6）,procalcitonin （PCT）,and N-terminal pro-B-type natriuretic peptide （NT-proBNP） in both group were gradually decreased.The IL-6,PCT,and NT-proBNP on the 3rd day after treatment in HVHF group were significantly lower than those in fluid resuscitation group [IL-6 （μg/L）：34.8 ± 15.8 vs.63.3 ± 21.2,PCT （μg/L）：7.5 ± 6.4 vs.17.3 ± 11.2,NT-proBNP （μg/L）：561.8 ± 23.7 vs.584.3 ± 56.7,P〈0.05 or P〈 0.01].② The hemodynamics indexes were improved after treatment in both groups.The levels of intrathoracic blood volume index （ITBVI）,EVLWI and pulmonary vascular permeability index （PVPI） on the 3rd day after treatment in HVHF group were significantly lower than those in fluid resuscitation group [ITBVI （mL/m2）：634.2 ± 125.8 vs.963.8 ± 321.0,EVLWI （mL/kg）：7.5 ±2.4 vs.12.3 ±4.2,PVPI：2.2 ± 1.2 vs.4.2 ±2.0,all P

关 键 词：高容量血液滤过 脉搏指示连续心排血量 感染性休克 炎症因子 血管外肺水 肺血管通透性 肺泡-动脉血氧分压差 急性生理学与慢性健康状况评分系统Ⅱ 序贯器官衰竭评分 

分 类 号：R459.7[医药卫生—急诊医学]