脉搏指示连续心排血量监测指导高容量血液滤过治疗急性呼吸窘迫综合征的评价  

Evaluation of high volume hemofiltration according to pulse-indicated continuous cardiac output on patients with acute respiratory distress syndrome

作　　者：陈小枫[1] 叶纪录[1] 朱志云[1] 薛寒[1] 濮雪华[1] 缪小莉[1] 

机构地区：[1]南通大学医学院附属泰州市人民医院重症医学科,江苏225300

出　　处：《中华危重病急救医学》2014年第9期650-654,共5页Chinese Critical Care Medicine

基　　金：江苏省泰州市社会发展项目（TS2013010）

摘　　要：目的 观察脉搏指示连续心排血量（PiCCO）监测指导下的高容量血液滤过（HVHF）对急性呼吸窘迫综合征（ARDS）治疗的影响.方法 采用前瞻性随机对照研究方法,选择2011年2月至2014年1月南通大学医学院附属泰州市人民医院收治的163例ARDS患者,按照随机数字表法将患者分为常规治疗组（50例）、HVHF组（55例）、PiCCO＋HVHF组（58例）.常规治疗组按ARDS治疗指南给予机械通气及药物治疗.HVHF组在常规治疗基础上分别于1、3、5、7d加用HVHF,每次持续18h.PiCCO＋HVHF组在HVHF组基础上辅以PiCCO监测指导液体管理.各组患者分别于入重症监护病房（ICU）时（治疗前）及治疗4d、7d记录肺功能及PiCCO监测指标,用酶联免疫吸附试验（ELISA）检测血清肿瘤坏死因子-α（TNF-α）、白细胞介素-1β（IL-1β）浓度,并记录患者预后指标.结果 3组患者随着治疗时间的延长,氧合指数（PaO2/FiO2）、肺静态顺应性（Cs）逐渐升高,呼吸频率（RR）、乳酸（Lac）逐渐下降;HVHF组和PiCCO＋ HVHF组各指标均较常规治疗组明显改善,且PiCCO＋ HVHF组各指标较HVHF组升高或降低明显,以治疗7d时更为显著[PaO2/FiO2（mmHg,1 mmHg=0.133 kPa）：189.3±36.8比166.3 ±36.1,Cs （mL/cmH2O）：76.7±18.9比67.0±18.2,RR（次/min）：16.4±5.2比19.2±5.4,Lac（mmol/L）：1.20±0.41比1.41±0.43,均P＜0.01].PiCCO＋ HVHF组治疗后心排血指数（CI）逐渐升高,血管外肺水指数（EVLWI）、胸腔内血容量指数（ITBVI）逐渐降低,治疗4d、7d各指标与治疗前比较差异均有统计学意义[CI（L·min-1·m-2）：4.62±1.13、4.83±1.10比4.01±1.02,EVLWI（mL/kg）：7.6±2.7、6.5±2.6比12.4±2.9,ITBVI（mL/m2）：801.3±120.9、785.4±118.7比980.1±168.6,均P＜0.01].3组患者治疗后TNF-α、IL-1β均逐渐降低;HVHF组和PiCCO＋ HVHF组治疗4d、7d时TNF-α、IL-1β明显低于常规治疗组,且以7d时更为显著[TNF-α（ng/L）：68.35±12.63、67.54±12.9Objective To study the effects of high volume hemofiltration （HVHF） according to pulse-indicated continuous cardiac output （PiCCO） on patients with acute respiratory distress syndrome （ARDS）.Methods A prospective randomly controlled trial was conducted.163 patients with ARDS admitted to Taizhou People＇s Hospital,Medical College,Nantong University,between February 2011 and January 2014,were enrolled.The patients were randomly divided into conventional therapy group （n= 50）,HVHF group （n =55）,and PiCCO ＋ HVHF group （n=58） by random number table.The patients in conventional therapy group received routine treatment including mechanical ventilation and drug treatment according to ARDS treatment guideline.The patients in the HVHF group received HVHF treatment of 18 hours per day on 1,3,5,7 days on the basis of conventional therapy.Patients in the PiCCO ＋ HVHF group received HVHF treatment according to PiCCO.The indexes of lung function and PiCCO monitoring were recorded at intensive care unit （ICU） admission （before） and 4 days and 7 days after treatment.The serum levels of tumor necrosis factor-α （TNF-α） and interleukin-1β （IL-1β） were determined by enzyme linked immunosorbent assay （ELISA）,and the prognosis of patients was recorded.Results In three groups,oxygenation index （PaO2/FiO2）,static lung compliance （Cs） were gradually increased,and respiratory rate （RR）,lactic acid （Lac） were gradually decreased.The indicators in HVHF and PiCCO ＋ HVHF groups were significantly improved compared with conventional therapy group.The indexes in PiCCO ＋ HVHF group were significantly increased or decreased compared with those in HVHF group,and the statistical differences were found on the 7th day after treatment [PaO2/FiO2 （mmHg,1 mmHg=0.133 kPa）：189.3 ± 36.8 vs.166.3 ± 36.1,Cs （mL/cmH2O）：76.7 ± 18.9 vs.67.0 ± 18.2,RR （times/min）：16.4 ±5.2 vs.19.2 ± 5.4,Lac （mmol/L）：1.20 ±0.41 vs.1.41 ±0.43,all P〈0.01].In PiCCO ＋HVHF group

关 键 词：脉搏指示连续心排血量监测 高容量血液滤过 急性呼吸窘迫综合征 炎症因子 病死率 

分 类 号：R563.8[医药卫生—呼吸系统]