连续性血液净化并强化目标控制温度管理救治热射病患者的临床观察  

Clinical investigation of continuous blood purification and intensive target controlled temperature for treatment and salvage of patients with severe heat stroke

作　　者：杨胜[1] 葛燕萍[1] 张冬惠[1] 王绍谦[1] 马汤力[1] 

机构地区：[1]开封市第二人民医院EICU,河南开封475002

出　　处：《中国中西医结合急救杂志》2017年第4期409-414,共6页Chinese Journal of Integrated Traditional and Western Medicine in Intensive and Critical Care

基　　金：河南省开封市科技发展计划项目（120371）

摘　　要：目的 探讨连续性血液净化（CBP）并强化目标控制温度（ITCT）管理救治热射病重症患者的临床疗效.方法 采用回顾性对照研究方法,选择2011年7月至2016年8月开封市第二人民医院急诊重症加强治疗病房（EICU）收治的符合热射病诊断标准的重症患者65例,按治疗方法不同分为观察组（32例）和对照组（33例）.所有患者均给予常规治疗,观察组在常规治疗基础上实施早期（在入院4 h内）CBP及ITCT管理：ITCT是体温降至目标控制温度（TCT）,保持肛温（35.0±0.5）℃,并维持72 h;CBP是指采用连续性静脉-静脉血液滤过（CVVH）和肾脏替代治疗（CRRT）.治疗前及治疗3 d、7 d检测血清肿瘤坏死因子-α（TNF-α）、白细胞介素-1β（IL-1β）、血清降钙素原（PCT）、C-反应蛋白（CRP）、肌酸激酶（CK）、乳酸脱氢酶（LDH）、D-二聚体水平,比较两组治疗前及治疗7 d、15 d急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分和序贯器官衰竭评分（SOFA评分）以及28 d病死率的差异.结果 随治疗时间延长,两组治疗后TNF-α及对照组IL-1β、CRP、PCT、CK、LDH、D-二聚体均呈先升高后降低趋势,观察组治疗后IL-1β、CRP、PCT、CK、LDH、D-二聚体则均逐渐降低,治疗后3 d、7 d观察组上述指标均明显低于对照组〔3 d：TNF-α（μg/L）为20.8±2.4比25.4±3.1,IL-1β（μg/L）为5.8±1.3比9.6±2.2,CPR（mg/L）为96.9±42.9比185.9±56.4,PCT（ng/L）为3.9±1.1比8.8±2.4,CK（kU/L）为2.8±0.9比5.6±1.1,LDH（U/L）为535.3±421.8比1535.5±528.6,D-二聚体（μg/L）为216.8±129.8比469.9±131.9;7 d：TNF-α（μg/L）为8.2±1.8比16.6±2.1,IL-1β（μg/L）为4.7±1.5比8.3±2.4,PCT（ng/L）为2.8±0.9比5.1±1.8,CRP（mg/L）为35.8±14.6比95.9±39.3,CK（kU/L）为1.0±0.2比6.2±0.8,LDH（U/L）为215.9±145.3比795.2±212.9,D-二聚体（μg/L）为179.5±65.3比321.8±116.6,均P〈0.01〕;观察组治疗7 d、15 d APACHEⅡ评分和SOObjective To explore the clinical efficacy of continuous blood purification （CBP） and intensive target controlled temperature （ITCT） in treatment and salvage of patients with severe heat stroke （HS）.Methods A retrospective controlled study was adopted, including 65 patients who met the standard diagnostic criteria of HS and were admitted into the Emergency Intensive Care Unit （EICU） in the Second Peoples＇ Hospital of Kaifeng City from July 2011 to August 2016. According to the difference in clinical treatment, they were divided into an observation group （32 cases） and a control group （33 cases）. All the patients in two groups were given routine therapy, in the observation group, on the basis of the conventional treatment, early CBP and ITCT management were applied timely （within 4 hours after admission）; ITCT management： ITCT was that the target controlled temperature （TCT） was kept at the rectal temperature （35±0.5） ℃ and maintained for 72 hours; in the mean time, early CBP treatment was adopted, that was continuous vein-vein hemofiltration （CVVH） and continuous renal replacement therapy （CRRT）. Before treatment and 3 days and 7 days after treatment, the levels of serum tumor necrosis-α （TNF-α）, interleukin-1β （IL-1β）, serum procalcitonin （PCT）, C-reactive protein （CRP）, creatine kinase （CK）, lactate dehydrogenase （LDH） and D-dimer were detected. Moreover, before treatment and 7 days and 15 days after treatment, the differences in acute physiology and chronic health evaluation Ⅱ （APACHE Ⅱ） score, sequential organ failure evaluation score （SOFA） and the 28-day mortality were compared between the two groups.Results With the prolongation of the therapeutic time, after treatment the levels of TNF-α in both groups, IL-1β, CRP, PCT, CK, LDH, D-dimer in the control group were firstly increased and then decreased, the levels of IL-1β, CRP, PCT, CK, LDH and D-dimer were all gradually reduced in observation group, and 3 days, 7 d

关 键 词：热射病 连续性血液净化 强化目标温度控制 多器官功能障碍综合征 预后 

分 类 号：R459.5[医药卫生—治疗学]