重症超声指导间歇性血液滤过治疗急性肾损伤的容量管理  

Volume management of intermittent hemofiltration guided by critical care ultrasound in the treatment of acute kidney injury

作　　者：崔晓琼[1] 邹永明[2] 高文卿[1] 刘欢[1] 王松[1] 魏蔚[1] 宋元申 吴昊 Cui Xiaoqiong;Zou Yongming;Gao Wenqing;Liu Huan;Wang Song;Wei Wei;Song Yuanshen;Wu Hao(Department of Cardiology Coronary Care Unit,the Third Central Hospital of Tianjin,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases,Clinical and Trainning Center of Tianjin Extracorporeal Membrane Oxygenation,Tianjin 300170,China;Department of Neurology,Huanhu Hospital,Tianjin 300350,China)

机构地区：[1]天津市第三中心医院心脏中心CCU,天津市重症疾病体外生命支持重点实验室,天津市ECMO治疗与培训基地,天津300170 [2]天津市环湖医院神经内科,天津300350

出　　处：《中华危重病急救医学》2023年第3期310-315,共6页Chinese Critical Care Medicine

基　　金：天津市医学重点学科建设项目(TJYXZDXK-035A);天津市"131"创新人才团队项目(201939)。

摘　　要：目的:探讨重症超声指导间歇性静脉-静脉血液滤过(IVVH)治疗心力衰竭(HF)合并急性肾损伤(AKI)患者的容量管理。方法:选择2019年4月至2022年6月天津市第三中心医院心脏重症监护病房(CCU)收治的216例行IVVH治疗的HF合并AKI患者作为研究对象,将患者随机分成常规指导组(107例)和超声指导组(109例)。根据肾功能恢复情况拟每日12 h或隔日12 h行日间IVVH,常规指导组选择常规方法制定IVVH处方,超声指导组在常规指导组基础上加用重症超声技术调整IVVH治疗参数。分别于每次治疗前及治疗开始3、6、9 h应用超声记录下腔静脉(IVC)呼吸变异度(RVI)、右左心室舒张末期面积比值、舒张早期二尖瓣血流速度峰值/二尖瓣瓣环速度峰值比值(E/E')、主动脉血流速度时间积分(VTI)、心排血量(CO)、双肺B线范围、双肾叶间动脉阻力指数(RI),根据综合结果实时调整净脱水速率。监测两组患者IVVH治疗前及首次治疗后3、7、10 d的尿量、血清肌酐(SCr)、估算肾小球滤过率(eGFR)和血B型脑钠肽(BNP)、β_(2)-微球蛋白(β_(2)-MG)、胱抑素C(Cys C)水平,记录两组患者肾功能恢复及临床预后指标。 结果:IVVH开始时超声指导组脱水速率较慢,6 h后开始逐渐增加,总体脱水速率明显慢于常规指导组。超声指导组应用重症超声扫查显示,RVI逐渐增大,右左心室舒张末期面积比值逐渐减小,E/E'比值逐渐下降,双肺B线范围逐渐缩小,双肾叶间动脉RI明显下降。两组患者首次IVVH开始后3、7、10 d的肾功能相关指标较治疗前明显改善,其中超声指导组β 2-MG和Cys C在早期(3 d)的下降速度即快于常规指导组〔β 2-MG(mg/L):3.69±1.31比3.99±1.45,Cys C(mg/L):2.91±0.95比3.14±0.96,均 P<0.05〕,7 d时尿量、SCr和eGFR也较常规指导组明显改善〔24 h尿量(mL):1 128.23±153.92比1 015.01±114.18,SCr(μmol/L):145.86±32.25比155.64±28.42,eGFR(mL/min):50.26±11.24比46.51±10.61,均 P<0.05〕�Objective To investigate the volume management of intermittent veno-venous hemofiltration(IVVH)guided by critical care ultrasound in the treatment of acute kidney injury(AKI)in patients with heart failure(HF).Methods A total of 216 patients with HF and AKI treated with IVVH in the coronary care unit(CCU)of the Third Central Hospital of Tianjin from April 2019 to June 2022 were selected as the study subjects,the patients were randomly divided into conventional guidance group(107 cases)and ultrasound guidance group(109 cases).According to the recovery of renal function,IVVH was performed 12 hours every day or 12 hours every other day.The conventional guidance group selected the conventional method to formulate IVVH prescription,and the ultrasound guidance group used critical care ultrasound to adjust the treatment parameters of IVVH on the basis of the conventional guidance group.Respiratory variation index(RVI)of inferior vena cava(IVC),right left ventricular end-diastolic transverse area ratio,early diastolic peak mitral flow velocity/mitral annulus velocity peak(E/E'),aortic flow velocity time integral(VTI),cardiac output(CO),bilateral lung ultrasound B-line range,bilateral renal interlobar arteries resistance index(RI)were recorded before and 3,6,9 hours after each treatment.The net dehydration rate was adjusted in real time according to the comprehensive results.Urine volume,serum creatinine(SCr),estimated glomerular filtration rate(eGFR),blood B-type brain natriuretic peptide(BNP),β2-microglobulin(β2-MG)and cystatin C(Cys C)levels of patients in both groups were monitored before and 3,7 and 10 days after initial treatment,and renal function recovery and clinical prognostic indexes of patients in both groups were recorded.Results The dehydration rate of the ultrasound guidance group was slow at the beginning of IVVH,and gradually increased after 6 hours,and the overall dehydration rate was significantly slower than that of the conventional guidance group.In the ultrasound guidance group using critical care u

关 键 词：重症超声 间歇性静脉-静脉血液滤过 急性肾损伤 容量管理 

分 类 号：R445.1[医药卫生—影像医学与核医学] R692[医药卫生—诊断学]