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

摘要

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＜0.01].③ The levels of PA-aDO2 and arterial blood lactic (Lac) were gradually decreased,and oxygenation index (PaO2/FiO2) was gradually increased in both groups.Compared with fluid resuscitation group,the PA~DO2 and Lac on the 3rd and the 7th day were significantly declined[PA-aDO2 (mmHg,1 mmHg=0.133 kPa) on the 3rd day:252.37 ± 29.45 vs.270.82 ± 38.07,on the 7th day:181.08 ± 21.81 vs.221.02 ± 29.13; Lac (mmol/L) on the 3rd day:3.17 ± 2.03 vs.4.07 ± 2.43,on the 7th day:1.95 ± 0.97 vs.2.45 ± 1.07,P＜0.05 or P＜0.01],and the PaO2/FiO2 on the 7th day was significantly elevated (mmHg:258 ± 41 vs.178 ± 34,P＜0.01).④ A significant positive correlation was found between EVLWI and PA-aDO2 (r=0.693,P=0.001),with the 95％ confident interval (95％CI) 0.617-0.773.⑤ The condition was improved after treatment in the two groups.The acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) scores and sepsis-related organ failure assessment (SOFA) scores on the 7th day after treatment in HVHF group were significantly reduced compared with those in fluid resuscitation group (APACHE Ⅱ score on the 3rd day:18.2 ± 7.7 vs.22.4 ± 8.6,on the 7th day:8.2 ± 3.8 vs.17.2 ± 6.8; SOFA score on the 3rd day:13.6 ± 3.4 vs.15.8 ± 5.0,on the 7th day:7.6 ± 3.3 vs.12.8 ± 3.9,P＜0.05 or P＜0.01).The 28-day mortality in HVHF group was significantly lower than that in fluid resuscitation group [15.22％ (7/46) vs.34.15％ (14/41),x2=4.242,P=0.038].Conclusions HVHF could decrease blood inflammatory factors,and reduce the vaso-permeability and extra vascular lung water with a result of the improvement of the levels of alveolar-arterial oxygen exchange in patients with septic shock and the prognosis at the same time.%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善,HVHF组治疗后3d、7d时APACHEⅡ评分、SOFA评分均显著低于容量复苏组[APACHEⅡ评分(分)3 d:18.2±7.7比22.4±8.6,7 d:8.2±3.8比17.2±6.8; SOFA(分)3 d:13.6±3.4比15.8±5.0,7 d:7.6±3.3比12.8±3.9,P＜ 0.05或P＜0.01].HVHF组28 d病死率明显低于容量复苏组[15.22％(7/46)比34.15％(14/41),x2=4.242,P=0.038].结论 HVHF可降低感染性休克患者血中炎症介质水平,降低肺血管通透性,减少血管外肺水,提高肺泡-动脉间氧的交换,改善预后.