两台血液灌流机组合实现双重血浆分子吸附系统治疗肝衰竭的临床研究

摘要

目的 观察两台血液灌流机组合实现双重血浆分子吸附系统(DPMAS)治疗肝衰竭患者的疗效.方法 回顾性分析2012年9月至2013年9月天津市第二人民医院42例肝衰竭患者的临床资料,42例患者共行血液净化治疗166例次,其中血浆置换(PE)97例次,DPMAS治疗69例次.DPMAS治疗采用两台血液灌流机组合,一台作为血液泵,另一台作为血浆泵,每次两种方法均治疗2～3h.于每次治疗前后检测肝功能、肿瘤坏死因子-α(TNF-α)、电解质及血常规,观察不良反应并总结护理经验.结果 42例肝衰竭患者存活率64.29％.PE和DPMAS治疗后均可使总胆红素(TBil)、血氨(NH3)、总胆汁酸(TBA)、TNF-α下降,白蛋白(ALB)升高,以各指标治疗前后变化率(治疗后/治疗前×100％)进行分析显示,PE治疗后TBil、TBA下降较DPMAS治疗后更明显[TBil:(62.21±5.51)％比(64.39±4.61)％,t=2.683,P=0.008;TBA:(77.10±4.44)％比(85.91±6.95)％,t=9.952,P=0.000],PE治疗后ALB升高较DPMAS治疗后更明显[(113.12±2.90)％比(101.87±2.91)％,t=24.602,P=0.000],PE治疗后与DPMAS治疗后NH3、TNF-α下降程度比较差异无统计学意义[NH3:(79.59±5.72)％比(80.56±7.56)％,t=0.934,P=0.351;TNF-α:(61.66±4.67)％比(62.73±3.67)％,t=1.638,P=0.108].DPMAS治疗前后血电解质及血常规均无明显变化[K+(mmol/L):3.92±0.83比3.91±0.82,t=0.501,P=0.618; Na+(mmol/L):136.89±5.69比136.74±5.83,t=1.077,P=0.285; Cl-(mmol/L):96.58±3.33比96.55±3.27,t=0.245,P=0.807;白细胞计数(×109/L):5.22±0.93比5.43±1.11,t=1.125,P=0.265;血红蛋白(g/L):110.97±19.20比112.69±19.67,t=0.643,P=0.522;血小板计数(×109/L):105.28±26.82比101.96±3.08,t=0.727,P=0.470].69例次DPMAS治疗中有64例次顺利完成治疗,5例次因管路内凝血提前中止治疗.DPMAS治疗过程中有53例次无任何不适;3例次出现血压下降;9例次出现周身不适、恶心等;4例次治疗后出现低热,经对症处理或未予处理均缓解.DPMAS治疗前后应对患者进行心理护理,减少其焦虑;治疗前管路充分预冲,防治凝血;治疗中严密监测患者情况变化,随时调整.结论 两台血液灌流机组合实现DPMAS治疗肝衰竭患者的疗效可靠、不良反应少、安全性高,其操作简单,可节约血浆资源.%Objective To evaluate the effect of the double plasma molecular adsorption system (DPMAS) with a combination of two hemoperfusion machines in treatment of liver failure.Methods A retrospective analysis was conducted.The clinical data from 42 patients with liver failure admitted to Tianjin Second People's Hospital from September 2012 to September 2013 were enrolled.Patients received 166 courses of blood purification treatment,including 97 courses of plasmapheresis (PE) and 69 courses of DPMAS.The DPMAS treatment was performed with a combination of two hemoperfusion machines,with one a blood pump and the other a plasma pump,for 2-3 hours.Liver function,tumor necrosis factor-α (TNF-α),electrolytes and blood routine were determined before and after treatment.Adverse reactions were observed and the nursing experiences were summarized.Results The survival rate of 42 liver failure patients was 64.29％,and the total bilirubin (TBil),NH3,total bile acid (TBA) and TNF-α were decreased and the albumin (ALB) was increased after PE and DPMAS.Further analysis of the rate of changes after treatment (after treatment/before treatment × 100％) showed that when compared with that in DPMAS,the TBil and TBA were decreased significantly in PE [TBil:(62.21 ± 5.51)％ vs.(64.39 ±4.61)％,t=2.683,P=0.008; TBA:(77.10 ± 4.44)％ vs.(85.91 ± 6.95)％,t=9.952,P=0.000],and the level of ALB was elevated significantly in PE when compared with that in DPMAS [(113.12 ± 2.90)％ vs.(101.87 ± 2.91)％,t=24.602,P=0.000].NH3 and TNF-α were decreased in both groups withe no statistical significance [NH3:(79.59 ± 5.72)％ vs.(80.56 ± 7.56)％,t=0.934,P=0.351; TNF-α:(61.66 ± 4.67)％ vs.(62.73 ± 3.67)％,t=1.638,P=0.108].The blood electrolytes and routine blood test showed that there was no significant change before and after treatments in DPMAS group [K+ (mmol/L):3.92 ± 0.83 vs.3.91 ±0.82,t=0.501,P=0.618; Na+ (mmol/L):136.89 ±5.69 vs.136.74 ±5.83,t=1.077,P=0.285; C1(mmol/L):96.58 ± 3.33 vs.96.55 ± 3.27,t=0.245,P=0.807; white cell count (× 109/L):5.22 ±0.93 vs.5.43 ± 1.11,t=1.125,P=0.265; hemoglobin (g/L):110.97 ± 19.20 vs.112.69± 19.67,t=0.643,P=0.522; platelet count (× 109./L):105.28 ± 26.82 vs.101.96 ± 3.08,t=0.727,P=0.470].Sixty-four out of the 69 courses of DPMAS treatment were successfully completed,and 5 times were ended because of line coagulation.There was no uncomfortable symptom complained by 53 patients during the treatment.Hypotension occurred for 3 times,and discomfort and nausea during treatment were complained for 9 times.Low fever occurred 4 times after treatment.Those uncomfortable symptoms were relieved spontaneously or by symptomatic treatment.Psychological nursing care should be given to the patients before and after DPMAS to relieve anxiety.Circulating tubes should be well rinsed to prevent line coagulation.General condition of the patient should be closely monitored in order to adjust therapeutic measures.Conclusion DPMAS could be effectively performed with a combination of two hemoperfusion machines without inadvertent side reactions,and it is safe in operation with smaller amount of plasma.