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

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SOFA评分均明显低于对照组〔APACHEⅡ评分(分):治疗7 d为16.7±5.9比20.6±6.6,治疗15 d为9.9±4.2比16.4±6.3;SOFA评分(分):治疗7 d为7.9±1.6比11.4±1.9,治疗15 d为5.6±1.4比10.7±2.2,均P<0.05〕,病死率明显低于对照组〔18.8%(6/32)比42.4%(14/33),P<0.01〕.结论 早期CBP治疗并ITCT管理能改善热射病重症患者和器官功能,有效防止多器官功能障碍综合征(MODS)的发生,降低病死率,显著改善预后.%Objective 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 days after treatment, above indicators in the observation group were significant lower than those in the control group [3 days: TNF-α (μg/L) was 20.8±2.4 vs. 25.4±3.1, IL-1β (μg/L) was 5.8±1.3 vs. 9.6±2.2, CPR (mg/L) was 96.9±42.9 vs. 185.9±56.4, PCT (ng/L) was 3.9±1.1 vs. 8.8±2.4, CK (kU/L) was 2.8±0.9 vs. 5.6±1.1, LDH (U/L) was 535.3±421.8 vs. 1 535.5±528.6, D-dimer (μg/L) was 216.8±129.8 vs. 469.9±131.9; 7 days: TNF-α (μg/L) was 8.2±1.8 vs. 16.6±2.1, IL-1β (μg/L) was 4.7±1.5 vs. 8.3±2.4, CRP (mg/L) was 35.8±14.6 vs. 95.9±39.3, PCT (ng/L) was 2.8±0.9 vs. 5.1±1.8, CK (kU/L) was 1.0±0.2 vs. 6.2±0.8, LDH (U/L) was 215.9±145.3 vs. 95.2±212.9,rnD-dimer (μg/L) was 179.5±65.3 vs. 321.8±116.6, all P < 0.01], 7 days and 15 days after treatment, the APACHE Ⅱ and SOFA scores in observation group were significantly lower than those in the control group (APACHE Ⅱ score: 7 days was 16.7±5.9 vs. 20.6±6.6, 15 days was 9.9±4.2 vs. 16.4±6.3, the SOFA scores: 7 days was 6.9±1.3 vs. 11.4±2.5, 15 days was 5.6±2.1 vs. 10.7±2.3, all P < 0.05), and the 28-day mortality in the observation group was obviously lower than that in the control group [18.8% (6/32) vs. 42.4% (14/33), P < 0.01]. Conclusions Early application of CBP and management of ITCT for treatment of patients with severe heat stroke can improve their organ functions, effectively prevent the incidence of multiple organ dysfunction syndrome (MODS), lower the mortality and obviously improve the prognosis.