三种连续性肾脏替代疗法对创伤性颅脑损伤及脑出血急性高钠血症的疗效及预后分析

摘要

目的：探讨连续性肾脏替代疗法（ CRRT）治疗创伤性颅脑损伤及脑出血所致急性高钠血症的最佳模式。方法采用血液净化仪对入选的76例急性高钠血症患者分别进行连续性静脉－静脉血液透析（ CVVHD）、前稀释及后稀释连续性静脉－静脉血液滤过（ CVVH）、前稀释及后稀释连续性静脉－静脉血液透析滤过（ CVVH-DF）治疗，测定不同透析液和置换液流量治疗前后患者血钠水平及其纠正速度，肌酐、血浆渗透压和血气的变化，以及血压、心率等改变，并分析不同治疗方案患者的预后。结果 CVVHD对血清钠、肌酐的清除率随着透析液流量的增大而升高。前稀释、后稀释模式下CVVH 和CVVHDF 对溶质的清除率均随着置换液量的增大而相应提高，3500 ml／h时达最高清除率。与相同置换液输注速度的前稀释模式相比，后稀释模式溶质清除率明显增高。在相同透析液和置换液流量情况下，CVVHDF模式溶质清除率最高。与非CRRT治疗比较，CRRT治疗可明显改善生存率（P＜0．05），CVVHDF组患者预后最佳（P＜0．05）。结论3种CRRT方式，包括前稀释和后稀释模式，均可有效且安全降低颅脑损伤和脑出血所致高钠血症患者的血钠水平，改善患者预后，CVVHDF方法效果最好。%Objective To discuss the optimum model of continuous renal replacement therapy ( CRRT) in the treat-ment of patients with acute hypernatremia caused by severe craniocerebral injury and cerebral encephalorrhagia.Methods A total of 76 acute hypernatremia patients were treated with continuous veno-venous hemodialysis ( CVVHD) , contin-uous veno-venous hemofiltration ( CVVH) with preoperative or postoperative dilution, or continuous veno-venous he-modiafiltration ( CVVHDF) with preoperative or postoperative dilution through GAMBO blood purification system.Then, serum sodium, sodium clearance rate, creatinine, plasma osmolality, blood gas analysis, blood pressure and heart rate were recorded for each patient before and after CRRT.Their prognosis was analyzed.Results The serum sodium clear-ance rate and creatinine clearance rate were significantly elevated in the CVVHD group along with the increase of dialysis buffer flow rate.Similar elevation was seen as to the serum sodium clearance rate and creatinine clearance rate in the oth-er four groups along with the increase of dialysis buffer flow rate.The clearance rate became the largest when the dialysis buffer flow rate was set as 3500 ml/h.The clearance rates in groups with postoperative dilution were higher than those in groups with preoperative dilution when the same flow rates were adopted.The rates of dialysis buffer in the CVVHDF groups were higher than those in other groups when the same flow rates were adopted.Compared with non-CRRT thera-py, CRRT could remarkably improve the survival rate (P<0.05) and the prognosis was optimum in the CVVHDF groups (P <0.05).Conclusion All the three types of CRRT, including preoperative dilution and postoperative dilution modes, can efficiently and safely decrease serum sodium level and improve the prognosis of patients with acute hyper-natremia caused by severe craniocerebral injury and cerebral encephalorrhagia.CVVHDF is recommended for its better prognosis than the other two therapies.