处方废液剂量相同的不同CRRT模式对脓毒症AKI患者治疗效果的影响

发布时间：2018-05-26 08:15

  本文选题：脓毒症 + 急性肾损伤　； 参考：《河北医科大学》2013年硕士论文

【摘要】：目的：由于到目前为止关于CRRT的治疗剂量尚未有统一的标准，并且关于CRRT治疗剂量与预后的关系并未达成共识。本研究采用处方废液剂量相同的方法直接检测溶质清除率，比较处方废液剂量、校正剂量、交付剂量和实际溶质清除剂量之间的关系，从而为脓毒症AKI患者的CRRT治疗剂量提供参考依据。 方法：选取河北医科大学第四医院ICU在2012年1月至2013年2月收治的采用CRRT治疗的脓毒症AKI患者23例，随机分为两组，CVVH组14例，CVVHDF组9例。两组患者性别、体重、年龄、APACHE II评分、SOFA评分以及各溶质（肌酐、β2-微球蛋白、白介素-6、白介素-8）水平均无统计学意义（p＞0.05）。随机分组两组处方废液剂量相同，均为40ml/kg/h，并都采用100%前稀释，其中CVVHDF组置换液与透析液流速为1:1，根据患者的出血风险、血小板计数以及APTT选择抗凝方式及剂量。采集开始CRRT治疗时，以及每次滤器下机时的动脉端血标本和废液各3ml，所有标本以3000r/min转速离心10min后取上清液于-80℃超低温保存箱冻存待检，血浆及废液的肌酐水平采用化学法进行检测，β2-微球蛋白、白介素-6、白介素-8的水平均采用液相平衡竞争放射免疫分析法（RIA）进行检测。处方废液剂量为上机时的废液量；校正剂量为校正前稀释置换液之后的剂量；交付剂量为24小时内实际废液量并校正前稀释置换液之后的剂量；实际溶质清除剂量为直接检测各溶质（肌酐、β2-微球蛋白、白介素-6、白介素-8溶质)在滤器动脉端以及废液中的浓度比值与24小时内的实际废液量的剂量。比较处方废液剂量，校正剂量，交付剂量以及实际溶质清除剂量之间的相互关系。比较两组患者的28天死亡率、总住院时间、住ICU时间、CRRT治疗时间、机械通气时间。 结果： 1对于小分子溶质（肌酐）的清除率 CVVH和CVVHDF两组各自的实际溶质清除剂量、交付剂量，校正剂量均明显少于处方废液剂量，，比较有统计学差异（p0.001）；两组各自的交付剂量也均少于校正剂量和处方废液剂量，比较有统计学差异（p0.001），两组各自的校正剂量均少于处方废液剂量。在CVVH组中实际溶质清除剂量较处方废液剂量、校正剂量和交付剂量相比分别下降40.3%、20.0%和12.2%；在CVVHDF组中分别下降为33.3%、22.3%和15.0%。CVVHDF组与CVVH组相比较，对小分子溶质（肌酐）的实际溶质清除剂量更高，且有统计学意义（p0.001）。 2对于中大分子溶质（β2-微球蛋白，白介素-6，白介素-8）的实际溶质清除剂量 CVVH和CVVHDF两组各自均能有效的清除β2微球蛋白、白介素-6、白介素-8，并且各自对不同溶质的实际溶质清除剂量（β2-微球蛋白，白介素-6，白介素-8）均有明显差异（p0.001）； CVVH组与CVVHDF组相比较，对中大分子溶质的清除效果更明显，具有明显差异（p0.001）。 3抗凝方案，滤器的使用时间，治疗转归及并发症 CVVH组与CVVHDF组比较两组采用抗凝方案及滤器的使用时间无明显差异（p＞0.05）。两组患者的28天死亡率、总住院时间、住ICU时间、CRRT治疗时间、机械通气时间均无明显差异（p＞0.05）。肝素诱导的低血小板血症的发生率无明显差异p＞0.05）。CVVH组与CVVHDF组都能清除炎性因子（IL-6，IL-8），两组相比较有统计学差异（p0.001），但相比28天死亡率无明显差异，两者相比无统计学差异（p＞0.05）。 结论： 1处方废液剂量相同时，CVVH组与CVVHDF组两者对于小分子溶质（肌酐）的实际溶质清除剂量均被高估，即处方废液剂量、校正剂量、交付剂量均明显高于实际溶质清除剂量。 2处方废液剂量相同时，CVVH组与CVVHDF组两者各自对不同溶质的实际溶质清除剂量（β2-微球蛋白，白介素-6，白介素-8）均不同，对于分子量大于20000的中大分子而言，清除效果两组均明显下降。CVVHDF组清除小分子溶质（肌酐）优于CVVH组。CVVH组清除中大分子溶质（β2-微球蛋白，白介素-6，白介素-8）优于CVVHDF组，因此在以清除中大分子溶质为目的时应优先选用CVVH。 3处方废液剂量相同时， CVVH组与CVVHDF组均能有效地除炎性介质（IL-6，IL-8）,两组患者的28天死亡率无明显差异，CVVH组较CVVHDF组并不能改善生存率。
[Abstract]:Objective: since there is no unified standard for the treatment dose of CRRT so far, and there is no consensus on the relationship between the dose of CRRT treatment and the prognosis. This study uses the same dosage of the prescription waste liquid to direct the test of the solute clearance rate, compared the dosage of the prescription waste liquid, the correction dose, the delivery dose and the actual solute clearance dose. Therefore, it can provide reference for CRRT treatment dose of AKI patients with sepsis.
Methods: 23 cases of septic AKI patients treated with CRRT in the fourth hospital of Hebei Medical University from January 2012 to February 2013 were randomly divided into two groups, 14 cases in group CVVH, 9 in group CVVHDF. The two groups were sex, weight, age, APACHE II score, SOFA score, and each of the solutes (creatinine, beta 2- microglobulin, IL -6, IL -8) There was no statistical significance (P > 0.05). The dosage of two groups of prescription waste liquid was the same, all of which were 40ml/kg/h, and all of them were diluted before 100%. The flow rate of the replacement solution and dialysate in group CVVHDF was 1:1, according to the risk of bleeding, platelet count, and APTT selection anticoagulant formula and dosage. The arterial end blood samples and the waste liquid were 3ml, and all the specimens were frozen at -80 centigrade cryopreservation box after 3000r/min rotational speed centrifuging 10min. The creatinine levels of plasma and waste liquid were detected by chemical method. The level of beta 2- microglobulin, interleukin -6 and interleukin -8 were measured by liquid phase equilibrium competitive radioimmunoassay (R). IA) test. The dosage of the prescription waste liquid is the amount of waste liquid on the machine; the corrected dose is the dose after the correction of the diluent replacement fluid; the dosage is 24 hours and the dose of the former dilute replacement fluid is corrected; the actual solute clearance dose is the direct detection of the solute (creatinine, beta 2- microglobulin, interleukin -6, interleukin -) 8 solute concentration ratio in the end of the filter artery and the waste liquid and the dose of the actual waste liquid within 24 hours. Compare the relationship between the dosage of the prescription waste liquid, the corrected dose, the delivery dose and the actual solute clearance dose. The 28 day mortality rate, the total hospitalization time, the ICU time, the CRRT treatment time, the mechanical ventilation and the mechanical ventilation of the two groups of patients were compared. Room.
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