目的 观察脉搏指示连续心排血量(PiCCO)监测指导下的高容量血液滤过(HVHF)对急性呼吸窘迫综合征(ARDS)治疗的影响.方法 采用前瞻性随机对照研究方法,选择2011年2月至2014年1月南通大学医学院附属泰州市人民医院收治的163例ARDS患者,按照随机数字表法将患者分为常规治疗组(50例)、HVHF组(55例)、PiCCO+HVHF组(58例).常规治疗组按ARDS治疗指南给予机械通气及药物治疗.HVHF组在常规治疗基础上分别于1、3、5、7d加用HVHF,每次持续18h.PiCCO+HVHF组在HVHF组基础上辅以PiCCO监测指导液体管理.各组患者分别于入重症监护病房(ICU)时(治疗前)及治疗4d、7d记录肺功能及PiCCO监测指标,用酶联免疫吸附试验(ELISA)检测血清肿瘤坏死因子-α(TNF-α)、白细胞介素-1β(IL-1β)浓度,并记录患者预后指标.结果 3组患者随着治疗时间的延长,氧合指数(PaO2/FiO2)、肺静态顺应性(Cs)逐渐升高,呼吸频率(RR)、乳酸(Lac)逐渐下降;HVHF组和PiCCO+ HVHF组各指标均较常规治疗组明显改善,且PiCCO+ HVHF组各指标较HVHF组升高或降低明显,以治疗7d时更为显著[PaO2/FiO2(mmHg,1 mmHg=0.133 kPa):189.3±36.8比166.3 ±36.1,Cs (mL/cmH2O):76.7±18.9比67.0±18.2,RR(次/min):16.4±5.2比19.2±5.4,Lac(mmol/L):1.20±0.41比1.41±0.43,均P＜0.01].PiCCO+ HVHF组治疗后心排血指数(CI)逐渐升高,血管外肺水指数(EVLWI)、胸腔内血容量指数(ITBVI)逐渐降低,治疗4d、7d各指标与治疗前比较差异均有统计学意义[CI(L·min-1·m-2):4.62±1.13、4.83±1.10比4.01±1.02,EVLWI(mL/kg):7.6±2.7、6.5±2.6比12.4±2.9,ITBVI(mL/m2):801.3±120.9、785.4±118.7比980.1±168.6,均P＜0.01].3组患者治疗后TNF-α、IL-1β均逐渐降低;HVHF组和PiCCO+ HVHF组治疗4d、7d时TNF-α、IL-1β明显低于常规治疗组,且以7d时更为显著[TNF-α(ng/L):68.35±12.63、67.54±12.90比85.35±13.70,IL-1β(ng/L):424.6±142.9、412.2±140.2比895.2±187.7,均P＜0.01],而PiCCO+ HVHF组与同期HVHF组比较,TNF-α和IL-1β虽有降低,但差异无统计学意义.HVHF组和PiCCO+ HVHF组衰竭器官数、机械通气时间、ICU住院时间、住院病死率均较常规治疗组降低,且PiCCO+ HVHF组较HVHF组降低更为明显[衰竭器官数(个):2.41±0.79比2.72±0.80,机械通气时间(d):4.8±2.0比5.7±2.1,ICU住院时间(d):11.5±3.4比13.1±3.6,住院病死率:31.0％(18/58)比41.8％(23/55),均P＜ 0.05].结论 HVHF能降低ARDS患者炎症因子水平.PiCCO监测指导下的HVHF可以改善患者的氧合及肺顺应性,减少器官衰竭,缩短机械通气时间和ICU住院时间,降低住院病死率.
目的 觀察脈搏指示連續心排血量(PiCCO)鑑測指導下的高容量血液濾過(HVHF)對急性呼吸窘迫綜閤徵(ARDS)治療的影響.方法 採用前瞻性隨機對照研究方法,選擇2011年2月至2014年1月南通大學醫學院附屬泰州市人民醫院收治的163例ARDS患者,按照隨機數字錶法將患者分為常規治療組(50例)、HVHF組(55例)、PiCCO+HVHF組(58例).常規治療組按ARDS治療指南給予機械通氣及藥物治療.HVHF組在常規治療基礎上分彆于1、3、5、7d加用HVHF,每次持續18h.PiCCO+HVHF組在HVHF組基礎上輔以PiCCO鑑測指導液體管理.各組患者分彆于入重癥鑑護病房(ICU)時(治療前)及治療4d、7d記錄肺功能及PiCCO鑑測指標,用酶聯免疫吸附試驗(ELISA)檢測血清腫瘤壞死因子-α(TNF-α)、白細胞介素-1β(IL-1β)濃度,併記錄患者預後指標.結果 3組患者隨著治療時間的延長,氧閤指數(PaO2/FiO2)、肺靜態順應性(Cs)逐漸升高,呼吸頻率(RR)、乳痠(Lac)逐漸下降;HVHF組和PiCCO+ HVHF組各指標均較常規治療組明顯改善,且PiCCO+ HVHF組各指標較HVHF組升高或降低明顯,以治療7d時更為顯著[PaO2/FiO2(mmHg,1 mmHg=0.133 kPa):189.3±36.8比166.3 ±36.1,Cs (mL/cmH2O):76.7±18.9比67.0±18.2,RR(次/min):16.4±5.2比19.2±5.4,Lac(mmol/L):1.20±0.41比1.41±0.43,均P＜0.01].PiCCO+ HVHF組治療後心排血指數(CI)逐漸升高,血管外肺水指數(EVLWI)、胸腔內血容量指數(ITBVI)逐漸降低,治療4d、7d各指標與治療前比較差異均有統計學意義[CI(L·min-1·m-2):4.62±1.13、4.83±1.10比4.01±1.02,EVLWI(mL/kg):7.6±2.7、6.5±2.6比12.4±2.9,ITBVI(mL/m2):801.3±120.9、785.4±118.7比980.1±168.6,均P＜0.01].3組患者治療後TNF-α、IL-1β均逐漸降低;HVHF組和PiCCO+ HVHF組治療4d、7d時TNF-α、IL-1β明顯低于常規治療組,且以7d時更為顯著[TNF-α(ng/L):68.35±12.63、67.54±12.90比85.35±13.70,IL-1β(ng/L):424.6±142.9、412.2±140.2比895.2±187.7,均P＜0.01],而PiCCO+ HVHF組與同期HVHF組比較,TNF-α和IL-1β雖有降低,但差異無統計學意義.HVHF組和PiCCO+ HVHF組衰竭器官數、機械通氣時間、ICU住院時間、住院病死率均較常規治療組降低,且PiCCO+ HVHF組較HVHF組降低更為明顯[衰竭器官數(箇):2.41±0.79比2.72±0.80,機械通氣時間(d):4.8±2.0比5.7±2.1,ICU住院時間(d):11.5±3.4比13.1±3.6,住院病死率:31.0％(18/58)比41.8％(23/55),均P＜ 0.05].結論 HVHF能降低ARDS患者炎癥因子水平.PiCCO鑑測指導下的HVHF可以改善患者的氧閤及肺順應性,減少器官衰竭,縮短機械通氣時間和ICU住院時間,降低住院病死率.
목적 관찰맥박지시련속심배혈량(PiCCO)감측지도하적고용량혈액려과(HVHF)대급성호흡군박종합정(ARDS)치료적영향.방법 채용전첨성수궤대조연구방법,선택2011년2월지2014년1월남통대학의학원부속태주시인민의원수치적163례ARDS환자,안조수궤수자표법장환자분위상규치료조(50례)、HVHF조(55례)、PiCCO+HVHF조(58례).상규치료조안ARDS치료지남급여궤계통기급약물치료.HVHF조재상규치료기출상분별우1、3、5、7d가용HVHF,매차지속18h.PiCCO+HVHF조재HVHF조기출상보이PiCCO감측지도액체관리.각조환자분별우입중증감호병방(ICU)시(치료전)급치료4d、7d기록폐공능급PiCCO감측지표,용매련면역흡부시험(ELISA)검측혈청종류배사인자-α(TNF-α)、백세포개소-1β(IL-1β)농도,병기록환자예후지표.결과 3조환자수착치료시간적연장,양합지수(PaO2/FiO2)、폐정태순응성(Cs)축점승고,호흡빈솔(RR)、유산(Lac)축점하강;HVHF조화PiCCO+ HVHF조각지표균교상규치료조명현개선,차PiCCO+ HVHF조각지표교HVHF조승고혹강저명현,이치료7d시경위현저[PaO2/FiO2(mmHg,1 mmHg=0.133 kPa):189.3±36.8비166.3 ±36.1,Cs (mL/cmH2O):76.7±18.9비67.0±18.2,RR(차/min):16.4±5.2비19.2±5.4,Lac(mmol/L):1.20±0.41비1.41±0.43,균P＜0.01].PiCCO+ HVHF조치료후심배혈지수(CI)축점승고,혈관외폐수지수(EVLWI)、흉강내혈용량지수(ITBVI)축점강저,치료4d、7d각지표여치료전비교차이균유통계학의의[CI(L·min-1·m-2):4.62±1.13、4.83±1.10비4.01±1.02,EVLWI(mL/kg):7.6±2.7、6.5±2.6비12.4±2.9,ITBVI(mL/m2):801.3±120.9、785.4±118.7비980.1±168.6,균P＜0.01].3조환자치료후TNF-α、IL-1β균축점강저;HVHF조화PiCCO+ HVHF조치료4d、7d시TNF-α、IL-1β명현저우상규치료조,차이7d시경위현저[TNF-α(ng/L):68.35±12.63、67.54±12.90비85.35±13.70,IL-1β(ng/L):424.6±142.9、412.2±140.2비895.2±187.7,균P＜0.01],이PiCCO+ HVHF조여동기HVHF조비교,TNF-α화IL-1β수유강저,단차이무통계학의의.HVHF조화PiCCO+ HVHF조쇠갈기관수、궤계통기시간、ICU주원시간、주원병사솔균교상규치료조강저,차PiCCO+ HVHF조교HVHF조강저경위명현[쇠갈기관수(개):2.41±0.79비2.72±0.80,궤계통기시간(d):4.8±2.0비5.7±2.1,ICU주원시간(d):11.5±3.4비13.1±3.6,주원병사솔:31.0％(18/58)비41.8％(23/55),균P＜ 0.05].결론 HVHF능강저ARDS환자염증인자수평.PiCCO감측지도하적HVHF가이개선환자적양합급폐순응성,감소기관쇠갈,축단궤계통기시간화ICU주원시간,강저주원병사솔.
Objective To study the effects of high volume hemofiltration (HVHF) according to pulse-indicated continuous cardiac output (PiCCO) on patients with acute respiratory distress syndrome (ARDS).Methods A prospective randomly controlled trial was conducted.163 patients with ARDS admitted to Taizhou People's Hospital,Medical College,Nantong University,between February 2011 and January 2014,were enrolled.The patients were randomly divided into conventional therapy group (n＝ 50),HVHF group (n =55),and PiCCO + HVHF group (n＝58) by random number table.The patients in conventional therapy group received routine treatment including mechanical ventilation and drug treatment according to ARDS treatment guideline.The patients in the HVHF group received HVHF treatment of 18 hours per day on 1,3,5,7 days on the basis of conventional therapy.Patients in the PiCCO + HVHF group received HVHF treatment according to PiCCO.The indexes of lung function and PiCCO monitoring were recorded at intensive care unit (ICU) admission (before) and 4 days and 7 days after treatment.The serum levels of tumor necrosis factor-α (TNF-α) and interleukin-1β (IL-1β) were determined by enzyme linked immunosorbent assay (ELISA),and the prognosis of patients was recorded.Results In three groups,oxygenation index (PaO2/FiO2),static lung compliance (Cs) were gradually increased,and respiratory rate (RR),lactic acid (Lac) were gradually decreased.The indicators in HVHF and PiCCO + HVHF groups were significantly improved compared with conventional therapy group.The indexes in PiCCO + HVHF group were significantly increased or decreased compared with those in HVHF group,and the statistical differences were found on the 7th day after treatment [PaO2/FiO2 (mmHg,1 mmHg=0.133 kPa):189.3 ± 36.8 vs.166.3 ± 36.1,Cs (mL/cmH2O):76.7 ± 18.9 vs.67.0 ± 18.2,RR (times/min):16.4 ±5.2 vs.19.2 ± 5.4,Lac (mmol/L):1.20 ±0.41 vs.1.41 ±0.43,all P＜0.01].In PiCCO +HVHF group,cardiac index (CI) was gradually increased,and extra vascular lung water index (EVLWI) and intra thoracic blood volume index (ITBVI) were gradually decreased.There were significant differences in the indexes 4 days and 7 days after treatment compared with those before treatment [CI (L·min-1·m-2):4.62 ± 1.13,4.83 ± 1.10 vs.4.01 ± 1.02,EVLWI (mL/kg):7.6 ± 2.7,6.5 ± 2.6 vs.12.4 ± 2.9,ITBVI (mL/m2):801.3 ± 120.9,785.4 ± 118.7 vs.980.1 ± 168.6,all P＜0.01].After treatment,the serum levels of TNF-α and IL-1β in three groups were gradually decreased.Compared with the conventional therapy group,the serum levels of TNF-α and IL-1β on 4 days and 7 days in the HVHF and PiCCO + HVHF groups were significantly decreased,and the statistical differences were found on 7 days [TNF-α (ng/L):68.35 ± 12.63,67.54 ± 12.90 vs.85.35 ± 13.70; IL-1β (ng/L):424.6 ± 142.9,412.2 ± 140.2 vs.895.2 ± 187.7,all P＜0.01].Compared with the HVHF group,the serum levels of TNF-α and IL-1β in the PiCCO + HVHF group were slightly decreased without statistical differences.Compared with the conventional therapy group,the number of organ failure,duration of mechanical ventilation,the length of stay in ICU and hospital mortality in HVHF group and PiCCO + HVHF group were lowered,and the statistical differences were found in PiCCO + HVHF group compared with HVHF group [number of organ failure:2.41 ± 0.79 vs.2.72 ± 0.80,duration of mechanical ventilation (days):4.8 ± 2.0 vs.5.7 ± 2.1,the length of stay in ICU (days):11.5 ± 3.4 vs.13.1 ± 3.6,hospital mortality:31.0％ (18/58) vs.41.8％ (23/55),all P＜0.05].Conclusions Levels of inflammatory factors in patients with ARDS could be reduced by HVHF.The oxygenation and compliance of lung can be improved,the number of organ failure can be lowered,the duration of mechanical ventilation and the length of stay in ICU can be shortened,and the hospital mortality could be declined by PiCCO guided HVHF.
