【摘要】 目的通过严重多发伤并发症的治疗,探究持续肾脏替代治疗(CRRT)适应证及治疗经验,进一步提高救治水平。方法 2017年11月—2018年10月镇江市第一人民医院创伤中心收治37例严重多发伤患者,其中男性29例,女性8例;年龄3～81岁,平均47.7岁;损伤部位2～5处,平均3.8处;ISS评分17～66分,平均42.5分。出现不同创伤后并发症:创伤性急性重症胰腺炎1例,急性肾衰(ARF)4例,急性呼吸窘迫综合征(ARDS)7例,肺栓塞2例,失血性休克13例,挤压综合征2例,脓毒症5例,均病因+综合支持治疗;其中3例难治性ARF、脓毒症休克和ARDS加以CRRT,回顾其治疗过程,总结治疗效果。结果 37例患者死亡2例,死因均为重度失血性休克,35例存活;大多数并发症经病因+综合支持治疗治愈。而3例难治性并发症加以CRRT后:肾功能及自主尿量恢复,治疗前、治疗后3d肌酐、尿素氮及自主尿量均值分别为569.67μmol/L vs. 107.12μmol/L、22.17mmol/L vs. 8.77mmol/L、93.33mL/d vs. 1 003.33mL/d;感染控制及炎性指标下降,停用血管活性药物,治疗前、治疗后5d降钙素原、白细胞数及CRP均值分别为12.67μg/L vs. 1.35μg/L、21.22×10~9/L vs. 9.22×10~9/L、135.22mg/L vs. 17.22mg/L;ARDS氧合改善成功撤机,治疗前、治疗后3d血氧分压及氧合指数均值分别为47.72mmHg vs. 87.22mmHg、83.27mmHg vs. 322.77mmHg;治疗过程中未出现CRRT使用并发症,难治性ARF、脓毒症休克和ARDS临床治愈。结论 CRRT对机体生理要求和扰乱少,具有清除毒素、炎性介质,控制全身炎症反应综合征(SIRS),减轻肺水肿等优势,是严重多发伤脏器功能不全和感染并发症的有力治疗措施。更多还原

【Abstract】 Objective To explore the indications and treatment experience of continuous renal replacement therapy(CRRT) in patients with refractory complications after severe multiple trauma.Methods From Nov.2017 to Oct.2018,37 severe multiple trauma patients in the Emergency Medical Center and Trauma Center,Zhenjiang First People’s Hospital,were enrolled in this study,including 29 males and 8 females,aged 3 to 81 years(mean 47.7 years).Patients had 2 to 5 injured sites,with an average of 3.8.The ISS score was 17 to 66 points,with an average of 42.5 points.There were different post-traumatic complications: 1 case of traumatic acute severe pancreatitis,4 cases of acute renal failure(ARF),7 cases of acute respiratory distress syndrome(ARDS),2 cases of pulmonary embolism,13 cases of hemorrhagic shock,2 cases of crush syndrome,and 5 cases of sepsis.Most of patients were cured,except 3 cases of refractory ARF,septic shock and ARDS were treated with CRRT additionally.Results Two of the 37 patients died of severe hemorrhagic shock and 35 survived.Most complications were cured by etiology and comprehensive treatment.Three refractory complications were treated with CRRT additionally, renal function and autonomic urine volume were restored.The mean values of creatinine,urea nitrogen and autonomic urine volume before and 3 days after treatment were 569.67 μmol/L vs.107.12 μmol/L,22.17 mmol/L vs.8.77 mmol/L,and 93.33 mL/d vs.1003.33 mL/d,respectively; Infection control and inflammatory markers decreased,and vasoactive drugs discontinued,the mean values of procalcitonin,white blood cell count and CRP before and after treatment were 12.67μg/L vs.1.35μg/L,21.22×10~9/L vs.9.22×10~9/L,and 135.22 mg/L vs.17.22 mg/L,respectively; ARDS oxygenation improved and the ventilator was successfully removed,the mean blood oxygen partial pressure and oxygenation index before and 3 days after treatment were 47.72 mmHg vs.87.22 mmHg,83.27 mmHg vs.322.77 mmHg.There was no CRRT complication during the treatment.Refractory acute renal failure,septic shock and ARDS were clinically cured.Conclusion Because of fewer physiological requirements and disturbances,and the advantages such as removing toxins and inflammatory mediators,controlling SIRS,and alleviating pulmonary edema,CRRT is a powerful treatment for severe multiple traumatic organ dysfunction and infection complications.更多还原