【作者】 蔡国龙；

【导师】 方强；

【作者基本信息】 浙江大学 ， 内科学， 2005， 硕士

【摘要】 严重感染(severe sepsis)及其相关的感染性休克(septic shock)和多脏器功能失常综合症(multiple organ dysfunction syndrome MODS)是当前重症监护病房(ICU)内主要的死亡原因,也是当代危重病医学面临的主要焦点及难点。尽管早期积极的抗感染、液体复苏及相关脏器的功能支持治疗,但近年来总体死亡率仍居高不下,一般的文献报道都在50～70%左右,老年患者中,由于脏器储备功能低下,预后更差。连续肾替代治疗(CRRT)是近年来发展起来的较有希望的治疗手段,其中高容量血液滤过(High Volume Hemofiltration,HVHF)更是受到医学界的广泛关注,在近几年的动物试验中已经体现出极佳的总体效果,但在临床应用中仍存在较多的争议。因此,有必要进一步进行临床研究,以期对临床的广泛应用提供依据。本研究通过对我科22例老年感染性休克合并MODS患者进行HVHF治疗,重点探讨血流动力学及细胞因子的影响。更多还原

【Abstract】 Severe sepsis and its sequential, such as septic shock and multiple organ dysfunction (MODS),are most common cause of death in intensive care unit(ICU).Despite the development of aggressive and new strategies(adequate antibiotics、 volume resuscitation、 early goal-directed therapy 、 general supportive treatment and so on),the mortality rate remains disappointingly high(about 50-70%), especially in elderly patients. Although there is an extensive range of therapies, a potent and convincingly effective option is lacking. Extracorporeal blood purification using continuous renal replacement therapy (CRRT) is a promising septic shock treatment, the results are more charming when the hemofiltration is high volume. Some animal studies have found that high volume hemofiltration(HVHF) is a effective method to manage septic shock accompanied with MODS. However, in human studies ,the results are puzzle. The aim of present study is to evaluate the effects of high volume hemofiltration on hemodynamics and cytokines in 22 septic shock patients with MODS in the elderly from our ICU, in order to provide with more results of human study for further large well-constructed trails.Materials and MethodsStudy PopulationA prospective, interventional study was conducted in the intensive care department of zhejiang hospital. Twenty-two patients with septic shock and MODS were included in the study between October 200land December 2004, 20 patients are male, the others are female. Septic shock and MODS were defined by the criteria of ACCP/SCCM.Hemofiltration TechniqueVascular access was obtained with 14F dual lumen catheters inserted in the right internal jugular vein or in the femoral vein using percutaneous Seldinger technique. The PRISMA machine was used for HVHF cycle during 24 hours, the hemofilter is M100(AN69,hospal,France),blood flow was set at 180ml/min and hemofiltration fluid flow between 3 to 4L/h, Bicarbonate buffered hemofiltration fluid was delivered in predilution, ultrafiltration flow was depended on every patients. The average hemofiltration volume of all 22 patients was 72~94L/d(78.5±4.3), and ultrafiltration volume wasl200-1750ml/d(1430±150). Blood was anti-coagulated by means of lower molecular weight heparin(Fraxiparine),3000u for the first bonus and then 500~u per hour for further.Hemodynamic, oxygenation parameters and cytokines levelHemodynamic variables of 22 patients were measure by monitor of Hewlett Packard Model 56s and a thermodilution pulmonary artery catheter and a artery catheter, Before starting HVHF and then 1,3,6,9,12,18 and 24h after, data were recorded about heart rate(HR), mean arterial pressure(MAP), central venous pressure(CVP),cardiac index(CI),systemic vascular resistance index(SVRI). Meanwhile, the oxygenation variable was recorded about oxygenation ratio(Pao2/Fio2). The bedside nurse was instructed to maintain MAP higher than70mmHg by adjusting the dose of dopamine infusion, the dopamine dose required was averaged every 4 hours and recorded. Blood sample and ultrafiltration volume were collected for cytokines analysis(radioimmunoassay) before beginning hemofiltration and then 1,3,6,9,12,18 and 24h after, all sample were stored under 70℃ refrigeration for further examination. In additional, APACHE II (acute physiology and chronic health evaluation II) scores and MODS scores of 22 patients were recorded before and after HVHF treatment. Mortality was recorded at 28 days.The analysis was performed using the SPSS 11.5 statistical software package, A p value <0.05 was considered statistically significant.Results一、 Clinical outcomesAll septic shock with MODS elderly patients fulfilled the treatment of HVHF, the total time of HVHF process is 528 hours. No severe side effects were observed. The APACHE II scores of 22 patients was 27.27±4.94 at starting HVHF, and 25.14±5.70 after HVHF (P<0.01,95%CI 1.46-2.81) ; The MODS scores of 22 patients was 15.14±3.08 at starting HVHF, and 13.64±3.35 after HVHF (P<0.01 95%CI 1.17-1.83) . 11 patients were survival at 28 days after HVHF, the mortality was 50更多还原