連續(xù)腎替代治療對(duì)心臟術(shù)后多器官功能障礙患者的救治

1、連續(xù)腎替代治療對(duì)心臟術(shù)后多器官功能障礙患者的救治               作者：崔勤,趙榮,金振曉,張勝利,鄭霄,張赤銘 【關(guān)鍵詞】  連續(xù)腎替代治療    Treatment on post cardiac surgery patients with multiorgan dysfunction by continuous renal replacement therapy (CRRT)【Abstract】 A

2、IM: To investigate the effectiveness of continuous renal replacement therapy (CRRT) in post cardiopulmonary bypass (CPB) patients with multiorgan dysfunction syndrome (MODS) and acute renal failure (ARF). METHODS:  The circulation stability of twentyseven post CPB patients with MODS and ARF was

3、 maintained with vascular active drugs and BM25 continuous blood purification system and M60 filter (AN69 membrane) were used to perform the predilution continuous venousvenous hemofiltration (CVVH). The dialysis solution was the same as literature. The low molecular mass heparin was used for antico

4、agulation. Blood flow was about 200-250 mL/min and the dialysis solution flow rate was 25-100 mL/min for a need of (39±10) L dialysis solution for 24 h therapy. The average therapy time was (52±13) h. Peripheral venous blood samples were collected before therapy and at 6:00 a.m. everyday a

5、fter CRRT to detect the serum Cr, Bun, HCO3- and K+. Arterial blood samples were collected to detect the serum pH and HCO3-. The CRRT was stopped when the urine volume of the patient reached 0.5 mL/（kgh）. RESULTS:  Twentysix of the 27 patients recovered their normal renal functions. Seven of th

6、e 11 patients with twoorgan failure and 3 the 10 patients with threeorgan failure survived the therapy. Only one of the 6 patients with 4 or more organs failure survived. The overall survival rate was 40%. CONCLUSION:  CRRT has a relatively good effect on the treatment of patients with MODS and

7、 ARF and can significantly increase the survival rate of these patients.【Keywords】 continuous renal replacement therapy； multiorgan dysfunction syndrome；acute renal failure；therapy【摘要】 目的： 探討連續(xù)腎替代治療(CRRT)對(duì)體外循環(huán)手術(shù)后多器官功能障礙綜合征(MODS)伴急性腎功能衰竭(ARF)患者的救治作用. 方法：體外循環(huán)手術(shù)后MODS伴ARF患者27例，在血管活性藥物維持循環(huán)條件下，均采用BM 25連續(xù)性

8、血液凈化系統(tǒng)，M60濾器(AN69膜)進(jìn)行前稀釋連續(xù)性靜脈靜脈血液濾過(guò)(CVVH)，透析液參考季大璽等配方，低分子肝素抗凝，血流速度200250 mL/ min，置換液流速25100 mL/min,24 h總置換液量(39±10) L，平均治療時(shí)間(52±13) h,所有患者在治療前以及CRRT后的每日晨06:00外周靜脈采血，檢查肌肝(Cr), 尿素氮(Bun), 碳酸氫根(HCO3-)及血清鉀離子(K+)，動(dòng)脈采血，檢查pH值及HCO3-，當(dāng)患者尿量達(dá)到0.5 mL/(kgh)時(shí)，停止CRRT. 結(jié)果：27例患者腎功能恢復(fù)26例，2臟器衰竭存活7例（7/11），3臟器衰

9、竭存活3例（3/10），4臟器以上衰竭存活1例（1/6），存活率40%. 結(jié)論：CRRT對(duì)MODS伴ARF患者病情有較好地控制作用，能明顯提高該類(lèi)患者的生存率.【關(guān)鍵詞】 連續(xù)腎替代治療；多器官功能障礙綜合征；急性腎功能不全；治療0引言多器官功能障礙綜合征(multiorgan dysfunction syndrome, MODS)伴急性腎功能衰竭（acute renal failure, ARF）致患者的病死率一直居高不下，合并3臟器衰竭死亡率在85%以上1-5，治療也趨于復(fù)雜. 我科自1999年開(kāi)展連續(xù)腎替代治療(continuous renal replacement therapy,

10、CRRT)技術(shù)以來(lái)，成功地救治了11例（11/27）體外循環(huán)術(shù)后 MODS伴ARF的患者，效果良好.1對(duì)象和方法1.1對(duì)象199901/200402，體外循環(huán)術(shù)后MODS伴ARF的危重患者27例(男14，女13)例，年齡669(40±12)歲，其中2器官衰竭者11例，3器官衰竭者10例，4器官以上衰竭者6例. MODS的診斷標(biāo)準(zhǔn)見(jiàn)文獻(xiàn)6.1.2方法經(jīng)頸內(nèi)靜脈置管，全部病例采用BM 25連續(xù)性血液凈化系統(tǒng)，M60濾器(AN69膜)進(jìn)行前稀釋連續(xù)性靜脈靜脈血液濾過(guò)(continuous venousvenous hemofiltration, CVVH)，透析液參考季大璽等7配方，床旁即

11、配即用碳酸氫鹽溶液，低分子肝素抗凝，根據(jù)患者病情決定血流速度，一般在200250 mL/min，置換液流速25100 mL/min,24 h總置換液量(39±10) L，平均治療時(shí)間(52±13) h，肝素或低分子肝素抗凝，個(gè)別患者無(wú)抗凝. 治療期間所有患者均行心電、呼吸、有創(chuàng)壓、中心靜脈壓、血氧飽和度、體溫及尿量等監(jiān)測(cè)，并且在治療前以及CRRT后的每日晨06:00外周靜脈采血，查肌酐清除率（Cr）,尿素氮（Bun）,血清鉀離子（K+），動(dòng)脈采血，檢查pH值及碳酸氫根（HCO3-）. 當(dāng)患者尿量達(dá)到0.5 mL/（kgh）時(shí)，停止CRRT.統(tǒng)計(jì)學(xué)處理：所得數(shù)據(jù)全部輸入SPSS統(tǒng)計(jì)處理程序，進(jìn)行OneWay ANOVA單因素方差分析.2結(jié)果27例患者腎功能恢復(fù)26例，11例存活，存活率40%，其中2臟器衰竭7（7/11）例，3臟器衰竭3（3/10）例，4臟器以上衰竭存活1（1/6）例. CRR