连续肾替代治疗对心脏术后多器官功能障碍患者的救治

1、连续肾替代治疗对心脏术后多器官功能障碍患者的救治               作者：崔勤,赵荣,金振晓,张胜利,郑霄,张赤铭 【关键词】  连续肾替代治疗    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： 探讨连续肾替代治疗(CRRT)对体外循环手术后多器官功能障碍综合征(MODS)伴急性肾功能衰竭(ARF)患者的救治作用. 方法：体外循环手术后MODS伴ARF患者27例，在血管活性药物维持循环条件下，均采用BM 25连续性

8、血液净化系统，M60滤器(AN69膜)进行前稀释连续性静脉静脉血液滤过(CVVH)，透析液参考季大玺等配方，低分子肝素抗凝，血流速度200250 mL/ min，置换液流速25100 mL/min,24 h总置换液量(39±10) L，平均治疗时间(52±13) h,所有患者在治疗前以及CRRT后的每日晨06:00外周静脉采血，检查肌肝(Cr), 尿素氮(Bun), 碳酸氢根(HCO3-)及血清钾离子(K+)，动脉采血，检查pH值及HCO3-，当患者尿量达到0.5 mL/(kgh)时，停止CRRT. 结果：27例患者肾功能恢复26例，2脏器衰竭存活7例（7/11），3脏器衰

9、竭存活3例（3/10），4脏器以上衰竭存活1例（1/6），存活率40%. 结论：CRRT对MODS伴ARF患者病情有较好地控制作用，能明显提高该类患者的生存率.【关键词】 连续肾替代治疗；多器官功能障碍综合征；急性肾功能不全；治疗0引言多器官功能障碍综合征(multiorgan dysfunction syndrome, MODS)伴急性肾功能衰竭（acute renal failure, ARF）致患者的病死率一直居高不下，合并3脏器衰竭死亡率在85%以上1-5，治疗也趋于复杂. 我科自1999年开展连续肾替代治疗(continuous renal replacement therapy,

10、CRRT)技术以来，成功地救治了11例（11/27）体外循环术后 MODS伴ARF的患者，效果良好.1对象和方法1.1对象199901/200402，体外循环术后MODS伴ARF的危重患者27例(男14，女13)例，年龄669(40±12)岁，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的诊断标准见文献6.1.2方法经颈内静脉置管，全部病例采用BM 25连续性血液净化系统，M60滤器(AN69膜)进行前稀释连续性静脉静脉血液滤过(continuous venousvenous hemofiltration, CVVH)，透析液参考季大玺等7配方，床旁即

11、配即用碳酸氢盐溶液，低分子肝素抗凝，根据患者病情决定血流速度，一般在200250 mL/min，置换液流速25100 mL/min,24 h总置换液量(39±10) L，平均治疗时间(52±13) h，肝素或低分子肝素抗凝，个别患者无抗凝. 治疗期间所有患者均行心电、呼吸、有创压、中心静脉压、血氧饱和度、体温及尿量等监测，并且在治疗前以及CRRT后的每日晨06:00外周静脉采血，查肌酐清除率（Cr）,尿素氮（Bun）,血清钾离子（K+），动脉采血，检查pH值及碳酸氢根（HCO3-）. 当患者尿量达到0.5 mL/（kgh）时，停止CRRT.统计学处理：所得数据全部输入SPSS统计处理程序，进行OneWay ANOVA单因素方差分析.2结果27例患者肾功能恢复26例，11例存活，存活率40%，其中2脏器衰竭7（7/11）例，3脏器衰竭3（3/10）例，4脏器以上衰竭存活1（1/6）例. CRR