本文選題：膿毒性休克 + 急性腎損傷　； 參考：《南京醫(yī)科大學(xué)》2016年博士論文

【摘要】：第一部分膿毒性休克患者臨床分析及死亡風(fēng)險(xiǎn)評(píng)估目的:膿毒性休克(Septic shock)及其導(dǎo)致的多臟器功能障礙綜合征(Multiple organ dysfunction syndrome,MODS)是重癥患者的主要死亡原因,許多患者未能得到救治即死亡于早期危險(xiǎn)階段。本章研究對(duì)臨床數(shù)據(jù)進(jìn)行分析和整合,探索能夠評(píng)估膿毒性休克患者死亡風(fēng)險(xiǎn)的臨床指標(biāo)。方法:納入2009年1月至2014年12月198例膿毒性休克患者的臨床數(shù)據(jù)。根據(jù)患者死亡時(shí)間的分布規(guī)律,將患者分為早期死亡組(5天內(nèi)死亡)、后期死亡組(6-28天內(nèi)死亡)及生存組(28天生存)。比較三組患者一般特征、臨床和實(shí)驗(yàn)室參數(shù),分析各參數(shù)對(duì)患者死亡及死亡時(shí)間的影響;探究導(dǎo)致患者死亡的獨(dú)立危險(xiǎn)因素,由此構(gòu)建死亡風(fēng)險(xiǎn)模型,ROC曲線驗(yàn)證其適用性。結(jié)果:相比于后期死亡及生存的患者,早期死亡患者具有低收縮壓(P0.001)、低舒張壓(P0.001)、低白細(xì)胞(P=0.011)、低白蛋白(P=0.009)及顯著降低的PH值(P0.001)。28天內(nèi)死亡的患者合并急性腎損傷(Acute kidney injury,AKI)(P=0.037)、糖尿病(P=0.042)、冠心病(P=0.049)及需要機(jī)械通氣(P0.001)的百分率顯著高于生存患者。相比于生存者,28天內(nèi)死亡者在休克發(fā)生時(shí)具有低體溫(P0.001)、高呼吸頻率(P=0.010)、高尿酸(P=0.002)、延長(zhǎng)的活化部分凝血酶原時(shí)間(activatedpartial thromboplastin time,APTT)(P=0.001)、高乳酸(P0.001)及明顯升高的急性生理及慢性健康狀況評(píng)估(Acute physiology and chronic health evaluation,APACHE Ⅱ)(P0.001)和序貫性組織衰竭評(píng)估(sequential organ failure assessment,SOFA)評(píng)分(P0.001);Cox比例風(fēng)險(xiǎn)模型多因素分析發(fā)現(xiàn):血尿酸(HR=1.001,P=0.037)、PH 值(HR=0.089,P0.001)、APTT(HR=1.012,P=0.001)和血乳酸水平(HR=1.088,P=0.016)為患者死亡的獨(dú)立影響因子。聯(lián)合上述4個(gè)參數(shù)建立死亡風(fēng)險(xiǎn)模型,ROC曲線驗(yàn)證發(fā)現(xiàn):死亡風(fēng)險(xiǎn)模型曲線下面積(AUC)為0.726、敏感性76.5%、特異性59.2,優(yōu)于SOFA評(píng)分(AUC為0.671,敏感性68.6%,特異性54.1%)及APACHE Ⅱ評(píng)分(AUC為0.630,敏感性68.6%,特異性54.1%)。結(jié)論:膿毒性休克發(fā)生時(shí),出現(xiàn)明顯低血壓、低白細(xì)胞、低白蛋白血癥及迅速發(fā)生失代償性酸中毒的患者可能處于早期死亡的危險(xiǎn)階段,而明顯的低體溫、高呼吸頻率、高尿酸、APTT延長(zhǎng)、高乳酸及明顯升高的APACHEⅡ和SOFA評(píng)分提示了疾病的嚴(yán)重性;合并AKI、糖尿病、冠心病及需要機(jī)械通氣患者死亡風(fēng)險(xiǎn)較大;以血尿酸、PH值、APTT和血乳酸聯(lián)合建立風(fēng)險(xiǎn)模型對(duì)膿毒性休克患者死亡有預(yù)警作用。第二部分膿毒性休克患者腎臟替代治療及開(kāi)始時(shí)機(jī)的探索目的:比較行腎臟替代治療(Renal replacement treatment,RRT)與未行RRT患者的一般特征、臨床和實(shí)驗(yàn)室參數(shù),觀察RRT在膿毒性休克治療中的應(yīng)用現(xiàn)狀,評(píng)估RRT對(duì)預(yù)后的影響;分析行RRT死亡患者與生存患者臨床參數(shù)的差異,探討膿毒性休克患者RRT開(kāi)始時(shí)機(jī)對(duì)患者預(yù)后的影響。方法:納入第一部分中198例膿毒性休克患者,其中行RRT患者87例,未行RRT患者111例,分析兩組患者28天死亡率及死亡時(shí)間,比較其臨床和實(shí)驗(yàn)室參數(shù)的差異,Cox比例風(fēng)險(xiǎn)模型多因素校正分析RRT對(duì)預(yù)后的影響;分析行RRT的死亡患者和生存患者臨床和實(shí)驗(yàn)室參數(shù),依據(jù)有統(tǒng)計(jì)學(xué)意義的參數(shù)及AKIN分級(jí)、休克發(fā)生至RRT開(kāi)始的時(shí)間,將患者分為不同層次,分層分析患者死亡率與生存率的差別。結(jié)果:行RRT患者早期死亡率明顯低于未行RRT者(P0.001),但兩組患者28天死亡率相似(P=0.738);與未行RRT患者相比,行RRT患者更多合并AKI(P0.001)、腫瘤(P=0.038)、冠心病(P=0.021)及充血性心衰(P=0.049),更多非手術(shù)患者行RRT(P=0.005);行RRT者APACHEⅡ評(píng)分明顯高于未行RRT患者(P0.001);Cox比例風(fēng)險(xiǎn)模型多因素分析發(fā)現(xiàn)RRT是有利于患者恢復(fù)的因素(β=-1.125,HR=0.325,95%可信區(qū)間 0.182-0.580,P0.001)。分層分析顯示:隨著 PH 值的下降(r=-3.840,P0.001)及 APACHEⅡ(r=3.793,P0.001)和SOFA評(píng)分的升高(r=7.143,P0.001),死亡率呈現(xiàn)增加趨勢(shì);膿毒性休克發(fā)生后RRT開(kāi)始時(shí)間與28天死亡呈正相關(guān)(r=3.369,P=0.001);休克發(fā)生至RRT開(kāi)始時(shí)間的延遲是患者死亡的獨(dú)立危險(xiǎn)因素(β=0.540,HR=1.175,P=0.031)。結(jié)論:膿毒性休克行RRT的患者病情更加危重,RRT是有利于患者恢復(fù)的治療方法;行RRT時(shí),PH值明顯下降及APACHE Ⅱ和SOFA評(píng)分的增高的患者預(yù)后不良;休克發(fā)生后及早開(kāi)始RRT有利于患者預(yù)后的改善。第三部分腎臟替代治療的模式對(duì)膿毒性急性腎損傷預(yù)后的影響目的:膿毒性AKI治療中,連續(xù)性腎臟替代治療(Continuous renal replacement treatment,CRRT 是否優(yōu)于間歇性腎臟替代治療(Intermittent renal replacement treatment,IRRT),目前仍不清楚。我們比較了連續(xù)性靜脈靜脈血液濾過(guò)(Continuous venovenous hemofiltration,CVVHF)(連續(xù)治療超過(guò) 72 小時(shí))與每天延長(zhǎng)的血液濾過(guò)(Extended daily hemofiltration,EDHF)(每天治療8-12小時(shí))對(duì)膿毒性AKI患者腎功能恢復(fù)和死亡率的影響。方法:回顧性分析145例2009年4月-2013年5月接受RRT膿毒性AKI患者。患者采用CVVHF或EDHF模式治療,統(tǒng)一使用聚砜膜透析器及碳酸氫鹽置換液。判斷預(yù)后的終點(diǎn)事件為28天腎功能恢復(fù)率及死亡率。結(jié)果:65例患者采用CVVHF治療,80例患者采用EDHF治療。CVVHF組的患者腎功能恢復(fù)率顯著增加(CVVHF組:50.77%,EDHF組:32.50%,P= 0.026)。CVWHF組患者平均腎功能恢復(fù)時(shí)間為17.26天,EDHF組患者平均腎功能恢復(fù)時(shí)間為25.46天(P=0.039)。CVVHF組和EDHF組28天死亡率相似,分別是44.62%和46.25%(P=0.844)。55.38%CVVHF和28.75%EDHF組的患者RRT中發(fā)生低磷血癥(P=0.001)。其它相關(guān)RRT的并發(fā)癥在兩組間無(wú)差異。包含臨床各相關(guān)變量的多因素分析發(fā)現(xiàn),CVVHF治療是有利于腎功能恢復(fù)的獨(dú)立影響因素(HR=3.81,95%可信區(qū)間為1.90-7.62,P0.001),但CVVHF治療不是死亡的影響因素(HR=0.81,95%可信區(qū)間為0.30-1.81,P= 0.312)。結(jié)論:CVVHF治療的患者腎功能恢復(fù)率明顯增加,CVVHF及EDHF治療的患者28天死亡率相似。
[Abstract]:The first part of the patients with septic shock and clinical analysis of death risk assessment objective: septic shock (Septic shock) and multiple organ dysfunction syndrome (MODS Multiple organ dysfunction syndrome) is a major cause of death in critically ill patients, many patients can get treatment and death in the early stage. This chapter studies the risk analysis and the integration of clinical data, to explore the clinical evaluation index the risk of death in patients with septic shock. Methods: the clinical data from January 2009 to December 2014 in 198 cases of patients with septic shock. According to the distribution of the time of death of patients, the patients were divided into early death group (died within 5 days), the late death group (died within 6-28 days) and survival group (28 days survival). Compared three groups of patients with general characteristics, clinical and laboratory parameters, analysis of parameters related to mortality and death time; inquiry Independent risk factors of causing death, thus constructing death risk model, ROC curve to verify its applicability. Results: compared to the late death and survival in patients with early death in patients with low systolic blood pressure (P0.001), low diastolic blood pressure (P0.001), low white blood cell (P=0.011), albumin (P=0.009) and low pH significantly reduced (P0.001) acute renal injury and death of patients within.28 days (Acute kidney injury, AKI) (P=0.037) (P=0.042), diabetes mellitus, coronary heart disease (P=0.049) and mechanical ventilation (P0.001) was significantly higher than that of survival. Compared to the survivor, died within 28 days with low temperature in the shock (P0.001), high frequency (P=0.010), uric acid (P=0.002), activated partial thromboplastin time prolonged (activatedpartial thromboplastin time, APTT) (P=0.001), lactic acid (P0.001) and acute physiology and chronic health increased significantly Situation assessment (Acute physiology and chronic health evaluation, APACHE II) (P0.001) and sequential organization (sequential organ failure assessment failure assessment score (P0.001), SOFA); Cox multivariate analysis showed that serum uric acid (HR=1.001, P= 0.037), pH value (HR=0.089, P0.001, APTT (HR=1.012). P=0.001) and blood lactate levels (HR=1.088, P=0.016) were independent influential factor. The death of patients with combined with the above 4 parameters set up death risk model, ROC curve proved: area under the curve of death risk model (AUC) was 0.726, the sensitivity of 76.5%, specificity of 59.2, better than the SOFA score (AUC = 0.671, the sensitivity was 68.6%. 54.1% specificity) and APACHE score (AUC = 0.630, sensitivity 68.6%, specificity 54.1%). Conclusion: septic shock occurs obvious hypotension, low white blood cells, hypoalbuminemia and rapid decompensation acidosis patients Who may be at risk of early death stage, and low temperature, high frequency, high uric acid, APTT prolonged, high lactic acid and significantly increased APACHE and SOFA II score indicates the severity of the disease; combined with AKI, diabetes, coronary heart disease and the need for mechanical ventilation in patients with death risk to blood uric acid, pH value; APTT, and blood lactate and establish the risk model have effect on the prediction of death in patients with septic shock. Second patients with septic shock and renal replacement therapy to explore Objective: To compare the timing of renal replacement treatment (Renal replacement treatment, RRT) and the general characteristics of non RRT patients, the clinical and laboratory parameters, application of observation RRT in the treatment of septic shock in the RRT impact assessment on the prognosis of RRT patients; analysis of differences between death and survival in patients with clinical parameters of patients with septic shock, RRT start time on patients Effect of prognosis. Methods: in the first part of 198 cases of patients with septic shock, 87 patients with RRT, 111 patients without RRT, analysis of two groups of patients with 28 day mortality and death time difference between the clinical and laboratory parameters, analysis of RRT effect on the prognosis in multivariate Cox proportional hazard model correction; analysis of death and survival in patients with clinical and laboratory parameters for RRT, based on the parameters and AKIN grading were statistically significant, RRT to the starting time of shock, the patients were divided into different levels, stratified analysis between patients with mortality and survival. Results: early mortality in patients with RRT was significantly lower than that of RRT who (P0.001), but the two groups were similar to the 28 day mortality rate (P=0.738); compared with non RRT patients, RRT patients with AKI (P0.001), more tumor (P=0.038) and coronary heart disease (P=0.021) and congestive heart failure (P=0.049), more than hand For patients with RRT (P=0.005); RRT APACHE score was significantly higher than that in non RRT patients (P0.001); Cox multivariate analysis showed that RRT is beneficial to the recovery of the patients factors (beta =-1.125, HR=0.325,95% CI 0.182-0.580, P0.001). The stratified analysis showed that as the pH value decreased (r=-3.840. P0.001) and APACHE II (r=3.793, P0.001) increased and SOFA scores (r=7.143, P0.001), the mortality rate increased; septic shock occurred after the beginning time of RRT was positively correlated with the death of 28 days (r=3.369, P=0.001); shock occurred delayed to the beginning time of RRT are independent risk factors of death in patients with beta (=0.540, HR=1.175, P=0.031). Conclusion: septic shock for RRT patients with more severe RRT, is conducive to the treatment of patients with recovery; for RRT, the pH value decreased significantly and APACHE II and SOFA score increased in patients with poor prognosis; shock After an early start RRT is conducive to improve the prognosis of the patients. The third part: the effect of renal replacement therapy on prognosis of septic acute kidney injury Objective: septic AKI therapy, continuous renal replacement therapy (Continuous renal replacement treatment, CRRT is superior to intermittent renal replacement therapy (Intermittent renal replacement treatment, IRRT). It is still not clear. We compared the continuous veno venous hemofiltration (Continuous venovenous hemofiltration, (CVVHF) for more than 72 hours a day) and prolonged hemofiltration (Extended daily hemofiltration, (EDHF) for 8-12 hours a day) on renal function in patients with AKI septic recovery and mortality. Methods: a retrospective review analysis of 145 cases of septic AKI patients receiving RRT April 2009 -2013 year in May. Patients with CVVHF or EDHF mode of treatment, uniform use of Polysulfone Dialyzer and bicarbonate replacement fluid. End point events prognosis 28 days for recovery of renal function and mortality. Results: 65 cases were treated by CVVHF, the rate of recovery was significantly increased in patients with renal function in 80 patients treated by EDHF.CVVHF group (group CVVHF 50.77%, group EDHF: 32.50%, P= 0.026) the average renal function.CVWHF group of patients recovered for 17.26 days, the average recovery time of renal function in EDHF patients was 25.46 days (P=0.039) of.CVVHF group and EDHF group in the 28 day mortality was similar, were 44.62% and 46.25% (P=0.844) of hypophosphatemia.55.38%CVVHF and 28.75%EDHF patients in group RRT (P=0.001). Other related RRT without complications the difference between the two groups. The clinical variables including multiple factors analysis showed that CVVHF treatment is independent factors conducive to the recovery of renal function (HR=3.81,95% CI 1.90-7.62, P0.001), but CVVHF treatment is not death The influencing factors (HR=0.81,95% confidence interval 0.30-1.81, P= 0.312). Conclusion: the recovery rate of renal function of CVVHF patients is significantly increased, and the 28 day mortality rate of CVVHF and EDHF patients is similar.

【學(xué)位授予單位】：南京醫(yī)科大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2016
【分類號(hào)】：R459.7

【相似文獻(xiàn)】

相關(guān)期刊論文 前10條

1 丁國(guó)治;;可治療膿毒性休克的新方法[J];國(guó)外醫(yī)學(xué)情報(bào);2003年05期

2 郭建秀;胡川閩;;巨噬細(xì)胞移動(dòng)抑制因子在膿毒性休克及其治療中的作用[J];醫(yī)學(xué)研究生學(xué)報(bào);2006年08期

3 吳建濃;雷澍;方強(qiáng);;中分子羥乙基淀粉對(duì)膿毒性休克病人胃粘膜灌注的影響[J];江西醫(yī)藥;2006年08期

4 何志捷;林小鴻;黃子通;;長(zhǎng)托寧在膿毒性休克治療中的應(yīng)用研究[J];嶺南急診醫(yī)學(xué)雜志;2006年06期

5 陶紅蕾;胡振快;劉敬臣;;精氨酸血管加壓素在膿毒性休克治療中的研究進(jìn)展[J];內(nèi)科;2007年01期

6 高偉士;;膿毒性休克[J];國(guó)外醫(yī)學(xué)(流行病學(xué)傳染病學(xué)分冊(cè));1980年02期

7 Schumer W;何亮家;;休克研究中的爭(zhēng)論:膿毒性休克時(shí)類固醇的作用[J];國(guó)外醫(yī)學(xué).創(chuàng)傷與外科基本問(wèn)題分冊(cè);1982年04期

8 劉樂(lè)欣;;膿毒性休克治療的現(xiàn)代概念[J];國(guó)外醫(yī)學(xué).外科學(xué)分冊(cè);1983年03期

9 Richard H C;邱守義;;膿毒性休克時(shí)心臟功能障礙[J];黑龍江醫(yī)藥科學(xué);1986年04期

10 徐增祥;;女性生殖道感染并發(fā)膿毒性休克的救治[J];人民軍醫(yī);1989年06期

相關(guān)會(huì)議論文 前10條

1 王晨;王昌明;張楚明;;膿毒性休克大量晶體液復(fù)蘇與腹腔間隔室綜合征的關(guān)系[A];2009年浙江省危重病學(xué)學(xué)術(shù)年會(huì)論文匯編[C];2009年

2 吳建濃;;中分子羥乙基淀粉(130/0.4)對(duì)膿毒性休克病人胃黏膜灌注的影響[A];第三屆重癥醫(yī)學(xué)大會(huì)論文匯編[C];2009年

3 林錫芳;;膿毒性休克的治療進(jìn)展[A];2006年浙江省危重病學(xué)學(xué)術(shù)年會(huì)論文匯編[C];2006年

4 李濤;魏捷;;亞低溫對(duì)豬膿毒性休克時(shí)心肌的影響[A];中華醫(yī)學(xué)會(huì)急診醫(yī)學(xué)分會(huì)第十三次全國(guó)急診醫(yī)學(xué)學(xué)術(shù)年會(huì)大會(huì)論文集[C];2010年

5 單紅衛(wèi);楊興易;景炳文;陳學(xué)云;;大鼠膿毒性休克時(shí)心、肝、腎組織能量代謝的變化[A];中華醫(yī)學(xué)會(huì)急診醫(yī)學(xué)學(xué)會(huì)第六次全國(guó)急診醫(yī)學(xué)學(xué)術(shù)會(huì)議論文匯編[C];1996年

6 吳建濃;;膿毒性休克復(fù)蘇的液體選擇[A];2005年浙江省危重病學(xué)學(xué)術(shù)年會(huì)論文匯編[C];2005年

7 吳建濃;雷澍;方強(qiáng);;中分子羥乙基淀粉(130/0．4)對(duì)膿毒性休克病人胃粘膜灌注的影響[A];2007年浙江省危重病學(xué)學(xué)術(shù)年會(huì)論文匯編[C];2007年

8 陳培服;;胸腔內(nèi)血容量指數(shù)在膿毒性休克診治中的應(yīng)用[A];首屆西湖重癥醫(yī)學(xué)論壇暨2011年浙江省重癥醫(yī)學(xué)學(xué)術(shù)年會(huì)論文匯編[C];2011年

9 董娟;施劍;;小劑量激素治療膿毒性休克的體會(huì)[A];中華醫(yī)學(xué)會(huì)第五次全國(guó)重癥醫(yī)學(xué)大會(huì)論文匯編[C];2011年

10 胡馬洪;許秀娟;孟建標(biāo);賴志珍;李玉花;季春蓮;陳揚(yáng);波張庚;;早期連續(xù)血液濾過(guò)對(duì)膿毒性休克肺循環(huán)通透性的影響[A];重癥醫(yī)學(xué)十年回顧與展望——2012年浙江省重癥醫(yī)學(xué)學(xué)術(shù)年會(huì)論文匯編[C];2012年

相關(guān)重要報(bào)紙文章 前4條

1 張獻(xiàn)懷;我國(guó)學(xué)者揭示膿毒性休克發(fā)病機(jī)理[N];中國(guó)醫(yī)藥報(bào);2003年

2 楊駿;治療膿毒性休克的新探索[N];中國(guó)醫(yī)藥報(bào);2003年

3 駐京記者 賈巖;治療膿毒性休克,時(shí)間是關(guān)鍵[N];醫(yī)藥經(jīng)濟(jì)報(bào);2011年

4 記者賈曉慧 通訊員張獻(xiàn)懷;生物喋呤/新喋呤是殺手[N];科技日?qǐng)?bào);2003年

相關(guān)博士學(xué)位論文 前2條

1 肖旭東;特利加壓素對(duì)膿毒性休克血管低反應(yīng)的治療作用及血管低反應(yīng)的年齡性別差異[D];第三軍醫(yī)大學(xué);2014年

2 孫治平;膿毒性休克患者死亡風(fēng)險(xiǎn)評(píng)估及腎臟替代治療的探索[D];南京醫(yī)科大學(xué);2016年

相關(guān)碩士學(xué)位論文 前10條

1 王龍廷;C-反應(yīng)蛋白/白蛋白與膿毒性休克患者長(zhǎng)期預(yù)后的研究[D];山西醫(yī)科大學(xué);2015年

2 朱娛;IMD1-53對(duì)膿毒性休克大鼠心臟功能的保護(hù)作用及機(jī)制[D];第三軍醫(yī)大學(xué);2015年

3 趙靜靜;膿毒性休克患者早期血紅細(xì)胞分布寬度變化的特點(diǎn)及其臨床意義[D];天津醫(yī)科大學(xué);2015年

4 周小洋;左心室—?jiǎng)用}失耦聯(lián)對(duì)老年膿毒性休克患者臨床預(yù)后的影響[D];浙江中醫(yī)藥大學(xué);2016年

5 陳容欣;動(dòng)—靜脈二氧化碳分壓差測(cè)定在小兒膿毒性休克中的意義[D];上海交通大學(xué);2015年

6 孫小鴿;血清C反應(yīng)蛋白/白蛋白比值對(duì)膿毒性休克患者的預(yù)后評(píng)價(jià)[D];鄭州大學(xué);2016年

7 高言國(guó);不同血管活性藥對(duì)膿毒性休克患者血流動(dòng)力學(xué)的影響[D];大連醫(yī)科大學(xué);2010年

8 吳建濃;中分子羥乙基淀粉（130/0.4）對(duì)膿毒性休克病人組織灌注的研究[D];浙江大學(xué);2005年

9 朱濤;膿毒性休克病人臨床指標(biāo)與預(yù)后的相關(guān)性分析[D];浙江大學(xué);2005年

10 何盛琴;血液灌流聯(lián)合血液濾過(guò)治療膿毒性休克的療效及治療機(jī)制研究[D];第三軍醫(yī)大學(xué);2011年

，

本文編號(hào)：1762023