本文選題：膿毒癥 + 急性腎損傷　； 參考：《河北醫(yī)科大學(xué)》2013年碩士論文

【摘要】：目的：由于到目前為止關(guān)于CRRT的治療劑量尚未有統(tǒng)一的標(biāo)準(zhǔn)，并且關(guān)于CRRT治療劑量與預(yù)后的關(guān)系并未達(dá)成共識。本研究采用處方廢液劑量相同的方法直接檢測溶質(zhì)清除率，比較處方廢液劑量、校正劑量、交付劑量和實(shí)際溶質(zhì)清除劑量之間的關(guān)系，從而為膿毒癥AKI患者的CRRT治療劑量提供參考依據(jù)。 方法：選取河北醫(yī)科大學(xué)第四醫(yī)院ICU在2012年1月至2013年2月收治的采用CRRT治療的膿毒癥AKI患者23例，隨機(jī)分為兩組，CVVH組14例，CVVHDF組9例。兩組患者性別、體重、年齡、APACHE II評分、SOFA評分以及各溶質(zhì)（肌酐、β2-微球蛋白、白介素-6、白介素-8）水平均無統(tǒng)計(jì)學(xué)意義（p＞0.05）。隨機(jī)分組兩組處方廢液劑量相同，均為40ml/kg/h，并都采用100%前稀釋，其中CVVHDF組置換液與透析液流速為1:1，根據(jù)患者的出血風(fēng)險、血小板計(jì)數(shù)以及APTT選擇抗凝方式及劑量。采集開始CRRT治療時，以及每次濾器下機(jī)時的動脈端血標(biāo)本和廢液各3ml，所有標(biāo)本以3000r/min轉(zhuǎn)速離心10min后取上清液于-80℃超低溫保存箱凍存待檢，血漿及廢液的肌酐水平采用化學(xué)法進(jìn)行檢測，β2-微球蛋白、白介素-6、白介素-8的水平均采用液相平衡競爭放射免疫分析法（RIA）進(jìn)行檢測。處方廢液劑量為上機(jī)時的廢液量；校正劑量為校正前稀釋置換液之后的劑量；交付劑量為24小時內(nèi)實(shí)際廢液量并校正前稀釋置換液之后的劑量；實(shí)際溶質(zhì)清除劑量為直接檢測各溶質(zhì)（肌酐、β2-微球蛋白、白介素-6、白介素-8溶質(zhì))在濾器動脈端以及廢液中的濃度比值與24小時內(nèi)的實(shí)際廢液量的劑量。比較處方廢液劑量，校正劑量，交付劑量以及實(shí)際溶質(zhì)清除劑量之間的相互關(guān)系。比較兩組患者的28天死亡率、總住院時間、住ICU時間、CRRT治療時間、機(jī)械通氣時間。 結(jié)果： 1對于小分子溶質(zhì)（肌酐）的清除率 CVVH和CVVHDF兩組各自的實(shí)際溶質(zhì)清除劑量、交付劑量，校正劑量均明顯少于處方廢液劑量，，比較有統(tǒng)計(jì)學(xué)差異（p0.001）；兩組各自的交付劑量也均少于校正劑量和處方廢液劑量，比較有統(tǒng)計(jì)學(xué)差異（p0.001），兩組各自的校正劑量均少于處方廢液劑量。在CVVH組中實(shí)際溶質(zhì)清除劑量較處方廢液劑量、校正劑量和交付劑量相比分別下降40.3%、20.0%和12.2%；在CVVHDF組中分別下降為33.3%、22.3%和15.0%。CVVHDF組與CVVH組相比較，對小分子溶質(zhì)（肌酐）的實(shí)際溶質(zhì)清除劑量更高，且有統(tǒng)計(jì)學(xué)意義（p0.001）。 2對于中大分子溶質(zhì)（β2-微球蛋白，白介素-6，白介素-8）的實(shí)際溶質(zhì)清除劑量 CVVH和CVVHDF兩組各自均能有效的清除β2微球蛋白、白介素-6、白介素-8，并且各自對不同溶質(zhì)的實(shí)際溶質(zhì)清除劑量（β2-微球蛋白，白介素-6，白介素-8）均有明顯差異（p0.001）； CVVH組與CVVHDF組相比較，對中大分子溶質(zhì)的清除效果更明顯，具有明顯差異（p0.001）。 3抗凝方案，濾器的使用時間，治療轉(zhuǎn)歸及并發(fā)癥 CVVH組與CVVHDF組比較兩組采用抗凝方案及濾器的使用時間無明顯差異（p＞0.05）。兩組患者的28天死亡率、總住院時間、住ICU時間、CRRT治療時間、機(jī)械通氣時間均無明顯差異（p＞0.05）。肝素誘導(dǎo)的低血小板血癥的發(fā)生率無明顯差異p＞0.05）。CVVH組與CVVHDF組都能清除炎性因子（IL-6，IL-8），兩組相比較有統(tǒng)計(jì)學(xué)差異（p0.001），但相比28天死亡率無明顯差異，兩者相比無統(tǒng)計(jì)學(xué)差異（p＞0.05）。 結(jié)論： 1處方廢液劑量相同時，CVVH組與CVVHDF組兩者對于小分子溶質(zhì)（肌酐）的實(shí)際溶質(zhì)清除劑量均被高估，即處方廢液劑量、校正劑量、交付劑量均明顯高于實(shí)際溶質(zhì)清除劑量。 2處方廢液劑量相同時，CVVH組與CVVHDF組兩者各自對不同溶質(zhì)的實(shí)際溶質(zhì)清除劑量（β2-微球蛋白，白介素-6，白介素-8）均不同，對于分子量大于20000的中大分子而言，清除效果兩組均明顯下降。CVVHDF組清除小分子溶質(zhì)（肌酐）優(yōu)于CVVH組。CVVH組清除中大分子溶質(zhì)（β2-微球蛋白，白介素-6，白介素-8）優(yōu)于CVVHDF組，因此在以清除中大分子溶質(zhì)為目的時應(yīng)優(yōu)先選用CVVH。 3處方廢液劑量相同時， CVVH組與CVVHDF組均能有效地除炎性介質(zhì)（IL-6，IL-8）,兩組患者的28天死亡率無明顯差異，CVVH組較CVVHDF組并不能改善生存率。
[Abstract]:Objective: since there is no unified standard for the treatment dose of CRRT so far, and there is no consensus on the relationship between the dose of CRRT treatment and the prognosis. This study uses the same dosage of the prescription waste liquid to direct the test of the solute clearance rate, compared the dosage of the prescription waste liquid, the correction dose, the delivery dose and the actual solute clearance dose. Therefore, it can provide reference for CRRT treatment dose of AKI patients with sepsis.
Methods: 23 cases of septic AKI patients treated with CRRT in the fourth hospital of Hebei Medical University from January 2012 to February 2013 were randomly divided into two groups, 14 cases in group CVVH, 9 in group CVVHDF. The two groups were sex, weight, age, APACHE II score, SOFA score, and each of the solutes (creatinine, beta 2- microglobulin, IL -6, IL -8) There was no statistical significance (P > 0.05). The dosage of two groups of prescription waste liquid was the same, all of which were 40ml/kg/h, and all of them were diluted before 100%. The flow rate of the replacement solution and dialysate in group CVVHDF was 1:1, according to the risk of bleeding, platelet count, and APTT selection anticoagulant formula and dosage. The arterial end blood samples and the waste liquid were 3ml, and all the specimens were frozen at -80 centigrade cryopreservation box after 3000r/min rotational speed centrifuging 10min. The creatinine levels of plasma and waste liquid were detected by chemical method. The level of beta 2- microglobulin, interleukin -6 and interleukin -8 were measured by liquid phase equilibrium competitive radioimmunoassay (R). IA) test. The dosage of the prescription waste liquid is the amount of waste liquid on the machine; the corrected dose is the dose after the correction of the diluent replacement fluid; the dosage is 24 hours and the dose of the former dilute replacement fluid is corrected; the actual solute clearance dose is the direct detection of the solute (creatinine, beta 2- microglobulin, interleukin -6, interleukin -) 8 solute concentration ratio in the end of the filter artery and the waste liquid and the dose of the actual waste liquid within 24 hours. Compare the relationship between the dosage of the prescription waste liquid, the corrected dose, the delivery dose and the actual solute clearance dose. The 28 day mortality rate, the total hospitalization time, the ICU time, the CRRT treatment time, the mechanical ventilation and the mechanical ventilation of the two groups of patients were compared. Room.
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本文編號：1936480