血液灌流和连续性肾脏替代治疗对百草枯中毒并发MODS患者的应用评价

doi:10.3969/j.issn.1004-583X.2023.04.007

摘要/Abstract

摘要：

目的探讨血液灌流(HP)和连续性肾脏替代治疗(CRRT)对百草枯中毒并发多器官功能障碍综合征(MODS)患者的疗效。方法回顾性分析2019年1月至2022年1月诊治的急性百草枯中毒并发MODS患者56例,其中HP治疗者27例,HP+CRRT治疗者29例,比较两组治疗前后肝肾功能、血气分析、MODS评分和APACHE II评分,Kaplan-Meier生存分析比较不同治疗方法的生存率。结果两组治疗前血液生化和血气分析参数、MODS和序贯性器官功能衰竭评分(sequential organ failure assessment,SOFA)比较差异无统计学意义(P>0.05),治疗后两组丙氨酸氨基转移酶(alanine aminotransferase,ALT)、天冬氨酸氨基转移酶(aspartate aminotransferase,AST)、血尿素氮(blood urea nitrogen,BUN)、血肌酐(serum creatinine,Scr)、凝血酶原时间(prothrombin time,PT)、凝血酶原活性(prothrombin activity,PA)、总胆红素(total bilirubin,TBil)、直接胆红素(direct bilirubin,DBil)、肌酸激酶同工酶(creatine kinase isoenzymes,CKMB)、二氧化碳分压(partial pressure of carbon dioxide,PaCO₂)、肺泡动脉氧分压差[P(A-a)O₂]、MODS和SOFA评分均低于治疗前,pH值、氧分压(partial pressure of oxygen,PaO₂)、碳酸氢根( $HCO 3 -$ )和氧合指数(PaO₂/FiO₂,P/F)均高于治疗前,且HP+CRRT组改善较HP组更为明显(均P<0.05)。56例患者总死亡率为44.64%,HP组总死亡率高于HP+CRRT组,生存曲线显示HP+CRRT组存活率更高(P<0.05)。结论 HP联合CRRT可减轻器官损害,降低百草枯并发MODS患者的死亡率,是一种有效的治疗方法。

关键词: 连续性肾替代疗法, 血液灌流, 百草枯中毒, 多器官功能障碍综合征

Abstract:

Objective To investigate the efficacy of hemoperfusion (HP) and continuous renal replacement therapy (CRRT) in paraquat (PQ) poisoning patients complicated with multiple organ dysfunction syndrome (MODS). Methods A total of 56 acute PQ poisoning patients complicated with MODS who received treatment from January 2019 to January 2022 were enrolled and retrospectively analyzed, including 27 patients treated with HP and 29 patients treated with HP+CRRT. The liver and kidney function, blood gas analysis, MODS score and Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ) score before and after treatment were compared between the two groups. Kaplan Meier survival analysis was used to compare the survival rates of different treatment methods. Results There was no significant difference in blood biochemistry, blood gas analysis parameters, MODS and sequential organ failure assessment (SOFA) scores between the two groups before treatment (P>0.05). After treatment, alanine aminotransferase (ALT), aspartate aminotransferase (AST), blood urea nitrogen (BUN), serum creatinine (Scr), prothrombin time (PT), prothrombin activity (PA), total bilirubin (TBil) Direct bilirubin (DBil), creatine kinase isoenzymes (CKMB), partial pressure of carbon dioxide (PaCO₂), alveolar arterial oxygen pressure difference (P (A-a) O₂), MODS and SOFA scores in the two groups were significantly lower than those before treatment (P<0.05). However, PH value, partial pressure of oxygen (PaO₂), bicarbonate ( $HCO 3 -$ ) and oxygenation index (PaO₂/FiO₂, P/F) were higher than those before treatment, and HP+CRRT group improved more significantly than HP group (P<0.05). The total mortality rate of 56 patients was 44.64%, which was higher in HP group than HP+CRRT group. Meanwhile, the survival curve showed that the survival rate of HP+CRRT group was obviously higher (P<0.05). Conclusion The combination of HP and CRRT can alleviate organ damage and reduce the mortality of PQ patients with MODS, making it an effective treatment therapy.

Key words: continuous renal replacement therapy, hemoperfusion, paraquat poisoning, multiple organ dysfunction syndrome

中图分类号:

R459.5

陶阳, 潘清泉, 李岩. 血液灌流和连续性肾脏替代治疗对百草枯中毒并发MODS患者的应用评价[J]. 临床荟萃, 2023, 38(4): 330-334.

Tao Yang, Pan Qingquan, Li Yan. Evaluation of hemoperfusion and continuous renal replacement therapy in paraquat poisoning patients complicated with MODS[J]. Clinical Focus, 2023, 38(4): 330-334.

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链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2023.04.007

https://huicui.hebmu.edu.cn/CN/Y2023/V38/I4/330

图/表 6

表1 两组一般临床资料比较

Tab. 1 Comparison of general clinical data between the two groups

变量	HP(n=27)	HP+CRRT(n=29)	t/χ²值	P值
年龄(岁)	35.41±12.33	36.72±13.23	0.383	0.704
男/女	15/12	12/17	1.125	0.289
入院时间(h)	7.35±3.64	7.82±4.74	0.414	0.681
呼吸衰竭[例(%)]	18(66.67)	19(65.52)	0.008	0.928
心力衰竭[例(%)]	13(48.15)	12(41.38)	0.259	0.611
急性胰腺炎[例(%)]	8(29.63)	7(24.14)	0.215	0.643
急性肝损伤[例(%)]	10(37.04)	12(41.38)	0.111	0.740
急性肾损伤[例(%)]	12(44.44)	14(48.28)	0.083	0.774
凝血功能障碍[例(%)]	3(11.11)	2(6.90)	0.305	0.580
横纹肌溶解[例(%)]	7(25.93)	9(31.03)	0.179	0.672
百草枯浓度(ng/ml)	1657.91±723.38	1629.37±714.51	0.148	0.883
中毒至就诊时间(h)	1.95±0.83	1.82±0.88	0.568	0.573
首次洗胃时间(h)	2.56±1.34	2.82±1.47	0.690	0.493
首次HP/CRRT/HP+CRRT时间(h)	15.67±2.38	15.72±1.45	0.096	0.924
HP/HP+CRRT治疗次数	8.37±1.46	6.15±1.79	5.063	<0.001
住院时间(d)	15.43±4.71	15.52±4.78	0.071	0.944

表2 两组肝肾功能指标比较($\bar{x} \pm s$)

Tab. 2 Comparison of liver and kidney function indexes between the two groups ($\bar{x} \pm s$)

组别	例数	ALT(U/L)				AST(U/L)				BUN(U/L)				Scr(U/L)				PT(s)
组别	例数	治疗前		治疗后		治疗前		治疗后		治疗前		治疗后		治疗前		治疗后		治疗前		治疗后
HP	27	267.31±131.46		181.74±72.34^*		248.63±75.58		171.46±73.41^*		23.52±6.59		13.53±6.62^*		374.24±133.26		280.31±134.34^*		17.63±5.23		15.42±3.78^*
HP+CRRT	29	264.63±128.46		99.34±53.76^*		253.51±80.45		90.54±34.26^*		23.56±5.17		7.31±3.11^*		379.56±118.46		127.43±74.17^*		17.79±4.45		13.39±2.27^*
t值		0.077		4.861		0.233		5.346		0.025		4.551		0.158		5.321		0.124		2.456
P值		0.939		<0.001		0.817		<0.001		0.980		<0.001		0.875		<0.001		0.902		0.017
组别	TBil(mmol/L)				DBil(mmol/L)				IBil(mmol/L)				CKMB(U/L)				PA(%)
组别	治疗前		治疗后		治疗前		治疗后		治疗前		治疗后		治疗前		治疗后		治疗前		治疗后
HP	58.65±24.56		39.59±12.35^*		37.41±13.32		25.65±12.52^*		12.64±5.47		12.88±5.35		18.57±7.41		16.46±6.23^*		62.15±12.41		70.48±12.24^*
HP+CRRT	57.53±33.82		28.45±10.63^*		36.67±12.34		15.65±8.35^*		12.36±6.12		12.65±6.47		18.64±8.27		13.48±3.53^*		61.41±10.71		81.12±11.49^*
t值	0.141		3.625		0.216		3.539		0.180		0.144		0.033		2.222		0.239		3.355
P值	0.888		0.001		0.830		0.001		0.858		0.886		0.974		0.030		0.812		0.001

表3 两组呼吸功能指标比较($\bar{x} \pm s$)

Tab. 3 Comparison of respiratory function indexes between the two groups ($\bar{x} \pm s$)

组别	例数		pH值(mmHg)				PaO₂(mmHg)				PaCO₂(mmHg)
组别	例数		治疗前		治疗后		治疗前		治疗后		治疗前	治疗后
HP	27		7.21±0.16		7.32±0.13^*		90.58±11.32		112.42±30.41^*		46.02±13.99	38.32±11.75^*
HP+CRRT	29		7.24±0.15		7.44±0.17^*		90.14±10.42		131.64±31.32^*		45.82±11.94	31.50±10.84^*
t值			0.724		2.951		0.151		2.327		0.058	2.259
P值			0.472		0.005		0.880		0.024		0.954	0.028
组别		$HCO 3 -$ (mmol/L)				P/F(mmHg)				P(A-a)O₂(mmHg)
组别		治疗前		治疗后		治疗前		治疗后		治疗前		治疗后
HP		17.19±3.14		20.51±2.99^*		76.27±24.61		310.56±95.39^*		348.53±64.89		261.93±38.77^*
HP+CRRT		18.45±3.93		24.72±2.26^*		75.39±22.85		382.41±97.64^*		337.81±67.33		183.21±36.75^*
t值		0.272		5.970		0.139		2.782		0.606		7.800
P值		0.786		<0.001		0.890		0.007		0.547		<0.001

表3 两组呼吸功能指标比较($\bar{x} \pm s$)

Tab. 3 Comparison of respiratory function indexes between the two groups ($\bar{x} \pm s$)

组别	例数		pH值(mmHg)				PaO₂(mmHg)				PaCO₂(mmHg)
组别	例数		治疗前		治疗后		治疗前		治疗后		治疗前	治疗后
HP	27		7.21±0.16		7.32±0.13^*		90.58±11.32		112.42±30.41^*		46.02±13.99	38.32±11.75^*
HP+CRRT	29		7.24±0.15		7.44±0.17^*		90.14±10.42		131.64±31.32^*		45.82±11.94	31.50±10.84^*
t值			0.724		2.951		0.151		2.327		0.058	2.259
P值			0.472		0.005		0.880		0.024		0.954	0.028
组别		$HCO 3 -$ (mmol/L)				P/F(mmHg)				P(A-a)O₂(mmHg)
组别		治疗前		治疗后		治疗前		治疗后		治疗前		治疗后
HP		17.19±3.14		20.51±2.99^*		76.27±24.61		310.56±95.39^*		348.53±64.89		261.93±38.77^*
HP+CRRT		18.45±3.93		24.72±2.26^*		75.39±22.85		382.41±97.64^*		337.81±67.33		183.21±36.75^*
t值		0.272		5.970		0.139		2.782		0.606		7.800
P值		0.786		<0.001		0.890		0.007		0.547		<0.001

表4 两组MODS和SOFA评分比较($\bar{x} \pm s$)

Tab. 4 Comparison of MODS scores and SOFA scores between the two groups ($\bar{x} \pm s$)

组别	例数	MODS评分(分)		SOFA评分
组别	例数	治疗前	治疗后	治疗前	治疗后
HP	27	5.19±2.40	3.14±1.53^*	14.31±3.29	11.58±2.97^*
HP+CRRT	29	5.47±2.52	2.15±0.92^*	14.61±4.67	8.23±1.84^*
t值		0.425	2.958	0.276	5.029
P值		0.672	0.005	0.784	<0.001

表5 两组死亡时间和死亡率比较[例(%)]

Tab. 5 Comparison of death time and mortality between the two groups [cases (%)]

组别	例数	死亡率
组别	例数	10天	10~30天	合计
HP	27	7(25.93)	9(33.33)	16(59.26)
HP+CRRT	29	1(3.45)	8(27.59)	9(31.03)
χ²值		5.769	0.218	4.507
P值		0.016	0.640	0.034

图1 两组生存曲线比较

Fig. 1 Comparison of survival curve between the two groups

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