连续性血液净化在地震致挤压综合征伴多器官功能障碍综合征救治中的应用
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摘要
目的:急性肾功能衰竭是挤压综合征最常见的严重并发症,本文报道了连续性血液净化(CBP)辅助治疗3例挤压综合征伴多器官功能障碍综合征患者获得成功的救治过程。方法:3例患者均在20080512中国四川省汶川大地震中受伤,分别在受伤后11、11和18天时被送到我院。患者受压的时间分别为5.5、22.5和28h,均合并少尿性急性肾功能衰竭,在当地均接受了输液、清创、筋膜切开和肾脏替代治疗。转来我院时,例1和例2仍持续无尿,血肌红蛋白分别为765和829ng/ml;例3已进入多尿期(早期即行CBP治疗),血肌红蛋白正常。来院后患者均给予扩大清创、清除坏死肌肉组织、引流、换药和抗感染等治疗,并给予连续性高容量血液滤过治疗(置换量4000ml/h),采用枸橼酸置换液或联合低分子量肝素抗凝,AV600滤器(聚砜膜,面积1.6m2),开始为持续24h不间断,在病情稳定后改为日间间歇性治疗8～12h/d治疗,连续监测中心静脉压(CVP)以调控容量状况。同时给予输注全血、红细胞悬液以提升Hb,新鲜冰冻血浆以补充胶体;予胰岛素泵控制血糖;大剂量促红细胞生成素、虫草制剂促进肾小管修复,并给予肠内营养支持治疗。结果:治疗过程中患者血流动力学稳定,无出血等与抗凝剂相关的并发症,患者体温和WBC趋于正常,Hb、血浆白蛋白回升。血、尿肌红蛋白、磷酸肌酸激酶均恢复正常。在少尿期分别持续20和22天后,例1和例2尿量逐渐增多,肾功能逐渐恢复,且未出现明显的多尿期;例3(少尿期仅10天)则在经历16天多尿期后尿量逐渐恢复正常。3例患者的肾小管功能亦基本恢复正常。在设定置换量4L/h和2L/h的条件下,计算对肌红蛋白的清除率分别为9.5ml/min和5.9ml/min。3例患者伤口均愈合良好,无一例需要截肢。结论:CBP可有效辅助治疗挤压综合征多器官功能障碍综合征患者,保持容量平衡、清除肌红蛋白、避免出血并发症和感染是保证CBP成功治疗挤压综合征的关键。
Objective:To evaluate the effectiveness of continuous blood purification (CBP) in three crush syndrome patients related to the earthquake. Methodology:Three victims from Wenchuan earthquake on May 12,2008 in the Southwest China were admitted to our hospital 11,11 and 18 days after their injuries. The duration to salvage was 5.5,22.5 and 28 hrs respectively. All of them were diagnosed as oliguric ARF,vigorous treatment in the local hospital including aggressive fluid infusion,fasciotomy and hemodialysis in the first 2 cases and CBP in the third patients. On admission,the first two cases were still oliguric,and had the high level of serum myoglobin (765 and 829 ng/ml); the third was in the polyuric stage (who had received CBP in the local hospital with polyuria of 5 000~9 000 ml/d),and the serum myoglobin was normal. Further debridement and drainage was performed. Continuous high volume hemofiltration (CHVHF) was conducted in all of patients,the replacement fluid rate was 4 L/h,citrate or combined with low molecular weight heparin was used for anticoagulation,and central venous pressure (CVP) was monitored to keep volume equilibrium. The blood and fresh frozen plasma were transfused. Erythropoietin and Cordyceps sinensis Sacc was used to promote regeneration of tubular epithelial cells,and enteral nutrition formula was administered. Results:CBP was well tolerated in all of patients,and the hemodynamic status was stable. No complication related with CBP and anticoagulation was noted. The body temperature and WBC decreased to normal gradually,anemia and hypoalbuminia was corrected. The levels of serum myoglobin and creatine phosphokinase were also decreased to normal range. The urine volume of the first two cases increased to normal after 20 and 22 days of oliguria,and it decreased to normal in the third after 16 days of polyuria. The tubular function recovered well in all of cases. The clearance of myoglobin during HVHF was 9.5 ml/min with the replacement fluid rate of 4 L/h and 5.9 ml/min with 2 L/h. All of patients were recuperated. None of them was performed amputation. Conclusion:CBP was effective in the treatment of crush syndrome related with earthquake. Fluid equilibrium,clearance of myoglobin,avoidance of bleeding and infection were fundamental during CBP.
Objective:To evaluate the effectiveness of continuous blood purification (CBP) in three crush syndrome patients related to the earthquake. Methodology:Three victims from Wenchuan earthquake on May 12,2008 in the Southwest China were admitted to our hospital 11,11 and 18 days after their injuries. The duration to salvage was 5.5,22.5 and 28 hrs respectively. All of them were diagnosed as oliguric ARF,vigorous treatment in the local hospital including aggressive fluid infusion,fasciotomy and hemodialysis in the first 2 cases and CBP in the third patients. On admission,the first two cases were still oliguric,and had the high level of serum myoglobin (765 and 829 ng/ml); the third was in the polyuric stage (who had received CBP in the local hospital with polyuria of 5 000~9 000 ml/d),and the serum myoglobin was normal. Further debridement and drainage was performed. Continuous high volume hemofiltration (CHVHF) was conducted in all of patients,the replacement fluid rate was 4 L/h,citrate or combined with low molecular weight heparin was used for anticoagulation,and central venous pressure (CVP) was monitored to keep volume equilibrium. The blood and fresh frozen plasma were transfused. Erythropoietin and Cordyceps sinensis Sacc was used to promote regeneration of tubular epithelial cells,and enteral nutrition formula was administered. Results:CBP was well tolerated in all of patients,and the hemodynamic status was stable. No complication related with CBP and anticoagulation was noted. The body temperature and WBC decreased to normal gradually,anemia and hypoalbuminia was corrected. The levels of serum myoglobin and creatine phosphokinase were also decreased to normal range. The urine volume of the first two cases increased to normal after 20 and 22 days of oliguria,and it decreased to normal in the third after 16 days of polyuria. The tubular function recovered well in all of cases. The clearance of myoglobin during HVHF was 9.5 ml/min with the replacement fluid rate of 4 L/h and 5.9 ml/min with 2 L/h. All of patients were recuperated. None of them was performed amputation. Conclusion:CBP was effective in the treatment of crush syndrome related with earthquake. Fluid equilibrium,clearance of myoglobin,avoidance of bleeding and infection were fundamental during CBP.
引文
1 KantarciG,Vanholder R,Tuglular S,etal.Acute renal failure due to crush syndrome duringMarmara earthquake.Am J Kidney Dis,2002,40:682-689.
2 Vanholder R,Sever MS,Erek E,etal.Acute renal failure related to the crush syndrome:towards an era of seismo-mephrology?Nephrol DialTransplant,2000,15:1517-1521.
3 Berns JS,Cohen RM,Rudnick MR.Removal of myoglobin by CAVH-D in traumatic rhabdomyolysis(letter).Am J Nephro,l1991,11:73.
4 Smith J,Greaves I.Crush injury and crush syndrome:a review.J Trauma,2003,54(Suppl):S226-230.
5 Erek E,SeverMS,SerdengectiK,et al.An overview ofmorbidity andmortality in patients with acute renal failure due to crush syn-drome:the Marmara earth quake experience.Nephrol Dial Trans-plant,2002,17:33-40.
6 SeverMS,VanholderR,Lamieire N.Management of crush-related injuries after disasters.N Engl JMed,2006,354:1052-1063.
7 GonzalezD.Crush syndrome.CritCareMed,2005,33(Suppl):S34-S41.
8 SeverMS,Erek E,VanholderR,etal.Renal replacement therapies in the aftermath of the catastrophicMarmara earthquake.Kidney Int,2002,62:2264-2271.
9 GongD,JiD,Xu B,et al.Regional citrate anticoagulation in criti-cally ill patients during continuous blood purification.Chin Med J(Engl),2003,116:360-363.
10Ronco C.Extracorporeal therapies in acute rhabdomyolysisand myo-globin clearance.CritCare,2005,9:141-142.
11Naka T,Jones D,Baldwin I,et al.Myoglobin clearance by super high-flux hemofiltration in a case of severerhabdomyolysis:a case re-port.CirtCare,2005,9:R90-R95.
12黎磊石,刘志红.连续性血液净化:一种协助重建机体免疫内稳状态的技术?肾脏病与透析肾移植杂志,2003,12:1.
13刘志红,苏健.见:黎磊石,季大玺主编.连续性血液净化.第1版.南京:东南大学出版社,2004,15-30.
2 Vanholder R,Sever MS,Erek E,etal.Acute renal failure related to the crush syndrome:towards an era of seismo-mephrology?Nephrol DialTransplant,2000,15:1517-1521.
3 Berns JS,Cohen RM,Rudnick MR.Removal of myoglobin by CAVH-D in traumatic rhabdomyolysis(letter).Am J Nephro,l1991,11:73.
4 Smith J,Greaves I.Crush injury and crush syndrome:a review.J Trauma,2003,54(Suppl):S226-230.
5 Erek E,SeverMS,SerdengectiK,et al.An overview ofmorbidity andmortality in patients with acute renal failure due to crush syn-drome:the Marmara earth quake experience.Nephrol Dial Trans-plant,2002,17:33-40.
6 SeverMS,VanholderR,Lamieire N.Management of crush-related injuries after disasters.N Engl JMed,2006,354:1052-1063.
7 GonzalezD.Crush syndrome.CritCareMed,2005,33(Suppl):S34-S41.
8 SeverMS,Erek E,VanholderR,etal.Renal replacement therapies in the aftermath of the catastrophicMarmara earthquake.Kidney Int,2002,62:2264-2271.
9 GongD,JiD,Xu B,et al.Regional citrate anticoagulation in criti-cally ill patients during continuous blood purification.Chin Med J(Engl),2003,116:360-363.
10Ronco C.Extracorporeal therapies in acute rhabdomyolysisand myo-globin clearance.CritCare,2005,9:141-142.
11Naka T,Jones D,Baldwin I,et al.Myoglobin clearance by super high-flux hemofiltration in a case of severerhabdomyolysis:a case re-port.CirtCare,2005,9:R90-R95.
12黎磊石,刘志红.连续性血液净化:一种协助重建机体免疫内稳状态的技术?肾脏病与透析肾移植杂志,2003,12:1.
13刘志红,苏健.见:黎磊石,季大玺主编.连续性血液净化.第1版.南京:东南大学出版社,2004,15-30.
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