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中国循证儿科杂志

中国循证儿科杂志 ›› 2021, Vol. 16 ›› Issue (3): 204-208.

• 论著 • 上一篇    下一篇

早期血液净化技术治疗儿童脓毒性休克的非随机对照试验

徐梅先, 刘刚, 曹利静, 白新凤, 康磊, 赵欣, 石晓娜, 李丽景   

  1. 河北省儿童医院重症医学科  石家庄，050000
  • 收稿日期:2021-01-11 修回日期:2021-06-25 出版日期:2021-06-25 发布日期:2021-06-25
  • 通讯作者: 徐梅先

Early continuous blood purification technology in sepsis shock children: A non-randomized controlled study

XU Meixian, LIU Gang, CAO Lijing, BAI Xinfeng, KANG Lei, ZHAO Xin, SHI Xiaona, LI Lijing   

  1. Pediatric Intensive Care Unit, HeBei Children`s Hospital, Shijiazhuang 050000, China
  • Received:2021-01-11 Revised:2021-06-25 Online:2021-06-25 Published:2021-06-25
  • Contact: XU Meixian

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摘要： 背景：脓毒性休克是儿童常见的危重症，病情进展快、病死率高。在常规支持治疗的基础上联合血液净化治疗（CBP）能否改善脓毒性休克患儿预后，尚存在争议。 目的：探讨CBP对脓毒性休克患儿的预后以及液体平衡的影响。 设计：非随机对照试验。 方法：纳入2015年5月至2020年5月河北省儿童医院PICU收治的脓毒性休克患儿（年龄1月龄至14岁），根据是否行CBP分为CBP组和非CBP组；CBP组再根据启动血液净化时间分为0~24 h亚组和~48 h亚组。CBP采用连续静脉-静脉血液滤过（CVVH）或CVVH透析（CVVHDF）模式，置换量 30~50 mL·kg-1·h-1。比较各组7 d和30 d生存率、CBP 72 h(简称72 h)的液体正平衡比例、血管活性药物评分、心率、动脉氧分压与吸氧浓度比（P/F值）、血淋巴细胞及其亚群计数绝对值、IL-6、PCT和PICU住院时间。 主要结局指标：入住PICU后的7 d生存率。 结果：CBP组64例，0~24 h亚组44例，~48 h亚组20例；非CBP组30例。CBP组与非CBP组年龄、男性比例、PRISM Ⅲ评分、有创机械通气比例、初始状态下血管活性药物评分、心率、P/F比值、血淋巴细胞及亚群计数、IL-6和PCT差异均无统计学意义。①CBP组7 d和30 d生存率（82.8%、78.1%）均高于非CBP组（70.0%、60.0%）,差异有统计学意义；②CBP组72 h液体正平衡比例 (31.2%)低于非CBP组(63.3%)，差异有统计学意义；③CBP组72 h血淋巴细胞及其亚群计数均高于非CBP组，差异有统计学意义；④72 h时血管活性药物评分、心率、P/F比值、IL-6和PCT在CBP组和非CBP组差异均无统计学意义；⑤72 h时，0~24 h亚组和~48 h亚组比较，液体正平衡比例、IL-6水平，血淋巴细胞及其亚群计数,差异均有统计学意义。 结论：CBP能够提高脓毒性休克患儿7 d和30 d的生存率，并有助于改善液体平衡，减少血管活性药物使用，促进细胞免疫抑制的解除；早期给予CBP效果更显著。

关键词: 连续性血液净化, 脓毒性休克, 液体负荷, 儿童

Abstract: Background: Sepsis，characterized by rapid progression and high mortality, is a common critical disease in PICU. It remains controversial whether the combination of routine supportive therapy and continuous blood purification (CBP) can improve the prognosis of children with septic shock. Objective: To observe the effect of CBP on the prognosis and fluid overload in sepsis shock children. Design: Non-randomized controlled study. Methods: Septic shock children at the age of one month to 14 years, admitted to PICU at HeBei Children's Hospital from May 2015 to May 2020, were enrolled. A total of 95 children were included into analysis with 64 in CBP group and 30 in non-CBP group. CVVH or CVVHDF mode was applied with fluid displacement rate of 30~50 mL·kg-1·h-1. The following indicators were compared—7-day and 30-day survival rate, fluid overload ration of CBP at 72 h, vasoactive agent score, heart rate, P/F value, amount of lymphocytes and their subtypes, IL-6, PCT and duration of hospital stay. Main outcome measures: 7-day survival rate. Results: CBP group included 64 cases with 44 cases in 0~24 h subgroup and 20 cases in 24~48 h subgroup, and non-CBP included 30 cases. There was no statistical difference in age, male percentage, PRISM Ⅲ score, ratio of invasive mechanical ventilation, as well as vasoactive agent score, heart rate, P/F value, amount of lymphocytes and their subtypes, IL-6 and PCT. The survival rates of 7-day and 30-day in CBP group (82.8%, 78.1%) were higher than those of non-CBP group (70.0%,60.0%) with P value of 0.022 and 0.038 respectively. The fluid overload ratio at 72 h was 31.2% in CBP group, lower than 63.3% in non-CBP group (P=0.003). The amount of lymphocytes and their subtype at 72 h in CBP group was higher than that of non-CBP group, with statistical differences. There were no statistical differences in vasoactive agent score, heart rate, P/F value, IL-6 and PCT between CBP group and non-CBP group. At 72 h, fluid overload ratio（P=0043）and IL-6 level（P=0.007）were lower, and the amount of lymphocytes and their subtypes was higher in 0~24 h subgroup with statistical differences. Conclusion: CBP is superior in elevating survival rate, keeping fluid balance, decreasing use of vasoactive agent, relieving immune inhibition in septic shock children, and the early use of CBP has significant efficacy.

Key words: Continuous blood purification technology, Sepsis shock, Fluid overload, Child