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中国循证儿科杂志

中国循证儿科杂志 ›› 2023, Vol. 18 ›› Issue (3): 176-181.DOI: 10.3969/j.issn.1673-5501.2023.03.002

• 论著 • 上一篇    下一篇

胸液含量预测危重患儿持续性肾脏替代治疗中容量状态的预后研究

刘雪,李凌霄,熊小雨,黄海霞,李静   

  1. 重庆医科大学附属儿童医院重症医学科，国家儿童健康与疾病临床医学研究中心，儿童发育疾病研究教育部重点实验室，儿科学重庆市重点实验室重庆，400014

  • 收稿日期:2022-06-23 修回日期:2023-01-11 出版日期:2023-06-25 发布日期:2023-06-25
  • 通讯作者: 李静

A prognostic study of thoracic fluid content in assessing volume status in critically ill children during continuous renal replacement therapy treatment

LIU Xue, LI Lingxiao, XIONG Xiaoyu, HUANG Haixia, LI Jing   

  1. Children's Hospital of Chongqing Medical University Department of Critical Care Medicine，National Clinical Research Center for Child Health and Disorders, Ministry of  Education Key Laboratory of Child Developmental and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing 400014，China

  • Received:2022-06-23 Revised:2023-01-11 Online:2023-06-25 Published:2023-06-25
  • Contact: LI Jing，Email：lijingwangyi@126.com

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摘要： 背景：胸液含量（TFC）是电子心力监测法（EC）以胸腔基础阻抗标准化导出的一项容量指标，反映血管内、血管外及胸腔组织间隙总液体含量，国内外有关危重患儿持续性肾脏替代治疗（CRRT）期间使用TFC评估容量状态的临床研究极少。 目的：TFC能否成为CRRT期间容量状态的评估指标，并指导CRRT期间的液体管理。 设计：预后研究。 方法：纳入PICU中行CRRT≥24 h的危重患儿，CRRT以颈内静脉、股静脉或锁骨下静脉双腔管为血管通路。采集基线、实验室、EC测量和临床液体状态指标，以发生血流动力学不良事件［低血压或心律失常，需行扩容治疗，正性肌力药物评分（IS）最大值（ISmax）＞IS］为结局指标，评估CRRT不同时点（开始时、24 h和结束时）容量指标［每搏输出变异（SVV）、TFC和B型钠尿肽（BNP)］与超滤量间的相关性，并评估容量指标是否可以预测结局事件的发生。 主要结局指标：血流动力学不良事件预测指标。 结果：①43例59例次CRRT数据进入本文分析。与CRRT开始相比，CRRT 24 h时TFC、Hct、Hb差异有统计学意义（P均＜0.05）；CRRT结束时与CRRT开始时相比，SVV、TFC、心肌收缩指数（ICON）、BNP、Hct、Scr、BUN、Hb、ALB差异均有统计学意义（P＜0.05）。②液体超负荷（FO）与TFC（始）、SVV（始）正相关；超滤量/体重与TFC（始）正相关，与ΔTFC（24 h）、ΔTFC（末）、TFCd0%（24 h）、TFCd0%（末）负相关；超滤速率与SVV（始）、TFC（始）、BNP（始）正相关，与ΔTFC（24 h）、ΔTFC（末）、TFCd0%（24 h）负相关；平衡量/体重与ΔTFC（24 h）、ΔTFC（末）、TFCd0%（24 h）、TFCd0%（末）、ΔBNP（末）正相关，与BNP（始）负相关。CRRT期间33例次发生了血流动力学不良事件，单因素分析显示，BNP（始）、ΔBNP（末）、超滤速率、TFCd0%（24 h）差异有统计学意义；多因素分析显示，TFCd0%（24 h）≤-3.64 kΩ-1（OR=8.84，95%CI：1.16~67.44，P=0.036）和ΔBNP（末）≤-133.8 pg·mL-1（OR=5.67，95%CI：1.24~26.03，P=0.007）更易发生血流动力学紊乱。 结论：TFC用于监测危重患儿CRRT治疗中的液体状态可行，特别是CRRT开始后24 h时TFCd0%≤-3.64 kΩ-1需警惕发生血流动力学不良事件。

关键词: 危重患儿, 持续性肾脏替代治疗, 胸液含量, 容量评估, 血流动力学不良事件

Abstract: Background：Thoracic fluid content (TFC) is a volume indicator derived from electrical cardiometry (EC) based on the standardization of thoracic basic impedance. It can reflect the total fluid content in intravascular areas, extravascular areas, and pleural tissue gaps. There are very few clinical studies using TFC to evaluate volume status during continuous renal replacement therapy (CRRT) in critically ill children at home and abroad. Objective：To identify whether TFC can be used as an assessment indicator of volume status during CRRT and guide volume management during CRRT. Design：Prognosis study. Methods：Critically ill children with CRRT ≥ 24 hours in PICU were enrolled into the study. The internal jugular vein, femoral vein or subclavian vein double lumen tube were the vascular pathway for CRRT. We collected the baseline, laboratory, EC measurements, and clinical fluid status indicators. The occurrence of hemodynamic disturbance was taken as the outcome, including hypotension or arrhythmia, requiring volume expansion treatment, and the maximum inotropic score (ISmax) greater than IS. We evaluated the correlation between stroke volume variation (SVV), TFC, and B-type natriuretic peptide (BNP) with ultrafiltration volume at different time points of CRRT(start, 24 hours and end), and investigated whether volume indicators can predict the outcome. Main outcome measures：Predictive factors for hemodynamic disturbance. Results：A total of 43 children with 59 CRRTs were included into the analysis. Compared with the beginning of CRRT, there was a statistically significant difference in TFC, Hct, and Hb at 24 hours of CRRT (P<0.05). Compared with the start of CRRT, there was a statistically significant difference in SVV, TFC, ICON, BNP, Hct, Scr, BUN, Hb, and ALB (P<0.05) at the end of CRRT. FO is significantly positively correlated with TFC and SVV at the start of CRRT. There is a significant positive correlation between ultrafiltration volume/body weight and TFC (start), and a significant negative correlation with ΔTFC(24 h), ΔTFC(end), TFCd0% (24 h) and TFCd0%(end). The ultrafiltration rate was positively correlated with SVV, TFC, BNP at the start of CRRT,and was negatively correlated with ΔTFC(24 h),ΔTFC(end), and TFCd0% (24 h). The balance/weight was positively correlated with ΔTFC(24 h),ΔTFC(end), TFCd0% (24 h), TFCd0%(end) and ΔBNP(end), and was negatively correlated with BNP (start). A total of 33 hemodynamic disturbance events occurred during CRRT. There is a statistical difference in BNP (start), ΔBNP(end), ultrafiltration rate, TFCd0% (24 h) between groups with and without adverse hemodynamic events. Multivariate analysis showed that TFCd0%（24 h）≤-3.64 kΩ-1（OR=8.84，95%CI：1.16~67.44，P=0.036）and ΔBNP(end)≤-133.8 pg·mL-1（OR=5.67，95%CI：1.24~26.03，P=0.007）were more likely to cause hemodynamic disorders. Conclusion：TFC can be used to monitor the fluid status of critically ill children during CRRT treatment. TFCd0%≤-3.64 kΩ-1 after 24 hours of CRRT can be a predictive factor for hemodynamic disturbance.

Key words: Critically ill children, Continuous renal replacement therapy, Thoracic fluid content, Volume assessment, Volume assessment