2021 年第 7 期 第 16 卷

连续性肾脏替代治疗联合低分子肝素应用于创伤性凝血病合并急性呼吸窘迫综合征患者的临床效果

Clinical effect of continuous renal replacement therapy combined with low molecular weight heparin on patients with trauma-induced coagulopathy complicated with acute respiratory distress syndrome

作者：易亚辉谭曦舒易辉宾卫星徐燕

英文作者：Yi Yahui Tan Xishu Yi Hui Bin Weixing Xu Yan

单位：长沙医学院附属株洲医院湖南省株洲市人民医院重症医学科412000

英文单位：Department of Intensive Care Unit Zhuzhou Hospital Affiliated to Changsha Medical University Zhuzhou People′s Hospital Hunan Prorince Zhuzhou 412000 China

关键词：创伤性凝血病；急性呼吸窘迫综合征；连续性肾脏替代治疗；低分子肝素

英文关键词：Trauma-inducedcoagulopathy;Acuterespiratorydistresssyndrome;Continuousrenalreplacementtherapy;Lowmolecularweightheparin

• 摘要：

• 目的 探讨连续性肾脏替代治疗（CRRT）联合低分子肝素应用于创伤性凝血病（TIC）合并急性呼吸窘迫综合征（ARDS）患者的临床效果。方法 选取2016年6月至2019年6月长沙医学院附属株洲医院收治的171例TIC合并ARDS患者作为研究对象。应用随机数字表法分为对照组、CRRT组和联合组，对照组给予常规综合治疗，CRRT组在常规综合治疗基础上给予CRRT，联合组在常规综合治疗基础上给予CRRT联合低分子肝素治疗。比较3组治疗前后血清炎症因子水平、氧合指数，14 d病死率和出血发生率以及存活患者治疗前后急性生理学与慢性健康状况评分系统Ⅱ（APACHE Ⅱ）评分、机械通气时间，比较CRRT组和联合组滤器使用时间。结果 治疗24、48、72 h后，3组血清白细胞介素6、肿瘤坏死因子α、C反应蛋白、降钙素原水平均低于本组治疗前且各时点之间逐渐降低，氧合指数均高于本组治疗前且各时点之间逐渐升高（均P＜0.05）。CRRT组和联合组各血清炎症因子水平均低于对照组同时点且联合组均低于CRRT组，氧合指数均高于对照组同时点且联合组均高于CRRT组（均P＜0.05）。联合组的14 d病死率低于对照组［16.9%(10/59)比37.5%（21/56）］，但出血发生率高于对照组和CRRT组［25.4%(15/59)比1.8%（1/56）、3.6%（2/56）］，滤器使用时间长于CRRT组［（11.0±2.4）h比（6.3±2.3）h］（均P＜0.05）。治疗3、7、10 d后，3组存活患者APACHE Ⅱ评分均低于本组治疗前，且各时点之间逐渐降低（均P＜0.05）。CRRT组和联合组APACHE Ⅱ评分均低于对照组同时点，且联合组均低于CRRT组（均P＜0.05）。CRRT组和联合组机械通气时间均短于对照组［(13.6±1.9)、(10.1±2.1)d比（15.6±2.0）d］，且联合组短于CRRT组（均P＜0.05）。结论 CRRT联合低分子肝素治疗可明显降低TIC合并ARDS患者血清炎症因子水平、APACHE Ⅱ评分和14 d病死率，升高氧合指数，缩短机械通气时间，但治疗过程中增加并发出血的风险。

• Objective To analyze the clinical effect of continuous renal replacement therapy (CRRT) combined with low molecular weight heparin on patients with trauma-induced coagulopathy (TIC) complicated with acute respiratory distress syndrome (ARDS). Methods From June 2016 to June 2019, 171 patients with TIC complicated with ARDS admitted to Zhuzhou Hospital Affiliated to Changsha Medical University were enrolled. Patients were randomly divided into control group, CRRT group and combined group. The control group was given conventional comprehensive treatment, the CRRT group was given CRRT on the basis of conventional comprehensive treatment, and the combined group was given CRRT combined with low molecular weight heparin on the basis of conventional comprehensive treatment. Serum levels of inflammatory factors and oxygenation index before and after treatment, 14 d mortality, concurrent bleeding rate, and acute physiology and chronic health evaluation scoring system Ⅱ (APACHE Ⅱ) score before and after treatment and mechanical ventilation time in surviving patients were compared among the three groups. The filter using time was compared between CRRT group and conbined group. Results After 24, 48 and 72 h of treatment, the serum levels of interleukin-6, tumor necrosis factor-α, C-reactive protein and procalcitonin in the three groups were lower than those before treatment and gradually decreased at each time point, and the oxygenation indexes in the three groups were higher than those before treatment and gradually increased at each time point (all P＜0.05). The levels of serum inflammatory factors in CRRT group and combined group were lower than those in control group at the same time points, and those in combined group were lower than those in CRRT group; the oxygenation indexes in CRRT group and combined group were higher than those in control group at the same time points, and those in combined group were higher than those in CRRT group (all P＜0.05). The 14 d mortality in combined group was lower than that in control group ［16.9%(10/59) vs 37.5% (21/56)］, but the rate of concurrent bleeding in combined group was higher than that in control group and CRRT group ［25.4%(15/59) vs 1.8%（1/56）, 3.6%（2/56）］, and the filter using time in combined group was longer than that in CRRT group ［(11.0±2.4)h vs (6.3±2.3)h］(all P＜0.05). At 3, 7, 10 d after treatment, APACHE Ⅱ scores of surviving patients in three groups were lower than those before treatment, and gradually reduced at each point (all P＜0.05). APACHE Ⅱ scores in CRRT group and combined group were lower than those in control group at the same time points, and those in combined group were lower than those in CRRT group (all P＜0.05). The mechanical ventilation time in CRRT group and combined group was shorter than that in control group ［(13.6±1.9), (10.1±2.1)d vs (15.6±2.0)d］, and that in combined group was shorter than that in CRRT group (all P＜0.05). Conclusion CRRT combined with low molecular weight heparin can obviously reduce serum levels of inflammatory factors, APACHE Ⅱ score and 14 d mortality in patients with TIC complicated with ARDS, increase oxygenation index, and shorten mechanical ventilation time, but increase the risk of concurrent bleeding during treatment.