连续性血液净化治疗新生儿脓毒性休克伴急性肾损伤临床分析

doi:10.12372/jcp.2023.22e1459

摘要/Abstract

摘要：

目的分析床旁连续性血液净化（CBP）技术治疗新生儿脓毒性休克伴急性肾损伤（AKI）的临床指标变化。方法回顾性分析2015年1月至2022年5月新生儿重症监护病房接受CBP治疗的脓毒性休克伴AKI患儿的临床资料。结果纳入脓毒性休克伴AKI新生儿15例。死亡8例，病死率53.3%。其中男10例，早产儿5例，入院日龄1.0（1.0~6.0）d，出生胎龄38.0（34.0~41.0）周，出生体重3 100.0（2 850.0~3 250.0）g，AKI分期2（2~3）期。所有患儿均需机械通气呼吸支持及使用血管活性药物，正性肌力药物评分（VIS）110.0（64.0~320.0）分。CBP治疗24 h和治疗结束组平均动脉压（MAP）高于治疗前组，尿量多于治疗前组，血清肌酐和尿素氮低于治疗前组，差异均有统计学意义（P<0.05）。最常见CBP相关不良事件为血小板减少症（45.5%）。单因素分析未发现CBP死亡相关危险因素（P>0.05）。结论床旁CBP可以及时维持脓毒性休克伴AKI新生儿的血流动力学稳定，纠正休克，明显改善肾功能，安全性好。

关键词: 连续性血液净化, 脓毒症, 急性肾损伤, 新生儿

Abstract:

Objective To analyze the clinical indicators of continuous blood purification (CBP) in the treatment of neonatal septic shock with acute kidney injury (AKI). Methods The clinical data of neonates with septic shock and AKI treated with CBP in the neonatal intensive care unit from January 2015 to May 2022 were retrospectively analyzed. Results Fifteen neonates with septic shock and AKI were included in this study, and eight patients died with a mortality rate of 53.3%. Among them, 10 were boys and 5 were premature infants. The age of admission was 1.0 (1.0-6.0) days, the gestational age was 38.0 (34.0-41.0) weeks, the birth weight was 3100.0 (2850.0-3250.0) grams, and the AKI stage was 2 (2-3). All children needed mechanical ventilation and vasoactive drugs. The vasoactive inotropic score (VIS) was 110.0 (64.0-320.0). The mean arterial pressure (MAP) and urine output of the CBP treatment group at 24 hours and at the end of treatment were higher than that of the pre-treatment group, and the serum creatinine and urea nitrogen were lower than that of the pre-treatment group, the difference was statistically significant (P<0.05).The commonest CBP related adverse event was thrombocytopenia (45.5%). Univariate analysis showed that no risk factors for death related to CBP were found (P>0.05). Conclusions Bedside CBP can timely maintain hemodynamic stability in neonates with septic shock and AKI, correct shock, and significantly improve the renal function. It has good security.

Key words: continuous blood purification, sepsis, acute kidney injury, neonate

许景林, 杨汉松, 陈新华, 陈江滨, 李晓庆, 张伟峰, 陈冬梅. 连续性血液净化治疗新生儿脓毒性休克伴急性肾损伤临床分析[J]. 临床儿科杂志, 2023, 41(6): 436-441.

XU Jinglin, YANG Hansong, CHEN Xinhua, CHEN Jiangbin, LI Xiaoqing, ZHANG Weifeng, CHEN Dongmei. Clinical analysis of continuous blood purification in the treatment of neonatal septic shock with acute kidney injury[J]. Journal of Clinical Pediatrics, 2023, 41(6): 436-441.

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参考文献 23

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时间点	MAP/mmHg	VIS评分	pH值	血乳酸/mg·dL^-1
治疗前	37.0(32.0~44.0)	91.0(61.0~253.0)	7.2(7.1~7.2)	142.8(99.1~184.9)
治疗12 h	54.0(38.0~55.0)	100.0(10.0~420.0)	7.2(7.2~7.4)	70.7(40.6~184.2)
治疗24 h	65.0(55.0~67.0)¹⁾	74.0(8.0~175.0)	7.3(7.2~7.4)	81.2(22.2~159.9)
治疗结束	61.0(57.0~68.0)¹⁾	7.0(5.0~9.0)	7.4(7.3~7.4)	32.9(8.4~57.7)
H值	10.01	0.95	7.27	5.87
P	0.019	0.814	0.064	0.118

时间点	尿量/mL·kg^-1·h^-1	血清肌酐/μmol·L^-1	尿素氮/mmol·L^-1	血钾/mmol·L^-1	血钠/mmol·L^-1
治疗前	0.28(0.00~0.57)	92.1(68.4~165.1)	7.5(5.1~15.4)	4.7(4.1~6.0)	131.7(127.2~139.7)
治疗12 h	0.80(0.14~2.16)	57.8(44.6~97.7)	7.6(4.4~9.8)	4.3(3.6~5.9)	142.7(131.4~145.5)
治疗24 h	1.77(0.85~3.70)¹⁾	44.3(32.6~71.4)¹⁾	5.9(4.8~6.4)¹⁾	4.4(3.8~5.3)	138.6(132.4~140.3)
治疗结束	1.47(1.10~2.82)¹⁾	39.5(30.2~66.6)¹⁾	4.7(3.6~8.2)¹⁾	4.3(3.9~4.9)	136.9(134.0~142.2)
H值	8.76	12.50	8.39	0.60	1.98
P	0.033	0.006	0.039	0.898	0.577

项目	存活组(n=7)	死亡组(n=8)	Z值	P
男[n(%)]	6(85.7)	4(50)	-	0.282¹⁾
胎龄[M(P₂₅~P₇₅)]/周	38.0(31.0~41.0)	39.0(35.0~41.0)	0.29	0.772
出生体重[M(P₂₅~P₇₅)]/g	3 200.0(1 800.0~3 250.0)	3 075.0(2 888.0~3 375.0)	0.06	0.954
AKI分期[M(P₂₅~P₇₅)]	2.0(2.0~3.0)	2.0(1.0~3.0)	0.79	0.428
NCIS评分[M(P₂₅~P₇₅)]	72.0(66.0~76.0)	64.0(61.0~76.0)	1.39	0.163
VIS评分[M(P₂₅~P₇₅)]	190.0(50.0~430.0)	91.0(70.0~270.0)	0.35	0.728
MAP[M(P₂₅~P₇₅)]/mmHg	37.0(29.0~44.0)	37.0(34.0~48.0)	0.23	0.817
pH值[M(P₂₅~P₇₅)]	7.2(7.1~7.2)	7.1(7.0~7.3)	0.58	0.563
血乳酸[M(P₂₅~P₇₅)]/mg·dL^-1	113.7(82.4~199.5)	166.4(92.4~188.5)	0.58	0.561
尿量[M(P₂₅~P₇₅)]/mL·kg^-1·h^-1	0.3(0.0~0.5)	0.34(0~0.75)	0.47	0.637
血清肌酐[M(P₂₅~P₇₅)]/μmol·L^-1	113.6(73.9~258.2)	92.1(39.8~128.1)	1.27	0.203
尿素氮[M(P₂₅~P₇₅)]/mmol·L^-1	12.9(6.9~17.6)	7.5(4.7~9.4)	1.50	0.132
CBP模式[n(%)]			-	1.000¹⁾
CVVHDF	3(42.9)	4(50.0)
CVVH	4(57.1)	4(50.0)
CBP启动日龄[M(P₂₅~P₇₅)]/d	10.0(3.0~47.0)	5.5(2.5~10.8)	0.81	0.415
CBP持续时间[M(P₂₅~P₇₅)]/h	44.0(28.0~88.0)	31.5(6.3~68.3)	0.58	0.562
导管置管位置[n(%)]
颈内静脉	7(100.0)	6(75.0)	-	0.467¹⁾
股静脉	5(71.4)	4(50.0)	-	0.608¹⁾
脐静脉	1(14.3)	1(12.5)	-	1.000¹⁾
锁骨下静脉	0(0.0)	3(37.5)	-	0.200¹⁾
CBP相关不良事件[n(%)]
血小板减少症	6(85.7)	4(50.0)	-	0.282¹⁾
出血或血栓	2(28.6)	4(50.0)	-	0.608¹⁾
管路堵塞	1(14.3)	2(25.0)	-	1.000¹⁾
低血压	1(14.3)	2(25.0)	-	1.000¹⁾