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Effects of Early Hemofiltration on TNF-α and IL-1β in Pigs with Severe Acute Pancreatitis

【Abstract】Objective To study the influence of early hemofiltration on plasma concentrations of proinflammatory cytokines TNF-α and IL-1β and their transcription levels in severe acute pancreatitis (SAP) pigs. Methods The model of SAP was induced by retrograde injection of artificial bile into pancreatic duct in pigs. Animals were divided randomly into two groups: SAP hemofiltration treatment group (HF group, n=8) and SAP no hemofiltration treatment group (NHF group, n=8). TNF-α and IL-1β plasma concentrations were measured by ELISA. Their transcription levels in the tissues of pancreas, liver and lung were assayed by semi-quantitative reverse transcription polymerase chain reaction. Results After hemofiltration treatment, the plasma concentrations of TNF-α and IL-1β increased gradually but were lower than those of NHF group at the same time spot 〔at 6 h after hemofiltration treatment, (618±276) pg/ml vs (1 375±334) pg/ml and (445±141) pg/ml vs (965±265) pg/ml, P＜0.01〕. At 6 h after hemofiltration treatment, the transcription levels of TNF-α and IL-1β in tissues of pancreas, liver and lung were lower than in NHF group (57.8±8.9 vs 85.7±17.4, 48.0±8.1 vs 78.1±10.2, 46.2±9.6 vs 82.4±10.5; 55.9±9.0 vs 82.2±15.7, 40.6±9.2 vs 60.0±10.6, 35.7±9.8 vs 58.1±9.3, P＜0.01). Conclusion Early hemofiltration can reduce TNF-α and IL-1β plasma concentrations and transcription levels in SAP pigs.

Analysis of Clinical Management in Patients with Severe Acute Pancreatitis

目的 探讨5例特重型胰腺炎的特点及治疗方法。方法 我院2001年8月至2003年8月共收治特重型胰腺炎患者5例。其中入院后18 h内心跳、呼吸骤停3次的重症急性胰腺炎（SAP）1例，治疗以及时血液滤过和心、肺、脑复苏为重点； SAP并发胰性脑病2例，以大剂量维生素B1的补充，或足量补给浓缩红细胞为治疗重点； 并发多个器官功能障碍的暴发性胰腺炎（FAP）2例，治疗重点是血液滤过和防治多器官功能衰竭的级联放大反应，其中1例以高渗性糖昏迷为主要表现，治疗重点是内稳态的纠正，血液滤过，重要器官功能维护。结果 5例特重型胰腺炎患者均治愈，平均住院时间为32.2 d。结论 器官功能的复苏和维护、外科ICU监护、短时血液滤过、内稳态的纠正、中西药综合治疗及病因、对症的个体化治疗是特重型胰腺炎的重要治疗措施。

危重患者持续静静脉血液滤过时血糖监测的影响因素研究

目的 观察危重患者持续静静脉血液滤过( CVVH) 过程中血糖监测的影响因素。方法 选择CVVH治疗的危重患者30 例, 根据其入选时的循环状态将患者分为休克组和非休克组, 同时监测两组患者动脉血糖、末梢血糖及CVVH 导管动脉端血糖, 比较同一时点各部位血糖监测值。结果 所有患者动脉血糖值与末梢血糖值比较有显著差异( P lt; 0. 05) , 动脉血糖值与CVVH 导管动脉端血糖值差异无统计学意义( P gt; 0. 05) , 且二者存在明显相关性( r = 0. 989, P lt; 0. 001) , 末梢血糖值与CVVH导管动脉端血糖值差异有统计学意义( P lt;0. 05) ; 休克组末梢血糖值较动脉血糖值低, 差异有统计学意义( P lt; 0. 05) , 非休克组末梢血糖值与动脉血糖值差异无统计学意义( P gt;0. 05) 。结论 危重患者末梢血糖监测值偏低, 该差异在休克患者中更加明显; CVVH时可通过导管动脉端采血监测血糖。

Applications of Ultrafiltration of Priming Solution with Blood in Pediatric Cardiac Surgery

Abstract: Objective To discuss whether priming solution with blood can reach a physiologic state after ultrafiltration and investigate the influence of this method on electrolytes, acidbase balance and cardiopulmonary function in patients in perioperative period. Methods Forty patients with congenital heart diseases treated in our hospital from February to June 2009 were enrolled in this study. The weight of these patients was less than 8 kg. They were randomly divided into two groups: the experimental group (n=20, 12 males and 8 females; age: 131.00±103.00 d; weight: 4.14±0.96 kg） and the control group (n=20, 11 males and 9 females; age: 127.00±88.00 d; weight: 4.38±1.05 kg). For patients in the experimental group, the priming solution was filtered with a blood ultrafilter in the cardiopulmonary bypass(CPB) circuit for twenty minutes, while the priming solution circulated in the CPB circuit without filtration for patients in the control group before operation. Data were obtained from the priming solution before and after ultrafiltration. Blood gas analysis was done and indexes like the electrolytes were detected during the operation. Fractional shorting (FS), ejection fraction (EF) and cardiac output (CO) were measured by echocardiography. Pulmonary function change was also observed. Results No death occurred in both groups. Mechanical ventilation time for the experimental group was significantly shorter than that of the control group (2.7±0.3 d vs. 4.1±0.4 d，Plt;0.05). After ultrafiltration for the experimental group, all indexes of the priming solution reached normal values: pH increased (from 6.89±0.22 to 7.40±0.57, P=0.001); base excess increased (from -16.12±0.98 mmol/L to +0.31±2.40 mmol/L, P=0.000); potassium concentration decreased (from 10.33±2.13 mmol/L to 4.27±0.93 mmol/L, P=0.000); interleukin8 (IL-8) decreased (from 78.40±6.10 pg/ml to 64.30±48.10 pg/ml, P=0.036); and bradykinin decreased (from 5 982±1 353 pg/ml to 531.00±35.00 pg/ml, P=0.031). The decrease of FS, EF and CO in the experimental group was smaller than that of the control group. Four hours after surgery, CO in the experimental group was significantly higher than that in the control group (2.77±0.95 L/min vs. 1.66±0.75 L/min, P=0.001). Twentyfour hours after surgery, EF in the experimental group was significantly higher than that in the control group (67.44%±6.89% vs. 61.17%±9.02%, P=0.003). Six hours after surgery, alveolararterial oxygen difference (A-aDO2) and respiratory index (RI) increased significantly (Plt;0.05) in both groups, and then started to drop to normal. Patients in the experimental group recovered gas exchange earlier than patients in the control group. Fortyeight hours after operation, A-aDO2 and RI in the experimental group were significantly lower than those in the control group (Plt;0.05). Conclusion Ultrafiltration of priming solution may confer an advantage in maintaining more physiological conditions, reducing inflammatory mediators, and improving cardiopulmonary function after operation, which is very important in performing cardiac surgery on the newborn and infants with complex congenital heart diseases.

高容量血液滤过治疗心脏手术后急性肾功能衰竭

Early Veno-venous Hemofiltration for Severe Acute Pancreatitis: A Systematic Review

Objective　To evaluate the effectiveness and safety of early veno-venous hemofiltration in patients with severe acute pancreatitis (SAP). Methods　We searched Cochrane Central Register of Controlled Trials (Issue 4, 2005), MEDLINE (1990 to 2006) and CBMdisc (1990 to 2006). We also handsearched the references of relevant articles. We included randomized controlled trials (RCTs) and non-randomized clinical controlled trials (CCTs) comparing early veno-venous hemofiltration versus conventional therapy only, which reported either mortality rate, cure rate, or both. Two reviewers assessed the quality of each trial and extracted data independently. Trials were graded methodologically. The Cochrane Collaboration’s RevMan 4.2.8 software was used for statistical analysis. Results　Ten RCTs and 6 CCTs involving 891 patients were included, all of which were China-based. The Jadad scores of all included RCTs were less than 3. Five trials were incorrectly described as having used random allocation. The baseline data of each trial were comparable. Meta-analyses showed that hemofiltration significantly increased the overall cure rate (OR 3.01, 95%CI 1.28 to 7.09) and decreased the overall mortality rate (OR 0.43, 95%CI 0.27 to 0.70). Moreover, APACHE-II score, conversion to operation rate and incidence of complications of SAP were reduced significantly., The duration of abdominal pain or distension and hospitalization stay were shortened compared with non-hemofiltration. However, continuous veno-venous hemofiltration (CVVH) did not improve overall prognosis, with greater possibility of adverse events. Repeated or intermittent short veno-venous hemfiltration (RSVVH/ISVVH) either with or without peritoneal dialysis, could improve the overall prognosis without any adverse events reported. Conclusions　Based on these findings, early RSVVH/ISVVH was effective and safe for SAP, but the efficacy of CVVH could not be proven. Current studies were only available from China and were poor in methodological quality. Further, high-quality, large-scale, randomized controlled trials are required to identify reliably the effectiveness and safety of early veno-venous hemofiltration for SAP.

Clinical Study of Continous Veno-venous Hemofiltration(CVVH) and Repeated Intermittent Veno-Venous Hemofiltration (RIVVH) in Treatment of Severe Acute Pancreatitis(SAP)

目的:研究早期连续性静脉-静脉血液滤过和反复间断静脉一静脉血滤治疗重症急性胰腺炎的临床价值。 方法:45例SAP患者随机分为CVVH组(25例)和RIVVH组(20例)。比较2组患者的生命体征、生化指标、治疗前后的APACHE Ⅱ评分、死亡率、好转率。 结果:CVVH 组中3例死于MODS,死亡率为12％,RIVVH组死亡3例 (15％),其差异有统计学意义(Plt;0.05);CVVH 组好转率为80％ (20/25),与RIVVH组的80％(16/20)一致。在治疗的早期阶段,对于改善生命体征,降低APACHEⅡ评分CVVH效果更显注,但随着治疗时间的延长,这种差异逐渐变小,在后期两组间不再存在疗效差异,最终疗效上没有明显的差异,而RIVVH组,在治疗费用和人员成本上具有优势。结论:早期RIVVH 治疗SAP可以作为SAP重要的辅助治疗措施。

Clinical Study of Early Repeated Intermittent Veno-Venous Hemofiltration in Treatment of Severe Acute Pancreatitis

Objective To evaluate the efficacy and mechanism of early repeated intermittent veno-venous hemofiltration (RIVVH) in treatment of severe acute pancreatitis (SAP). Methods Sixty-five patients were randomly divided into RIVVH group (35 cases) and control group (30 cases). Symptoms, physical signs, serum concentration of BUN, Cr, AST, ALT, AMS were observed and compared between two groups. The changes of C-reactive protein (CRP) and result of bacteria culture, APACHEⅡ grades and Balthazar CT grades, open-belly surgery rate, complications, mortality rate, average hospital stay and costs were compared between these two groups. Results Two patients died of multiple organ failure in the RIVVH group, with 5.7% mortality rate, which was significantly lower than that in the control group (26.7%, 8/30), P＜0.05. Twenty-four hours after treatment, symptoms and signs were alleviated more in RIVVH group; blood biochemical indicator, oxygenation index and CRP level improved significantly in RIVVH group compared with those in control group （P＜0.05，P＜0.01）. Balthazar CT grades and APACHEⅡ grades decreased significantly after treatment in patients of RIVVH group （P=0.002, P＜0.001）. The hospital stay, costs, open-belly surgery rate, complications rate and infection rate were also significantly lower in RIVVH group comparing with those in control group （P＜0.05, P＜0.001）. Conclusion RIVVH can decrease the mortality rate of SAP with high recovery rate, less cost and shorter hospital stay.

血液灌流联合连续性静脉-静脉血液滤过治疗脓毒血症合并急性肾损伤的护理

目的探讨血液灌流（HP）联合连续性静脉-静脉血液滤过（CVVH）治疗脓毒血症合并急性肾损伤（AKI）的护理。 方法对2011年7月－2013年7月收治的48例脓毒血症合并AKI的患者进行HP联合CVVH治疗。比较治疗前后的血肌酐（Cr）、血尿素氮（BUN）和外围血小板计数（PLT）差异，并分析处理治疗过程中产生的护理问题。 结果48例患者行HP联合CVVH治疗后，Cr由（311.90±183.06）μmol/L降至（108.51±43.93）μmol/L，BUN由（18.21±8.58）mmol/L降至（8.51±2.64）mmol/L，PLT由（94.68±30.40）×109/L降至（131.61±39.79）×109/L，差异均有统计学意义（P＜0.05）。5例（10.42%）死亡，33例（68.75%）好转出院，10例（20.83%）肾功能恢复转入普通病房。 结论HP联合CVVH治疗脓毒血症合并AKI，能有效改善患者的肾功能，而高质量的护理有助于治疗的顺利完成。

间断性血液灌流和连续性血液滤过治疗脓毒症的疗效比较

目的探讨血液灌流（hemoperfusion，HP）和连续性静脉-静脉血液滤过（continuous veno-venous hemofiltration，CVVH）治疗脓毒症患者的临床疗效。 方法采用随机对照研究方法，将天水市第一人民医院重症监护病房（ICU）2012～2014年期间收治的67例革兰阴性脓毒症患者按抽签法随机分为常规治疗组（24例）、HP治疗组（18例）及CVVH治疗组（25例）3组，观察3组患者治疗前和治疗后24、48及72 h的心率（HR）、平均动脉压（MAP）、APACHEⅡ评分、降钙素原（PCT）、C反应蛋白（CRP）和血清内毒素（ET）水平的变化。 结果治疗后24、48及72 h CVVH治疗组的各项指标改善均较常规治疗组和HP治疗组明显（P<0.05）；HP治疗组仅在治疗后24 h各项指标相较于常规治疗组下降（P<0.05），但在治疗后48及72 h时与常规治疗组相比差异无统计学意义（P>0.05）。 结论HP和CVVH都能不同程度地降低炎症介质，但以CVVH治疗的效果更明显；脓毒症的转归可能有更多的影响因素。