血液净化治疗小儿重症肺炎的疗效评价

doi:10.3877/cma.j.issn.1673-5250.2013.06.004

目的

评价血液净化技术用于治疗儿童重症肺炎的临床疗效。

方法

回顾性分析2009年1月至2013年2月在四川大学华西第二医院接受住院治疗的51例重症肺炎患儿的临床病历资料，按照是否接受血液净化治疗将其分为实验组(n = 27)与对照组(n = 24)（本研究遵循的程序符合本院人体试验委员会制定的伦理学标准，得到该委员会批准，分组征得受试对象监护人的知情同意，并与其签署临床研究知情同意书）。两组患儿的年龄，性别，呼吸机辅助通气率及治疗前小儿危重症评分(PCIS)，体温，呼吸频率，心率，白细胞(WBC)计数，C-反应蛋白(CRP)，血糖，丙氨酸转氨酶(ALT)，血尿素氮(BUN)，血Na⁺异常率，血K⁺异常率，动脉血PH值，HCO₃^-及血气分析结果等比较，差异均无统计学意义(P>0.05)。采用统计学方法分析评价两组患儿的死亡率，平均住院日及治疗前及治疗后5 d的体温、呼吸频率、心率及各项实验室检查指标。

结果

实验组患儿的死亡率显著低于对照组[40. 7%(11/27) vs. 70.8%(17/24)]，差异有统计学意义(P = 0.031)。治疗5 d后，实验组患儿体温、心率均明显下降，疗效优于对照组[(37. 13 ± 0. 71)℃ vs. (37. 94±1. 34)℃，(121. 63±21.16)次/min vs. (151. 11±29. 31)次/min]，且差异有统计学意义(P<0.05);实验组血清Na⁺异常率下降[由64%(16/27)下降至20% (5/27)]较对照组[无改变，均为53.3%(8/24)]明显，差异有统计学意义(P=0.029)；实验组血清K⁺异常率下降[由48% (12/27)下降至28%(7/27)]较对照组[由40%(6/24)上升为60%(9/24)]明显，差异有统计学意义(P = 0. 046)；实验组患儿的CRP水平较治疗前明显下降，差异有统计学意义(P<0. 05)；对照组动脉血PH值较治疗前明显上升，差异有统计学意义(P<0. 05)。两组患儿治疗前和治疗5 d后WBC计数、血糖水平、ALT和动脉血HCO₃^-水平、动脉血二氧化碳分压()改变比较，差异均无统计学意义(P>0.05)。

结论

血液净化治疗儿童重症肺炎疗效较好，但是否值得临床推广应用，尚需多中心、大样本随机对照研究进一步证实。

关键词: 血液净化, 重症肺炎, 儿童

Objective

To evaluate clinical effect of blood purification in treatment of children with severe pneumonia.

Methods

This was a retrospective study with institutional ethics approval and written parents of each participating children consent. From January 2009 to February 2013,a total of 51 children with severe pneumonia admitted to West China Second University Hospital, Sichuan University were recruited. According to whether being given blood purification, they were divided into treatment group(n = 27) and control group(n= 24). There had no significance difference between two groups among sex, age, pediatric critical illness score (PCIS) before treatment, rate of mechanical ventilation, and body temperature,breathing rate,heart rate,white blood cell (WBC) count, C-reactive protein (CRP),blood glucose,alanine transarninase (ALT) , Na⁺ and K⁺ in blood,and result of blood gas analysis before treatment (P>0. 05). Mortality rate,hospital days, clinical situations and laboratory data before and after treatment for 5 d were analyzed by statistics.

Results

Mortality rate in treatment group was significantly lower than that in control group [40. 7% (11/27) vs. 70. 8% (17/24) , P<0. 05]. After 5 d treatment, temperature and heart rate in treatment group were significantly lower than those before treatment [ (37. 13℃±0. 71) ℃ vs. (37. 94±1. 34)℃, (121. 63±21. 16)/min vs. (151.11±29. 31)/min; P<0. 05], which were lower than those in control group(P<0. 05). There had significance difference between two groups among serum Na⁺ and K⁺ abnormal rates(P = 0. 029 ,0. 046),in treatment group that Na⁺ and K⁺ abnormal rate which decreased after 5 d treatment fell to 20%(5/27) from 64%(16/27) and fell to 28%(7/ 27)from 48(12/27), respectively; but no change in control group [53. 3%(8/24)] and while rised from 40% (6/24) to 60%(9/24) ,respectively. There had significance difference of CRP level in treatment group after 5 d treatment than that before treatment (P<0. 05) ; the PH value of arterial blood was rising after 5 d treatment than that before treatment in control group (P< 0. 05). There was no significance difference between two groups among WBC count, blood glucose,ALT, creatinine,blood urea nitrogen (BUN) and arterial carbon dioxide tension () before treatment and after 5 d treatment (P>0. 05).

Conclusions

Blood purification in treatment of pediatric severe pneumonia can get better results. More prospective studies are necessary to determine the effectiveness of blood purification in pediatric severe pneumonia.

Key words: blood purification, severe pneumonia, child

表1 实验组患儿血液净化治疗方式[±s(rang)]

Table 1 Treatment strategies of blood purification in treatment group [±s (rang)]

治疗方式	n	平均次数(次）	总时间(h)
CRRT	19	3. 16±1. 77(1. 0~7. 0)	24. 18±14. 34(8. 0~56. 0)
CRRT+HP	3	1 HP+[2. 67±1. 53](1. 0~4. 0)CRRT	2. 0 (HP) + [22. 00±12. 17](8. 0～30. 0)(CRRT)
HP	2	1. 50 ± 0. 71(1. 0～2. 0)	3. 00 ± 1. 41(2. 0～4. 0)
PE	3	1. 67±0. 58(1. 0~2. 0)	2. 50±1. 32(1. 5~4. 0)

表1 实验组患儿血液净化治疗方式[±s(rang)]

Table 1 Treatment strategies of blood purification in treatment group [±s (rang)]

治疗方式	n	平均次数(次）	总时间(h)
CRRT	19	3. 16±1. 77(1. 0~7. 0)	24. 18±14. 34(8. 0~56. 0)
CRRT+HP	3	1 HP+[2. 67±1. 53](1. 0~4. 0)CRRT	2. 0 (HP) + [22. 00±12. 17](8. 0～30. 0)(CRRT)
HP	2	1. 50 ± 0. 71(1. 0～2. 0)	3. 00 ± 1. 41(2. 0～4. 0)
PE	3	1. 67±0. 58(1. 0~2. 0)	2. 50±1. 32(1. 5~4. 0)

表2 两组患儿一般情况临床资料比较[n(%)]

Table 1 Comparison of general clinical data between two groups [n(%)]

组别	n	性别		年龄（岁）		呼吸机辅助通气率
组别	n	男性	女性	≤1	>1	呼吸机辅助通气率
实验组	27	16(59. 3)	11(40. 7)	4(14. 8)	23(85. 2)	14(51. 9)
对照组	24	17(70. 8)	7(29. 2)	9(37. 5)	15(62. 5)	13(54. 2)
χ²	?	0. 745		3. 443		0. 027
P	?	0. 388		0. 640		0. 869

表2 两组患儿一般情况临床资料比较[n(%)]

Table 1 Comparison of general clinical data between two groups [n(%)]

组别	n	性别		年龄（岁）		呼吸机辅助通气率
组别	n	男性	女性	≤1	>1	呼吸机辅助通气率
实验组	27	16(59. 3)	11(40. 7)	4(14. 8)	23(85. 2)	14(51. 9)
对照组	24	17(70. 8)	7(29. 2)	9(37. 5)	15(62. 5)	13(54. 2)
χ²	?	0. 745		3. 443		0. 027
P	?	0. 388		0. 640		0. 869

表3 两组患儿治疗前PCIS评分比较(±s)

Table 2 Comparison of PCIS scores before treatment between two groups(±s)

组别	n	PCIS评分(分）	t	P
实验组	27	79. 41 ± 9. 48	1. 098	0. 277
对照组	24	81. 92±6. 31	?	?

表3 两组患儿治疗前PCIS评分比较(±s)

Table 2 Comparison of PCIS scores before treatment between two groups(±s)

组别	n	PCIS评分(分）	t	P
实验组	27	79. 41 ± 9. 48	1. 098	0. 277
对照组	24	81. 92±6. 31	?	?

表4 两组患儿病死率比较[n(%)]

Table 4 Comparison of mortality between two groups[n(%)]

?	n	病死率	χ²	P
实验组	27	11(40. 7)	4. 647	0. 031
对照组	24	17(70.8)	?	?

表4 两组患儿病死率比较[n(%)]

Table 4 Comparison of mortality between two groups[n(%)]

?	n	病死率	χ²	P
实验组	27	11(40. 7)	4. 647	0. 031
对照组	24	17(70.8)	?	?

表5 两组患儿治疗前和治疗5 d后生命体征组内与组间比较（实际受试例数）

Table 5 Comparison of physical signs before and after treatment 5 days within and between two groups (actual cases)

组别	n	体温(℃)		呼吸频率(次/min)		心率(次/min)
组别	n	治疗前	治疗5 d后	治疗前	治疗5 d后	治疗前	治疗后
实验组	27	37. 94±1. 34(27)	37. 13±0. 71(27)^b	41. 81±14. 10(27)	36. 11±9. 60(27)^b	151.11±29. 31(27)	121. 63±21. 16(27)^b
对照组	24	37. 74±1. 13(20)	37. 86 ± 0. 98(20)^a	47. 90± 8.56(20)	38. 4±11. 8(20)^a	160. 25 ± 33. 99(20)	137. 50 ± 25. 83(20)^a
t	?	0. 543	—2. 965	-2. 145	—0. 732	—0. 987	—2. 313
P	?	0. 59	0. 005	0. 037	0. 468	0. 329	0. 025

表5 两组患儿治疗前和治疗5 d后生命体征组内与组间比较（实际受试例数）

Table 5 Comparison of physical signs before and after treatment 5 days within and between two groups (actual cases)

组别	n	体温(℃)		呼吸频率(次/min)		心率(次/min)
组别	n	治疗前	治疗5 d后	治疗前	治疗5 d后	治疗前	治疗后
实验组	27	37. 94±1. 34(27)	37. 13±0. 71(27)^b	41. 81±14. 10(27)	36. 11±9. 60(27)^b	151.11±29. 31(27)	121. 63±21. 16(27)^b
对照组	24	37. 74±1. 13(20)	37. 86 ± 0. 98(20)^a	47. 90± 8.56(20)	38. 4±11. 8(20)^a	160. 25 ± 33. 99(20)	137. 50 ± 25. 83(20)^a
t	?	0. 543	—2. 965	-2. 145	—0. 732	—0. 987	—2. 313
P	?	0. 59	0. 005	0. 037	0. 468	0. 329	0. 025

表6 两组患儿治疗前及治疗5 d后实验室监测指标组内与组间比较（实际受试例数）

Table 6 Comparison of laboratory indexes before and after treatment 5 days within and between two groups (actual cases)

组别	WBC(10⁹/L)		CRP(mg/L)		血糖(?mmoL?/L)
组别	治疗前	治疗后	治疗前	治疗后	治疗前	治疗后
实验组	13. 88±10. 09(27)	13. 37±7. 59(27)^a	103. 10±122. 88(20)	22. 75±31. 08(20)^b	9. 00 ± 4. 99(20)	7. 21±2. 68(20)^a
对照组	10. 42±5. 58(14)	11. 28 ± 4. 84(14)^d	50. 27± 67. 70(11)	30. 27±52. 11(11)^d	6. 45±3. 03(12)	5. 67 ± 2. 34(12)^d
t	1. 413	0. 949	1. 314	-0. 506	1. 597	1. 649
P	0. 166	0. 349	0. 199	0. 617	0. 121	0. 110
组别	Cr(?μmol?/L)		BUN(?mmol?/L)		ALT(U/L)
组别	治疗前	治疗后	治疗前	治疗后	治疗前	治疗后
实验组	89. 33±92. 99(20)	46. 25 ± 37. 86(20)^c	10. 71±10. 14(20)	7. 08 ± 4. 81(20)^a	249. 59 ± 394. 34(22)	173. 27±422. 52(22)^a
对照组	39. 11 ± 28. 43(9)^d	42. 56 ± 37. 31(9)^d	5. 69 ± 4. 35(9)	6. 17±5. 39(9)^d	173. 00 ± 348. 06(8)	176. 50±339. 86(8)^d
t	2. 198	0. 240	1. 862	0. 457	0. 484	-0. 019
P	0. 037	0. 809	0. 074	0. 651	0. 632	0. 985
组别	PH值		HCO₃^- (?mmol?/L)		(?kPa?)
组别	治疗前	治疗后	治疗前	治疗后	治疗前	治疗后
实验组	7. 36±0. 17(18)	7. 39±0. 11(18)^a	23. 09±10. 29(18)	26. 08±8. 93(18)^a	5. 29±2. 19(18)	5. 70±2. 62(18)^a
对照组	7. 36±0. 08(14)	7. 45±0. 08(14)^e	22. 86± 7. 71(14)	29. 04±9. 57(14)^d	5. 31±1. 56(14)	5. 56±1. 87(14)^d
t	0. 084	-1. 559	0. 068	-0. 901	-0. 027	0. 172
P	0. 934	0. 130	0. 946	0. 375	0. 530	0. 970

表6 两组患儿治疗前及治疗5 d后实验室监测指标组内与组间比较（实际受试例数）

Table 6 Comparison of laboratory indexes before and after treatment 5 days within and between two groups (actual cases)

组别	WBC(10⁹/L)		CRP(mg/L)		血糖(?mmoL?/L)
组别	治疗前	治疗后	治疗前	治疗后	治疗前	治疗后
实验组	13. 88±10. 09(27)	13. 37±7. 59(27)^a	103. 10±122. 88(20)	22. 75±31. 08(20)^b	9. 00 ± 4. 99(20)	7. 21±2. 68(20)^a
对照组	10. 42±5. 58(14)	11. 28 ± 4. 84(14)^d	50. 27± 67. 70(11)	30. 27±52. 11(11)^d	6. 45±3. 03(12)	5. 67 ± 2. 34(12)^d
t	1. 413	0. 949	1. 314	-0. 506	1. 597	1. 649
P	0. 166	0. 349	0. 199	0. 617	0. 121	0. 110
组别	Cr(?μmol?/L)		BUN(?mmol?/L)		ALT(U/L)
组别	治疗前	治疗后	治疗前	治疗后	治疗前	治疗后
实验组	89. 33±92. 99(20)	46. 25 ± 37. 86(20)^c	10. 71±10. 14(20)	7. 08 ± 4. 81(20)^a	249. 59 ± 394. 34(22)	173. 27±422. 52(22)^a
对照组	39. 11 ± 28. 43(9)^d	42. 56 ± 37. 31(9)^d	5. 69 ± 4. 35(9)	6. 17±5. 39(9)^d	173. 00 ± 348. 06(8)	176. 50±339. 86(8)^d
t	2. 198	0. 240	1. 862	0. 457	0. 484	-0. 019
P	0. 037	0. 809	0. 074	0. 651	0. 632	0. 985
组别	PH值		HCO₃^- (?mmol?/L)		(?kPa?)
组别	治疗前	治疗后	治疗前	治疗后	治疗前	治疗后
实验组	7. 36±0. 17(18)	7. 39±0. 11(18)^a	23. 09±10. 29(18)	26. 08±8. 93(18)^a	5. 29±2. 19(18)	5. 70±2. 62(18)^a
对照组	7. 36±0. 08(14)	7. 45±0. 08(14)^e	22. 86± 7. 71(14)	29. 04±9. 57(14)^d	5. 31±1. 56(14)	5. 56±1. 87(14)^d
t	0. 084	-1. 559	0. 068	-0. 901	-0. 027	0. 172
P	0. 934	0. 130	0. 946	0. 375	0. 530	0. 970

表7 两组患儿治疗前和治疗5 d后血电解质水平异常率比较[n'/n(％)]

Table 7 Comparison of abnormal rates of blood electrolyte level before and after treatment 5 days between two groups [n'/n(%)]

组别	n	Na⁺		K⁺		?Cl?^-
组别	n	治疗前	治疗后	治疗前	治疗后	治疗前	治疗后
实验组	27	16/25(64. 0)	5/25(20. 0)	12/25(448. 0)	7/25(28. 0)	12/24(50.0)	6/24(25.0)
对照组	24	8/15(53. 3)	8/15(53. 3)	6/15(40. 0)	9/15(60. 0)	3/13(23. 1)	5/13(38. 5)
χ²	?	0. 444	4. 748	0. 242	4. 000	2. 536	0. 731
P	?	0. 505	0. 029	0. 622	0. 046	0. 111	0. 392

表7 两组患儿治疗前和治疗5 d后血电解质水平异常率比较[n'/n(％)]

Table 7 Comparison of abnormal rates of blood electrolyte level before and after treatment 5 days between two groups [n'/n(%)]

组别	n	Na⁺		K⁺		?Cl?^-
组别	n	治疗前	治疗后	治疗前	治疗后	治疗前	治疗后
实验组	27	16/25(64. 0)	5/25(20. 0)	12/25(448. 0)	7/25(28. 0)	12/24(50.0)	6/24(25.0)
对照组	24	8/15(53. 3)	8/15(53. 3)	6/15(40. 0)	9/15(60. 0)	3/13(23. 1)	5/13(38. 5)
χ²	?	0. 444	4. 748	0. 242	4. 000	2. 536	0. 731
P	?	0. 505	0. 029	0. 622	0. 046	0. 111	0. 392

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Evaluation Clinical Effect of Blood Purification in Pediatric Severe Pneumonia

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Evaluation Clinical Effect of Blood Purification in Pediatric Severe Pneumonia