目的 比较连续性肾脏替代治疗（continuous renal replacement therapy,CRRT）时两种连接引血方式对急性肾损伤（acute kidney injury,AKI）患者血流动力学的影响。方法 回顾分析2019年8月—2022年3月于我院重症监护室行CRRT的AKI患者312例,1∶1倾向性匹配选定168例分为单连组（由动脉端引血至管路静脉壶后再连接静脉端）和双连组（导管动静脉端同时连接设备）。观察两组引血前、引血至静脉壶时和上机后10 min时的血流动力学参数,以及上机后2 h内的血流动力学波动情况。利用广义线性混合模型评价不同连接引血方式对AKI患者的血流动力学影响及上机期间的时间变化趋势。结果 无论模型是否矫正,两组收缩压、舒张压、心率及平均动脉压在上机期间（引血开始至上机后10 min）的差异均无统计学意义（P>0.05）;上机期间收缩压、舒张压及平均动脉压较引血前显著下降（P<0.05）,心率无显著变化（P>0.05）;不同连接方式与AKI患者行CRRT后2 h内的血流动力学不稳定无显著关联（P>0.05）。结论 连接引血本身将影响AKI患者血流动力学稳定,CRRT不同连接引血方式在上机期间、上机后2 h内对血流动力学的影响没有差异。建议在CRRT开始时要谨慎,并更密切地监测血流动力学,后期可进一步进行更严谨的大样本试验以验证该研究中的相关结论。
Objective To compare the effects of two types of blood induction connecting methods on hemodynamics during continuous renal replacement therapy（CRRT）in patients with acute kidney injury（AKI）. Methods A retrospective analysis was performed on 312 patients with AKI who received CRRT in the intensive care unit of our hospital from August 2019 to March 2022,and 168 patients were selected with 1：1 propensity matching and divided into single connecting group（blood was drawn from the artery end to the venous pot and then connected to the venous end）and double connecting group（device was connected to the arteriovenous end of the catheter at the same time）. We observed hemodynamic parameters before blood induction,at the time of blood induction to the venous pot,10 min after the start of the machine,and the hemodynamic fluctuations within 2 h after the start of the machine in the two groups. The generalized linear mixed model was used to evaluate the influence of different connection methods on hemodynamics of AKI patients and the time change trend during CRRT. Results Whether the model was corrected or not,there were no significant differences in systolic blood pressure,diastolic blood pressure,heart rate and mean arterial pressure between the two groups during the period（before blood induction to 10min after CRRT）（P>0.05）. Systolic blood pressure,diastolic blood pressure and mean arterial pressure decreased significantly during CRRT compared with those before blood induction（P<0.05）,while heart rate had no significant change（P>0.05）. Different connecting methods had no significant relationship with instable hemodynamics within 2 h of CRRT. Conclusion Connecting blood induction itself will affect the hemodynamic stability of AKI patients,and there is no difference in the influence of different CRRT connections on hemodynamics during machine connection and within 2 hours of CRRT. It is suggested that caution should be exercised at the beginning of CRRT and hemodynamics should be monitored more closely,and more rigorous large-sample tests can be conducted to verify the relevant conclusions in this study.
[1] Connor MJ Jr,Karakala N.Continuous renal replacement therapy:reviewing current best practice to provide high-quality extracorporeal therapy to critically ill patients[J]. Adv Chronic Kidney Dis,2017,24(4):213-218.
[2] 国家卫生健康委. 国家卫生健康委办公厅关于印发血液净化标准操作规程(2021版)的通知[EB/OL].[2023-03-18]. http://www.nhc.gov.cn/yzygj/s7659/202111/6e25b8260b214c55886d6f0512c1e53f.shtml.
National Health Commission. Notice of the General Office of the National Health Commission on Issuing Standard Operating Procedures for Blood Purification(Version2021)[EB/OL].[2023-03-18]. http://www.nhc.gov.cn/yzygj/s7659/202111/6e25b8260b214c 55886d6f0512c1e53f.shtml.
[3] Eknoyan G,Lameire N.KDIGO clinical practice guideline for acute kidney injury[J]. Kidney Int Suppl,2012,2(1):1-138.
[4] K/DOQI Workgroup. K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients[J]. Am J Kidney Dis,2005,45:16-153.
[5] Uchino S,Bellomo R,Morimatsu H,et al.Continuous renal replacement therapy:a worldwide practice survey[J]. Intensive Care Med,2007,33(9):1563-1570.
[6] VA/NIH Acute Renal Failure Trial Network,Palevsky PM,Zhang JH,et al. Intensity of renal support in critically ill patients with acute kidney injury[J]. N Engl J Med,2008,359(1):7-20.
[7] Vinsonneau C,Camus C,Combes A,et al.Continuous venove-nous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome:a multicentre randomised trial[J]. Lancet,2006,368(9533):379-385.
[8] Kim IB,Fealy N,Baldwin I,et al.Circuit start during continuous renal replacement therapy in vasopressor-dependent patients:the impact of a slow blood flow protocol[J]. Blood Purif,2011,32(1):1-6.
[9] Fernández Lafever SN,Santiago MJ,López J,et al.Hemodynamic effects of connection to continuous renal replacement therapy in a pediatric animal model[J]. Artif Organs,2018,42(6):640-646.
[10] Fernández S,Santiago MJ,González R,et al.Hemodynamic impact of the connection to continuous renal replacement therapy in critically ill children[J]. Pediatr Nephrol,2019,34(1):163-168.
[11] Dasselaar JJ,Slart RH,Knip M,et al.Haemodialysis is associated with a pronounced fall in myocardial perfusion[J]. Nephrol Dial Transplant,2009,24(2):604-610.
