High-sodium replacement fluid for continuous blood purification in children with cerebral edema
-
摘要: 目的 探讨高钠置换液连续性血液净化治疗在儿童脑水肿中的应用价值。方法 将42例合并脑水肿且具备连续性血液净化指征的患儿随机分为2组，常规组20例，高钠组22例。常规组连续性血液净化治疗选用钠浓度为140 mmol/L的置换液，高钠组选用钠浓度为148 mmol/L的置换液，比较2组患儿治疗期间血钠水平、并发症发生率及治疗结局。结果 以入院1周为时间截点，常规组共进行连续性血液净化治疗48次，高钠组45次。常规组及高钠组治疗期间血钠高值分别为(136.7±4.6) mmol/L和(140.4±6.1) mmol/L，2组间差异有统计学意义(P < 0.05)；常规组及高钠组治疗结束时血钠分别为(135.4±5.2) mmol/L和(138.3±6.2) mmol/L，2组间差异有统计学意义(P < 0.05)。常规组治疗结束时血钠与治疗前的(133.8±4.3) mmol/L相比，差异无统计学意义(P>0.05)；高钠组治疗结束时与治疗前的(133.1±4.5) mmol/L相比，差异有统计学意义(P < 0.05)。2组患儿治疗过程中均未出现明显高血钠及高血压病例；常规组低血压发生率为16.7%(8/48)，高钠组为2.2%(1/45)，2组间差异有统计学意义(P < 0.05)。结论 对于合并脑水肿的患儿，在连续性血液净化治疗期间，适当提高置换液钠浓度，能够提升患儿血钠水平，减少低血压发生率，优化连续性血液净化治疗对脑水肿的疗效。Abstract: Objective To assess the value of applying high-sodium replacement fluid to continuous blood purification(CBP) in children with cerebral edema.Methods Forty-two cases complicated with cerebral edema and indicated for CBP were randomized into two groups, with one group(n=20) administered with routine CBP(rCBP group) and the other(n=22) receiving CBP with high-sodium replacement fluid(hsCBP group). The rCBP group underwent CBP with 140 mmol/L sodium, while the hsCBP group used replacement fluid containing 148 mmol/L sodium to compare blood sodium during treatment, complication rate, and treatment outcomes between the two groups.Results Within the first week of hospitalization, the rCBP and hsCBP groups underwent 48 and 45 CBP sessions, respectively. During treatment, high-level blood sodium reached(136.7±4.6) mmol/L in the rCBP group and(140.4±6.1) mmol/L in the hsCBP group, suggesting a difference of statistical significance(P < 0.05); at the end of the treatment course, blood sodium was(135.4±5.2) mmol/L in the rCBP group and(138.3±6.2) mmol/L in the hsCBP group, demonstrating a significant difference between the two groups(P < 0.05). In the rCBP group, blood sodium did not differ greatly before and after treatment: (133.8±4.3) mmol/L vs(135.4±5.2) mmol/L; in the hsCBP group, the pre-treatment blood sodium was(133.1±4.5) mmol/L, significantly different from the blood sodium level(138.3±6.2) mmol/L at the end of treatment(P < 0.05). High blood sodium and hypertension were not evident in either group throughout the treatment course; besides, hypotension had an incidence of 16.7%(8/48) in the rCBP group and merely 2.2%(1/45) in the hsCBP group, representing a difference of statistical significance between the two groups(P < 0.05).Conclusion In children complicated with cerebral edema, the sodium concentration of the replacement fluid for CBP should be mildly increased to raise the blood sodium level, reduce the risk of hypotension and improve the efficacy of CBP.
-
Key words:
- cerebral edema /
- continuous blood purification /
- high-sodium replacement fluid /
- children
-
-
表 1 42例患儿原发疾病及病例特点
例序 性别 年龄 体重/kg 原发疾病 伴随症状 机械通气 意识障碍 头痛 惊厥 呕吐 前囟隆起 瞳孔改变 高血压 颅脑影像 MODS 1 女 10月2天 9.0 支气管异物 + + + + + + 2 女 13岁 43.0 甲亢危象 + + + + 3 女 1岁9月 8.0 急性坏死性脑病 + + + + + + 4 男 6岁10月 20.5 FIRES + + + + 5 男 10岁4月 51.0 暴发性心肌炎 + + + 6 女 1岁7月 9.5 纵隔脓肿 + + 7 男 5月7天 8.5 铜绿假单胞菌败血症 + + 8 男 8岁 27.0 溶血尿毒症综合征 + + 9 女 14岁 46.0 暴发性心肌炎 + + + 10 女 1岁4月 7.0 丙酸血症 + + + 11 男 1岁5月 11.5 化脓性脑膜炎 + + + 12 女 5岁5月 20.0 暴发性心肌炎 + + + 13 女 10月12天 8.0 严重复合创伤 + + + 14 女 12岁4月 23.0 急性肾衰竭 + + + 15 男 11岁1月 31.0 脓毒症 + + + 16 男 12岁11月 35.0 狼疮危象 + + 17 男 9岁8月 26.0 毒蕈中毒 + + 18 女 9岁7月 16.5 严重复合创伤 + + + + + + 19 男 3岁 13.5 脓毒性休克 + + + 20 男 9岁2月 45.0 特重度烧伤 + + 21 男 11岁10月 35.0 斯-琼综合征 + + + 22 女 7岁7月 22.0 化脓性脑膜炎 + + + + + + 23 男 6岁9月 18.5 急性肝衰竭 + + + 24 女 9岁9月 29.0 暴发性心肌炎 + + + 25 男 13岁3月 50.0 特重度烧伤 + + 26 女 6岁5月 16.5 毒蕈中毒 + + + + 27 男 8岁10月 28.0 重症肺炎 + + 28 女 12岁8月 50.0 异丙嗪中毒 + + 29 女 6岁8月 20.0 重症肺炎 + + + 30 男 12岁8月 60.0 蜂螫伤 + + 31 男 1岁11月 11.5 肝衰竭 + + 32 男 2岁7月 12.0 毒蕈中毒 + + + 33 男 5岁4月 17.0 重症肺炎 + + 34 女 13岁9月 46.0 狼疮危象 + + + + 35 男 13岁11月 50.0 脓毒性休克 + + 36 男 2岁11月 7.4 有机磷中毒 + + 37 男 4月19天 8.0 脓毒症 + + 38 男 13岁2月 49.0 百草枯中毒 + + + 39 男 6岁9月 23.5 肝衰竭 + + 40 女 8岁2月 23.5 蜂蜇伤 + + + 41 女 7岁7月 17.0 毒蕈中毒 + + 42 男 6岁4月 22.0 毒蕈中毒 + + + 注：FIRES，热性感染相关性癫痫综合征；意识障碍，昏迷或昏睡；瞳孔改变，瞳孔不等大或扩大；颅脑影像，头颅CT和(或)MRI提示脑水肿；MODS，2个及以上器官功能障碍。 
下载: 导出CSV
表 2 2组患儿入院时一般资料比较
M(Q1，Q3)，X±S 组别 例数 性别/例 年龄/月 体重/kg GCS评分/分 血钠/(mmol/L) 男 女 常规组 20 10 10 89(17.5，130.8) 20.3(9.1，34) 8.2±3.2 134.6±5.5 高钠组 22 14 8 91(72.3，152) 22.8(16.9，46.8) 7.7±2.4 132.7±4.7 t/Z/χ2 0.795 0.907 1.147 0.597 1.185 P 0.372 0.365 0.252 0.554 0.243
下载: 导出CSV
表 3 2组患儿入院时凝血功能指标比较
M(Q1，Q3) 组别 例数 血小板/(×109/L) 凝血酶原时间/s 活化部分凝血酶时间/s 国际标准化值 纤维蛋白原/(g/L) 常规组 20 174.5(105.8，212.5) 12.4(11.4，22.5) 36.2(30.2，43.4) 1.1(1.0，2.0) 2.3(1.6，3.2) 高钠组 22 220.0(89.8，322.8) 13.0(12.1，21.3) 33.7(27.4，40.8) 1.1(1.0，1.9) 2.5(1.4，3.5) Z 0.970 0.277 0.919 0.189 0.391 P 0.332 0.782 0.358 0.850 0.696
下载: 导出CSV
表 4 2组患儿CBP治疗期间临床资料比较
X±S 组别 CBP次数 CBP前血钠/(mmol/L) CBP中血钠高值/(mmol/L) CBP结束时血钠/(mmol/L) CBP中低血压次数/次(%) 常规组 48 133.8±4.3 136.7±4.6 135.4±5.2 8(16.7) 高钠组 45 133.1±4.5 140.4±6.1 138.3±6.21) 1(2.2) t/ χ2 0.817 3.256 2.473 4.015 P 0.416 0.002 0.015 0.045 与本组CBP前血钠比较，1) P < 0.05。
下载: 导出CSV
表 5 2组患儿CBP治疗结束时血氯及酸碱指标比较
X±S 组别 CBP次数 血氯/(mmol/L) pH值 碳酸氢根/(mmol/L) 剩余碱/(mmol/L) 常规组 48 103.1±4.3 7.44±0.07 24.9±3.8 0.9±4.6 高钠组 45 105.1±3.9 7.41±0.08 24.0±4.4 -0.7±5.0 t 2.367 1.762 1.080 1.578 P 0.020 0.081 0.283 0.118
下载: 导出CSV
表 6 2组患儿入院1周治疗结局比较
例(%) 组别 例数 好转 无效 常规组 20 15(75.0) 5(25.0) 高钠组 22 19(86.4) 3(13.6) χ2 0.295 P 0.587
下载: 导出CSV
-
[1] Halstead MR, Geocadin RG. The medical management of cerebral edema: past, present, and future therapies[J]. Neurotherapeutics, 2019, 16(4): 1133-1148. doi: 10.1007/s13311-019-00779-4
[2] Hinduja A, Gokun Y, Ibekwe E, et al. Risk factors for development of cerebral edema following cardiac arrest[J]. Resuscitation, 2022, 181: 297-303. doi: 10.1016/j.resuscitation.2022.10.013
[3] Cook AM, Morgan Jones G, Hawryluk GWJ, et al. Guidelines for the acute treatment of cerebral edema in neurocritical care patients[J]. Neurocrit Care, 2020, 32(3): 647-666. doi: 10.1007/s12028-020-00959-7
[4] Holden DN, Mucksavage JJ, Cokley JA, et al. Hypertonic saline use in neurocritical care for treating cerebral edema: A review of optimal formulation, dosing, safety, administration and storage[J]. Am J Health Syst Pharm, 2023, 80(6): 331-342. doi: 10.1093/ajhp/zxac368
[5] 刘春峰. 血液净化技术在儿童重症疾病中的应用[J]. 中华实用儿科临床杂志, 2020, 35(18): 1365-1368. doi: 10.3760/cma.j.cn101070-20200724-01247
[6] 胡马洪, 赖志珍, 孟建标, 等. 高容量血液滤过改善重型颅脑损伤患者脑功能的多中心随机对照研究[J]. 中华危重症医学杂志(电子版), 2019, 12(2): 98-103. doi: 10.3877/cma.j.issn.1674-6880.2019.02.005
[7] 江载芳, 申昆玲, 沈颖. 诸福棠实用儿科学[M]. 8版. 北京: 人民卫生出版社, 2015: 2725-2735.
[8] 儿童危重症连续性血液净化应用共识工作组. 连续性血液净化在儿童危重症应用的专家共识[J]. 中华儿科杂志, 2021, 59(5): 352-360. doi: 10.3760/cma.j.cn112140-20210302-00169
[9] Laws JC, Jordan LC, Pagano LM, et al. Multimodal neurologic monitoring in children with acute brain injury[J]. Pediatr Neurol, 2022, 129: 62-71. doi: 10.1016/j.pediatrneurol.2022.01.006
[10] Jha RM, Kochanek PM, Simard JM. Pathophysiology and treatment of cerebral edema in traumatic brain injury[J]. Neuropharmacology, 2019, 145(Pt B): 230-246.
[11] Shi JM, Tan LH, Ye J, et al. Hypertonic saline and mannitol in patients with traumatic brain injury: a systematic and meta-analysis[J]. Medicine(Baltimore), 2020, 99(35): e21655.
[12] Desai A, Damani R. Hyperosmolar therapy: a century of treating cerebral edema[J]. Clin Neurol Neurosurg, 2021, 206: 106704. doi: 10.1016/j.clineuro.2021.106704
[13] 陈胜龙, 曾红科. 高渗盐水在脑水肿颅高压患者中的临床应用[J]. 中华急诊医学杂志, 2014, 23(12): 1305-1306. doi: 10.3760/cma.j.issn.1671-0282.2014.12.001
[14] Regensburger AP, Konrad V, Trollmann R, et al. Treatment of severe traumatic brain injury in German pediatric intensive care units—a survey of current practice[J]. Childs Nerv Syst, 2019, 35(5): 815-822. doi: 10.1007/s00381-019-04098-z
[15] Erkol Tuncer GH, Ekim M, Okulu E, et al. Continuous renal replacement therapy in critically ill children: single-center experience[J]. Turk J Med Sci, 2021, 51(1): 188-194. doi: 10.3906/sag-2006-227
[16] Hamdi T, Yessayan L, Yee J, et al. High sodium continuous veno-venous hemodialysis with regional citrate anticoagulation and online dialysate generation in patients with acute liver failure and cerebral edema[J]. Hemodial Int, 2018, 22(2): 184-191. doi: 10.1111/hdi.12572
[17] Fang DA, Chabrier-Rosello JO, McMahon BA, et al. Achieving osmotic stability in the context of critical illness and acute kidney injury during continuous renal replacement therapy[J]. ASAIO J, 2020, 66(7): e90-e93. doi: 10.1097/MAT.0000000000001100
[18] Ságová M, Wojke R, Maierhofer A, et al. Automated individualization of dialysate sodium concentration reduces intradialytic plasma sodium changes in hemodialysis[J]. Artif Organs, 2019, 43(10): 1002-1013. doi: 10.1111/aor.13463
[19] Fernández Lafever SN, López J, González R, et al. Hemodynamic disturbances and oliguria during continuous kidney replacement therapy in critically ill children[J]. Pediatr Nephrol, 2021, 36(7): 1889-1899. doi: 10.1007/s00467-020-04804-z
[20] Sanderson KR, Harshman LA. Renal replacement therapies for infants and children in the ICU[J]. Curr Opin Pediatr, 2020, 32(3): 360-366. doi: 10.1097/MOP.0000000000000894
[21] 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. doi: 10.1007/s00467-018-4047-7
[22] Lund A, Damholt MB, Wiis J, et al. Intracranial pressure during hemodialysis in patients with acute brain injury[J]. Acta Anaesthesiol Scand, 2019, 63(4): 493-499.
[23] Kanbay M, Ertuglu LA, Afsar B, et al. An update review of intradialytic hypotension: concept, risk factors, clinical implications and management[J]. Clin Kidney J, 2020, 13(6): 981-993. doi: 10.1093/ckj/sfaa078
[24] Álvarez-Nadal M, Martín-Capón I, Viera-Ramírez ER, et al. Impact of dialysate sodium concentration on vascular refilling[J]. Hemodial Int, 2022, 26(1): 30-37. doi: 10.1111/hdi.12957
[25] 刘静, 邓亚楠, 李静. 血液透析液钠浓度与尿毒症合并高血压患者血压变异性及预后的相关性[J]. 实验与检验医学, 2021, 39(4): 951-955. doi: 10.3969/j.issn.1674-1129.2021.04.058
-