药物评价研究  2016, Vol. 39 Issue (6): 1024-1027
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大剂量呋塞米持续静脉泵入对早期急性肾损伤伴急性肺水肿的临床疗效
唐龙, 陈新军, 姜保周     
陕西省人民医院 急诊内科, 陕西 西安 710068
摘要: 目的 研究大剂量呋塞米持续静脉泵入对早期急性肾损伤伴急性肺水肿的临床疗效。 方法 选择2012年2月~2015年12月在陕西省人民医院进行诊治的早期急性肾损伤伴急性肺水肿患者180例,所有患者均先持续静脉泵入1~2 mg/min呋塞米,再按照患者尿量的多少调整呋塞米的用药剂量。分别在治疗前和治疗后6、12、24、48、72 h,观察并记录患者的血肌酐、血尿素氮、氧合指数、血钾、机械通气时间、pH值、预后情况和不良反应发生情况。 结果 呋塞米用药剂量开始减少的时间平均为(12.15±3.12)h;呋塞米的应用时间平均为(46.31±4.89)h;治疗后各时间点患者的血肌酐、血尿素氮、氧合指数、pH值和血钾均与治疗前有明显差异(P < 0.05),且治疗后各时间点上述观察指标均有明显差异(P < 0.05);180例患者中,治疗后有161例肾功能恢复,占89.44%,呼吸困难的症状得到明显减轻,X线胸片发现肺水肿有明显好转,成功停止机械通气,机械通气时间平均为(35.28±11.37)h;在治疗过程中,180例患者血流动力学稳定,均未出现低血压、耳聋和耳鸣等不良反应。 结论 给予大剂量呋塞米治疗早期急性肾损伤伴急性肺水肿,能明显增加尿量,改善肾功能、内环境紊乱和预后,提高救治成功率。
关键词: 呋塞米     急性肺水肿     急性肾损伤    
Clinical effect of high-dose cefuroxime continuous intravenous pumping for early acute renal injury accompanied by acute lung edema
TANG Long, CHEN Xin-jun, JIANG Bao-zhou     
Department of Emergency Internal Medicine, Shanxi Provincial People's Hospital, Xi'an 710068, China
Abstract: Objective To investigate the clinical effect of high-dose cefuroxime continuous iv pumping on early acute renal injury accompanied by acute lung edema. Methods Selected 180 cases of patients with early acute renal injury accompanied by acute lung edema who were treated in Shanxi Provincial People's Hospital from January 2012 to December 2015. All patients were treated with 1-2 mg/min furosemide continuous infusion, the amount of furosemide was adjusted according to a target urine output. The serum creatinine, blood urea nitrogen, oxygenation index, potassium, mechanical ventilation time, pH, prognosis and adverse reactions before and after treatment 6, 12, 24, 48, and 72 h were observed and recorded. Results Cefuroxime dosage began to decrease at the average time point of (12.15±3.12) h; The average application time was (46.31±4.89) h; Compared with before treatment, serum creatinine, blood urea nitrogen, oxygen and index, pH and potassium at each time point after treatment have obvious difference (P < 0.05), and each time point after treatment had significant difference (P < 0.05); After treatment, 161 cases had renal function recovery, accounted for 89.44%, the symptoms of dyspnea, X-ray chest radiograph had improved markedly, successful stop mechanical ventilation; The average mechanical ventilation time was (35.28±11.37) h; In the process of treatment, 180 cases of patients with stable hemodynamics, all did not appear adverse reactions such as deafness and tinnitus. Conclusion Using high-dose cefuroxime to treat early acute renal injury accompanied by acute lung edema can obviously increase urine output, improve renal function, disorder of internal environment and prognosis, and improve the successful rate.
Key words: high-dose cefuroxime     acute lung edema     acute renal injury    

急性肾损伤是急诊内科常见的器官功能障碍,常伴有利尿剂抵抗、肺水肿、容量负荷过度、代谢性酸中毒和高血钾症等严重并发症,患者死亡率较高[1-2]。临床上多采用呋塞米治疗急性肾损伤,呋塞米不仅具有较强的利尿作用,还可以降低左室充盈压,增加全身静脉血容量,进而减轻肺水肿[3-4]。但关于大剂量呋塞米对早期急性肾损伤伴急性肺水肿的疗效和安全性目前尚未确认。本研究对大剂量呋塞米持续静脉泵入对早期急性肾损伤伴急性肺水肿的临床疗效进行了探讨。

1 资料与方法 1.1 一般资料

180例早期急性肾损伤伴急性肺水肿患者来自陕西省人民医院2012年2月至2015年12月,男98例,女82例;年龄46~82岁,平均(60.52±15.37)岁;其中心肺复苏术后28例,冠心病心力衰竭140例,脓毒症12例。

纳入标准:(1)早期急性肾损伤并伴有严重的呼吸衰竭,X线胸片结果显示急性肺水肿的患者;(2)患者和家属拒绝进行连续性肾脏替代治疗;(3)用呋塞米常规剂量(100 mg/d)治疗无效果;(4)所有患者均签署知情同意书。排除标准:对呋塞米过敏者、慢性肾衰竭终末期者、梗阻性肾损伤者、要求进行连续性肾脏替代治疗者、脓毒症休克者和低血容量休克者。

1.2 治疗方法

所有患者均持续静脉泵入剂量为1~2 mg/min呋塞米(上海禾丰制药有限公司,规格20 mg,产品批号34150505),按照患者全身容量、每小时尿量、平均动脉压、氧合指数和组织缺氧情况等来调整呋塞米的用药剂量[5]。治疗过程中注意监测患者生命体征和电解质的变化,及时纠正电解质紊乱。当患者出现以下情况时,需立即停药:患者接受肾脏替代治疗;持续泵入6 h后尿量仍无改变;患者肾脏功能恢复;患者死亡;出现与治疗相关的严重不良反应。

1.3 观察指标

分别在治疗前和治疗后6、12、24、48、72 h,观察并记录患者的血肌酐、血尿素氮、氧合指数、血钾、机械通气时间、pH值、预后情况和不良反应发生情况。肾功能恢复标准[6]:持续24 h自主尿量超过1. 0 mL/(kg∙h);与治疗前相比,血肌酐水平降低10%。

1.4 统计学分析

采用SPSS15.00软件,计量资料表示为x±s,治疗前后各指标的比较采用单因素方差分析,两两比较采用LSD(最小显著性差异法)检验。

2 结果 2.1 治疗前后呋塞米的用量和尿量情况

呋塞米用药剂量开始减少的时间平均为(12.15±3.12)h;呋塞米的应用时间平均为(46.31±4.89)h,治疗前后呋塞米的用量和尿量情况见表 1

表 1 治疗前后呋塞米的用量和尿量情况(x±s, n=180) Table 1 Furosemide dosage and urine volume before and after treatment (x±s, n=180)

2.2 治疗前后各观察指标的比较

治疗后各时间点患者的血肌酐、血尿素氮、氧和指数、pH和血钾均与治疗前有明显差异(P<0.05),且治疗后各时间点上述观察指标均有明显差异(P<0.05),见表 2

表 2 治疗前后各观察指标的比较(x±s, n=180) Table 2 Comparison of observed indexes before and after treatment (x±s, n=180)

2.3 机械通气时间和肾功能恢复情况

180例患者中,经治疗后有161例肾功能恢复,占89.44%,呼吸困难的症状得到明显减轻,X线胸片发现肺水肿有明显好转,成功停止机械通气。机械通气时间平均为(35.28±11.37)h。

2.4 不良反应发生情况

在治疗过程中,180例患者血流动力学稳定,均未出现低血压、耳聋和耳鸣等不良反应。

3 讨论

急性肾损伤的临床特征主要表现为酸碱平衡紊乱、少尿、无尿及尿毒症[7]。当两侧肾脏有大约75%肾单位的功能丧失时,就会导致肾功能衰竭的发生[8]。呋塞米是一种临床常用的袢利尿剂,可通过增加肾小球滤过率,对肾脏近曲小管和远曲小管再吸收钠离子和水进行抑制,而增加尿量,畅通肾小管;另外,呋塞米还能使肺静脉得到扩张,降低毛细血管通透性,使得回心血量减少,联合其利尿作用能有效治疗肺水肿[9-12]。间断静脉推注呋塞米易

产生一过性效应,并发低血钾、低血压等不良反应,因此,本研究采取持续静脉泵入的给药方法,可持续均衡利尿,减少利尿剂抵抗现象的发生,使血流动力学更平稳。国内关于大剂量呋塞米治疗急性肾损伤的研究报道较少。Triposkiadis等[13]采用剂量为400 mg/d呋塞米治疗急性肾损伤获得了较好的治疗效果。大剂量持续静脉泵入呋塞米能避免因肾血管收缩和肾小管阻塞而造成的作用部位呋塞米浓度过低,使血药浓度能够达到阈值,达到利尿的治疗效果[14-15]

呋塞米的用药剂量应做到个体化,开始使用最小有效剂量,然后按照尿量的多少调整其剂量,以减少水、电解质紊乱等不良反应的发生[16]。本研究中呋塞米用药剂量开始减少的时间平均为(12.15±3.12)h;呋塞米的应用时间平均为(46.31±4.89)h。血肌酐和尿素氮的水平变化最能反映肾功能状况。当肾功能严重损伤时,血肌酐和尿素氮的水平就会升高,出现氮质血症。高血钾症是急性肾损伤所有并发症中最危险的一种,能造成心室传导阻滞、降低心肌收缩性和兴奋性,甚至发生心脏停搏。治疗后各时间点患者的血肌酐、血尿素氮、氧合指数、pH和血钾均与治疗前有明显差异(P<0.05),且治疗后各时间点上述观察指标均有明显差异(P<0.05);180例患者中,经治疗后有161例肾功能恢复,占89.44%,呼吸困难的症状得到明显减轻,X线胸片发现肺水肿有明显好转,成功停止机械通气;机械通气时间平均为(35.28±11.37)h;表明大剂量呋塞米能明显改善患者的肾功能并减轻肺水肿。在治疗过程中,180例患者血流动力学稳定,均未出现低血压、耳聋和耳鸣等不良反应。可能是因为高水平的呋塞米在肾小管腔内持续存在,发生持续利尿的作用,这就避免了一次静脉注射大剂量呋塞米时可能造成患者血管内物浓度过快下降和发生低血压的可能性以及耳中毒的风险。

综上所述,给予大剂量呋塞米治疗早期急性肾损伤伴急性肺水肿,能明显增加尿量,改善肾功能、内环境紊乱和预后,提高救治成功率。

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