摘要目的 探讨床旁连续性血液净化(CBP)治疗在抢救儿童重症急性胰腺炎(SAP)中的作用.方法 回顾性病例总结,分析上海市儿童医院儿科重症监护病房(PICU) 2013至2016年收治的11例临床诊断SAP患儿的临床和实验室资料,包括儿童危重病例评分(PCIS评分)和第三代小儿死亡危险评分(PRISMⅢ评分)评估危重程度.对合并脏器功能障碍的SAP患儿,常规治疗效果欠佳时进行CBP治疗,观察分析病情演变与转归情况.采用Wilcoxon秩和检验进行治疗前、后的比较.结果 11例SAP患儿中7例合并多器官功能障碍综合征(MODS).经保守治疗12～24 h后,其中6例患儿病情仍进一步加重,进行CBP治疗,使用PRISMA或PRISMA flex血液净化机和Gambroprisma滤器,采用连续性静-静脉血液滤过透析(CVVHDF)或高容量血液滤过(HVHF)模式.6例SAP患儿经CBP治疗[中位数时间48.5 (48.0,55.5)h]后均存活,治疗前、后血淀粉酶为675(495,1 334)比176(136,246) U/L,脂肪酶为551(385,1 075)比143(117,185)U/L,C反应蛋白为168(125,192)比67(28,87) mg/L,炎症细胞因子:肿瘤坏死因子(TNF)-α为67.2(51.0,72.9)比22.6(19.3,31.O)ng/L,白细胞介素(IL)-6为47.8(35.2,88.4)比23.6(20.3,42.9) ng/L,IL-10为21.3(16.8,23.9)比35.6(26.5,38.6) ng/L,治疗后较治疗前均改善(P均＜0.05);治疗前、后动脉血氧分压与吸入氧浓度的比值(PaO2/FiO2)分别为192(101,208)和240(207,267) mmHg(1 mmHg=0.133 kPa),平均动脉压(MAP)分别为58.3(56.3,62.5)和83.3(74.0,87.4) rmmHg,PCIS评分分别为66(62.5,72)和92(89,94)分,均明显好转(P均＜0.05).结论 CBP治疗儿童SAP可迅速降低SAP患儿血液淀粉酶、脂肪酶等指标,稳定内环境,阻断全身炎症反应,改善脏器功能和体液平衡,可能是儿童SAP综合抢救治疗中的重要有效手段.

abstractsObjective To explore the therapeutic role of bedside continuous blood purification (CBP) in children with severe acute pancreatitis (SAP).Method The clinical and laboratory data of 11 children with SAP who were admitted to Pediatric Intensive Care Unit (PICU) of Shanghai Children's Hospital from June 2013 to May 2016 were analyzed,including using pediatric critical illness score (PCIS) and pediatric risk of score mortality (PRISM)-Ⅲ score to assessing the severity of the disease.For those patients with severe organ dysfunction,CBP treatment was used when conventional therapy was not efficient.The evolution and prognosis of the disease were observed and analyzed.The measurement data were analyzed by Wilcoxon signed rank test.Result From June 2013 to May 2016,11 cases with SAP were treated in PICU,of whom 7 cases had combined multiple organ dysfunction syndrome (MODS).After conservative treatment for 12-24 h,6 cases with SAP deteriorated aggressively and were treated with CBP.PRISMA and PRISMA flex machines were used with Gambro PRISMA filter,and continuous venovenous hemodiafiltration(CVVHDF) or high volume hemofiltration (HVHF) were chosen as the therapy model.All 6 SAP patients survived after bedside CBP treatment(the median time spent on CBP were 48.5 (48.0,55.5) h).The serum concentration of amylase before and after the CBP treatment were respectively 675(495,1 334)vs.176(136,246) U/L,lipase 551(385,1 075)vs.143(117,185) U/L,CRP 168(125,192) vs.67 (28,87) mg/L,and inflammatory cytokines (TNF alpha 67.2 (51.0,72.9) vs.22.6 (19.3,31.0) ng/L,IL-6 47.8(35.2,88.4)vs.23.6(20.3,42.9) ng/L,IL-10 21.3(16.8,23.9)vs.35.6(26.5,38.6) ng/L),which were obviously improved after CBP treatment(all P ＜0.05).And after CBP treatment,partial pressure of oxygen (PaO2)/fraction of inspiration O2 (FiO2) (192 (101,208) and 240 (207,267) mmHg,1 mmHg =0.133 kPa),MAP (58.3(56.3,62.5) and 83.3(74.0,87.4) mmHg) and PCIS scores (66(62.5,72)and 92(89,94) scores) were higher (all P ＜0.05).Conclusion CBP in critically ill with SAP can rapidly reduce blood amylase and lipase,help to keep the stable internal environment,block the systemic inflammatory response,improve the organ functions and maintain the fluid balance.CBP treatment may be a potential therapy in children with SAP.