摘要： 目的 探讨血浆置换（PE）联合连续性肾脏替代疗法（CRRT）治疗劳力性热射病（EHS）效果的影响因素。方法 收集2017年6月至2021年12月中国医科大学附属盛京医院、武警辽宁省总队医院与北部战区总医院急诊医学科采用PE联合CRRT治疗的62例EHS患者的临床资料。根据患者治疗前后急性生理与慢性健康状况评分（APACHEⅡ）下降幅度，将患者分为改善≥40%组（n=34）和改善<40%组（n=28）。采用t检验或χ²检验比较2组患者年龄、体质量指数（BMI）、发病2 h内体温控制水平、发病至PE联合CRRT治疗的间隔时间、置换血浆量、治疗前动脉血乳酸（Lac）水平、肌红蛋白（Mb）、肌酸激酶（CK）、血清尿素氮（BUN）、肌酐（Scr）、丙氨酸转氨酶（ALT）、天冬氨酸转氨酶（AST）、血小板（PLT）、活化部分凝血活酶时间（APTT）、纤维蛋白原（Fib）指标的差异。将单因素分析有统计学意义（P<0.05）的指标进行多因素logistic回归分析。结果 62例EHS患者应用PE联合CRRT治疗前后APACHEⅡ评分分别为（23.5±2.8）分、（10.6±1.3）分，2者差异有统计学意义（P<0.05）。与改善<40%组比较，改善≥40%组患者发病2 h内体温控制水平、发病至PE联合CRRT治疗的间隔时间、Lac、CK、Scr、PLT比较差异均有统计学意义（均P<0.05）。多因素logistic回归分析结果显示，治疗后APACHEⅡ评分下降幅度与发病2 h内体温控制水平、发病至PE联合CRRT治疗的间隔时间、Lac、CK、Scr、PLT显著相关（均P<0.05）。与改善<40%组比较，改善≥40%组全身并发症（横纹肌溶解、急性肾损伤、肝功能不全、弥散性血管内凝血）发生率及病死率均显著降低（均P<0.05）。结论 发病2 h内体温下降幅度、发病至PE联合CRRT治疗的间隔时间、Lac、CK、Scr、PLT是PE联合CRRT治疗EHS效果的影响因素，发病早期采取降温、扩容补液、PE联合CRRT等集束化治疗是提高EHS救治成功率的关键。

血浆置换联合连续性肾脏替代疗法治疗劳力性热射病效果的影响因素

李建军¹, 孟强², 张越², 高燕³, 李志伟²

1. 中国医科大学附属盛京医院创伤骨科, 沈阳 110004;
2. 武警辽宁省总队医院急诊医学科, 沈阳 110034;
3. 北部战区总医院急诊医学科, 沈阳 110016

收稿日期:2022-10-12出版日期:2023-03-30发布日期:2023-03-21
通讯作者:李志伟E-mail:172092067@qq.com
作者简介:李建军(1971-),男,主任医师,博士.
基金资助:国家自然科学基金（81971829）


关键词: 血浆置换, 连续性肾脏替代疗法, 劳力性热射病, 影响因素
Abstract: Objective To study the factors influencing plasma exchange （PE） combined with continuous renal replacement therapy （CRRT） in the treatment of exertional heat stroke （EHS）. Methods The clinical data of 62 patients with EHS who were treated with PE combined with CRRT in the emergency medicine department of Shengjing Hospital of the China Medical University，Liaoning Provincial Armed Police Force Corps Hospital，and General Hospital of Northern Theater Command were collected from June 2017 to December 2021. They were divided into improvement≥40% group （n=34） and improvement <40% group （n=28） according to the decrease in acute physiology and chronic health evaluationⅡ （APACHEⅡ） score before and after the treatment. The index differences of the patients’ age，body mass index （BMI），temperature control level within 2 h，interval time from incidence to PE combined with CRRT，plasma exchange dosage，arterial blood lactate level before the treatment，myoglobin （Mb），creatine kinase （CK），blood urea nitrogen （BUN），serum creatinine （Scr），alanine aminotransferase （ALT），aspartate aminotransferase （AST），platelet （PLT），activated partial thromboplastin time （APTT），and fibrin （Fib） in the two groups were compared using t test or χ² test. The indexes that have statistical differences （P<0.05） in single-factor analysis were analyzed using multiple-factor logistic regression analysis. Results The APACHE Ⅱ scores of 62 patients with EHS were 23.5±2.8 and 10.6±1.3 before and after treatment with PE combined with CRRT，respectively，and the difference was statistically significant （P<0.05）. The improvement≥40% group was statistically significant in the differences in temperature control level within 2 h，interval time from incidence to PE combined with CRRT，Lac，CK，Scr，and PLT compared with the improvement <40% group （P<0.05）. Multifactor logistic regression analysis results showed that the decrease in the APACHE Ⅱ score after treatment was significantly correlated with the temperature control level within 2 h，interval time from incidence to PE combined with CRRT，Lac，CK，Scr，and PLT （P<0.05）. The total incidence of systemic complications，such as rhabdomyolysis，acute kidney injury，hepatic insufficiency，disseminated intravascular coagulation，and mortality，was significantly reduced （P<0.05） compared with that of the <40% improvement group. Conclusion The influencing factors for PE combined with CRRT in the treatment of EHS were temperature control level within 2 h，interval time from incidence to PE combined with CRRT，Lac，CK，Scr，and PLT. Cluster treatment should be adopted as early as possible，such as cooling，rehydration，and PE combined with CRRT，and it is a key point to improve the treatment success rate of EHS.
Key words: plasma exchange, continuous renal replacement therapy, exertional heat stroke, influencing factor
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