Chung Kevin K, Lundy Jonathan B, Matson James R, Renz Evan M, White Christopher E, King Booker T, Barillo David J, Jones John A, Cancio Leopoldo C, Blackbourne Lorne H, Wolf Steven E
Burn Center, United States Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA.
Crit Care. 2009;13(3):R62. doi: 10.1186/cc7801. Epub 2009 May 1.
Acute kidney injury (AKI) is a common and devastating complication in critically ill burn patients with mortality reported to be between 80 and 100%. We aimed to determine the effect on mortality of early application of continuous venovenous hemofiltration (CVVH) in severely burned patients with AKI admitted to our burn intensive care unit (BICU).
We performed a retrospective cohort study comparing a population of patients managed with early and aggressive CVVH compared with historical controls managed conservatively before the availability of CVVH. Patients with total body surface area (TBSA) burns of more than 40% and AKI were treated with early CVVH and their outcomes compared with a group of historical controls.
Overall, the 28-day mortality was significantly lower in the CVVH arm (n = 29) compared with controls (n = 28) (38% vs. 71%, P = 0.011) as was the in-hospital mortality (62% vs. 86%, P = 0.04). In a subgroup of patients in shock, a dramatic reduction in the pressor requirement was seen after 24 and 48 hours of treatment. Compared with controls (n = 19), significantly fewer patients in the CVVH group (n = 21) required vasopressors at 24 hours (100% vs 43%, P < 0.0001) and at 48 hours (94% vs 24%, P < 0.0001). In those with acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), there was a significant increase from baseline in the partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) ratio at 24 hours in the CVVH group (n = 16, 174 +/- 78 to 327 +/- 122, P = 0.003) but not the control group (n = 20, 186 +/- 64 to 207 +/- 131, P = 0.98).
The application of CVVH in adult patients with severe burns and AKI was associated with a decrease in 28-day and hospital mortality when compared with a historical control group, which largely did not receive any form of renal replacement. Clinical improvements were realized in the subgroups of patients with shock and ALI/ARDS. A randomized controlled trial comparing early CVVH to standard care in this high-risk population is planned.
急性肾损伤（AKI）是危重症烧伤患者常见且严重的并发症，据报道死亡率在80%至100%之间。我们旨在确定在入住我院烧伤重症监护病房（BICU）的重度烧伤合并AKI患者中早期应用连续性静脉 - 静脉血液滤过（CVVH）对死亡率的影响。
我们进行了一项回顾性队列研究，将早期积极接受CVVH治疗的患者群体与在CVVH可用之前采用保守治疗的历史对照组进行比较。全身表面积（TBSA）烧伤超过40%且合并AKI的患者接受早期CVVH治疗，并将其结果与一组历史对照组进行比较。
总体而言，CVVH组（n = 29）的28天死亡率显著低于对照组（n = 28）（38%对71%，P = 0.011），住院死亡率也是如此（62%对86%，P = 0.04）。在休克患者亚组中，治疗24小时和48小时后升压药需求量显著降低。与对照组（n = 19）相比，CVVH组（n = 21）在24小时时需要血管升压药的患者明显更少（100%对43%，P < 0.0001），48小时时也是如此（94%对24%，P < 0.0001）。在急性肺损伤（ALI）/急性呼吸窘迫综合征（ARDS）患者中，CVVH组（n = 16）在24小时时动脉血氧分压（PaO2）与吸入氧分数（FiO2）的比值较基线有显著升高（从174±78升至327±122，P = 0.003），而对照组（n = 20）则无明显变化（从186±64升至207±131，P = 0.98）。
与基本未接受任何形式肾脏替代治疗的历史对照组相比，在成年重度烧伤合并AKI患者中应用CVVH可降低28天和住院死亡率。在休克和ALI/ARDS患者亚组中实现了临床改善。计划在这一高危人群中开展一项比较早期CVVH与标准治疗的随机对照试验。
