血液灌流治疗脓毒症的应用与时机选择

doi:10.3877/cma.j.issn.2096-1537.2026.02.016

脓毒症是ICU常见的危急病症，病死率高，一直是临床治疗所面临的关键难题。血液灌流（HP）以吸附方式清除血液中内源性或外源性毒物或致病物，是一种临床常用的血液净化方式，近年来其在脓毒症中的治疗价值逐渐受到重视。本文概述了HP治疗脓毒症的作用机制与应用现状，重点探讨了其治疗脓毒症的时机选择，针对中至重度病情且需要增加血管活性药物用量的脓毒症患者，早期启动并相对延长HP治疗，或许更能使患者获益。

关键词: 血液灌流, 脓毒症, 应用, 时机选择

Sepsis is a common and critical illness in the intensive care unit (ICU) with high mortality, and remains a major challenge in clinical practice. Hemoperfusion, a blood purification method based on adsorption that removes either endogenous or exogenous toxins and pathogens, has attracted more and more interest for its therapeutic possibilities in the management of sepsis. This paper summarizes the mechanism and current application of hemoperfusion in sepsis treatment, with a particular focus on the timing of treatment. Early initiation and relatively prolonged continuous hemoperfusion may be quite helpful for individuals with moderate to severe sepsis requiring vasopressors.

Key words: Hemoperfusion, Sepsis, Application, Timing selection

表1 HP治疗中重度脓毒症的主要临床研究

研究作者	年份	地点	研究设计	干预/样本量	类型/亚组	主要发现
Klein DJ，et al ^［25］	2018	北美	RCT	PMX-HP/450例	脓毒性休克/EAA≥0.60，0.60~0.89（MODS≥9分），≥0.90	总体：28 d病死率、EAA无差异；0.60~0.89组：PMX-HP组28 d病死率、90 d病死率更低，MAP更高、VFDs更长，并依据NE是否＞0.1 μg/（kg•min）再分亚组，NE＞0.1 μg/（kg•min）组病死率也更低
Rachoin JS，et al ^［31］	2020	北美	RCT	PMX-HP/450例	脓毒性休克/EAA≥0.6，0.6~0.9（MODS≥9分），＞0.9	总体：28 d病死率、EAA无差异；0.6~0.9组：PMX-HP组，如第3天EAA≤0.65，28 d病死率更低，如第3天EAA降幅＞10.4%（中位数），VFDs更长，PAR改善更明显
Sekino M，et al ^［32］	2023	日本	回顾性探索性观察研究	PMX-HP/122例	脓毒性休克/PAI ＜1（外周灌注正常组），≥1（外周灌注异常组）	总体：两组VIS、CVP、心率、乳酸水平降低；亚组：外周灌注正常组与异常组28 d病死率、住院病死率无差异（异常组病死率应更高），异常组PAI明显改善，正常组改善不明显（但PAI≥1组PMX-HP开始时间更早）
Garcia-Ramos S，et al ^［24］	2023	西班牙	队列研究	PMX-HP/93例	腹部脓毒性休克/SOFA（分） 0~7，8~13，＞13	总体：实际30 d病死率低于APACHE Ⅱ所预测的病死率；亚组：SOFA 8~13分组实际病死率显著低于预测病死率，而其他两组实际与预测病死率无差异。
Fujimori K，et al ^［33］	2021	日本	队列研究	PMX-HP/4066例	脓毒症/SOFA（分） 0~6，7~9，10~12，13~15，16~24	亚组：7~12分的2组28 d病死率更低，其他分组无差异；0~12分的3组无CHDF时间更长，7~12分2组VFDs、无NE时间更长；SOFA组成成分中呼吸、凝血、肝脏、心血管和肾脏高评分组（≥2分），28 d病死率更低
Lee W Y，et al ^［34］	2021	韩国	队列研究	PMX-HP/60例	腹部脓毒症（已手术）/EA＜0.54，≥0.54	总体：PMX-HP组未显示生存获益；亚组：EA≥0.54组，EA下降更明显，多因素Logistics分析显示PMX-HP对EA≥0.54组有生存益处，而对EA＜0.54组无生存益处
Fujimori K，et al ^［35］	2021	日本	队列研究	PMX-HP/8282例	脓毒性休克/NE日最大剂量（mg/d）＜6，6~9.9，10~19.9，＞20	总体：PMX-HP组28 d病死率降低，无CHDF、NE、MV天数延长；亚组：＜19.9 mg/d的3组PMX-HP有生存益处，其中10~19.9 mg/d组比值比最高，＞20 mg/d组未显示生存益处
Hawchar F，et al ^［36］	2022	多国	病例系列研究	CytoSorb/936例	脓毒症/APACHE Ⅱ（分）＜30，≥30	总体：实际ICU病死率与APACHEⅡ所预测的病死率无差异，CRP、PCT下降；亚组：15~25分组实际ICU病死率高于预测的病死率，而≥30分组实际ICU病死率低于预测
Chang T，et al ^［37］	2017	多国	Meta分析	PMX-HP/1332例	脓毒症/常规治疗组病死率（%）＜30%，30%~60%，＞60%	总体：病死率降低，但在RCT研究的分组Meta分析中未观察到此情况；亚组：中、高死亡风险组（常规治疗组病死率≥30%）病死率显著降低（但论文中病死率指标不统一，证据质量偏低）
田兴国，等^［38］	2020	多国	Meta分析	PMX-HP/926例	脓毒症/中重度脓毒性休克	总体：不能降低28 d病死率；亚组：PMX-HP治疗使中重度脓毒性休克组28 d病死率降低（仅纳入4个RCT研究，且异质性过大，且未明确中重度脓毒性休克的评价标准，证据质量偏低）
Chen JJ，et al ^［39］	2023	多国	网状Meta分析	17种方式/4595例	严重感染、脓毒症、脓毒性休克/常规治疗组病死率（%）＜70%，≥70%	总体：PMX-HP与低死亡风险相关；亚组：高死亡风险组（常规治疗组病死率≥70%），PMX-HP降低其病死率（中度异质性，证据质量偏低）

表1 HP治疗中重度脓毒症的主要临床研究

研究作者	年份	地点	研究设计	干预/样本量	类型/亚组	主要发现
Klein DJ，et al ^［25］	2018	北美	RCT	PMX-HP/450例	脓毒性休克/EAA≥0.60，0.60~0.89（MODS≥9分），≥0.90	总体：28 d病死率、EAA无差异；0.60~0.89组：PMX-HP组28 d病死率、90 d病死率更低，MAP更高、VFDs更长，并依据NE是否＞0.1 μg/（kg•min）再分亚组，NE＞0.1 μg/（kg•min）组病死率也更低
Rachoin JS，et al ^［31］	2020	北美	RCT	PMX-HP/450例	脓毒性休克/EAA≥0.6，0.6~0.9（MODS≥9分），＞0.9	总体：28 d病死率、EAA无差异；0.6~0.9组：PMX-HP组，如第3天EAA≤0.65，28 d病死率更低，如第3天EAA降幅＞10.4%（中位数），VFDs更长，PAR改善更明显
Sekino M，et al ^［32］	2023	日本	回顾性探索性观察研究	PMX-HP/122例	脓毒性休克/PAI ＜1（外周灌注正常组），≥1（外周灌注异常组）	总体：两组VIS、CVP、心率、乳酸水平降低；亚组：外周灌注正常组与异常组28 d病死率、住院病死率无差异（异常组病死率应更高），异常组PAI明显改善，正常组改善不明显（但PAI≥1组PMX-HP开始时间更早）
Garcia-Ramos S，et al ^［24］	2023	西班牙	队列研究	PMX-HP/93例	腹部脓毒性休克/SOFA（分） 0~7，8~13，＞13	总体：实际30 d病死率低于APACHE Ⅱ所预测的病死率；亚组：SOFA 8~13分组实际病死率显著低于预测病死率，而其他两组实际与预测病死率无差异。
Fujimori K，et al ^［33］	2021	日本	队列研究	PMX-HP/4066例	脓毒症/SOFA（分） 0~6，7~9，10~12，13~15，16~24	亚组：7~12分的2组28 d病死率更低，其他分组无差异；0~12分的3组无CHDF时间更长，7~12分2组VFDs、无NE时间更长；SOFA组成成分中呼吸、凝血、肝脏、心血管和肾脏高评分组（≥2分），28 d病死率更低
Lee W Y，et al ^［34］	2021	韩国	队列研究	PMX-HP/60例	腹部脓毒症（已手术）/EA＜0.54，≥0.54	总体：PMX-HP组未显示生存获益；亚组：EA≥0.54组，EA下降更明显，多因素Logistics分析显示PMX-HP对EA≥0.54组有生存益处，而对EA＜0.54组无生存益处
Fujimori K，et al ^［35］	2021	日本	队列研究	PMX-HP/8282例	脓毒性休克/NE日最大剂量（mg/d）＜6，6~9.9，10~19.9，＞20	总体：PMX-HP组28 d病死率降低，无CHDF、NE、MV天数延长；亚组：＜19.9 mg/d的3组PMX-HP有生存益处，其中10~19.9 mg/d组比值比最高，＞20 mg/d组未显示生存益处
Hawchar F，et al ^［36］	2022	多国	病例系列研究	CytoSorb/936例	脓毒症/APACHE Ⅱ（分）＜30，≥30	总体：实际ICU病死率与APACHEⅡ所预测的病死率无差异，CRP、PCT下降；亚组：15~25分组实际ICU病死率高于预测的病死率，而≥30分组实际ICU病死率低于预测
Chang T，et al ^［37］	2017	多国	Meta分析	PMX-HP/1332例	脓毒症/常规治疗组病死率（%）＜30%，30%~60%，＞60%	总体：病死率降低，但在RCT研究的分组Meta分析中未观察到此情况；亚组：中、高死亡风险组（常规治疗组病死率≥30%）病死率显著降低（但论文中病死率指标不统一，证据质量偏低）
田兴国，等^［38］	2020	多国	Meta分析	PMX-HP/926例	脓毒症/中重度脓毒性休克	总体：不能降低28 d病死率；亚组：PMX-HP治疗使中重度脓毒性休克组28 d病死率降低（仅纳入4个RCT研究，且异质性过大，且未明确中重度脓毒性休克的评价标准，证据质量偏低）
Chen JJ，et al ^［39］	2023	多国	网状Meta分析	17种方式/4595例	严重感染、脓毒症、脓毒性休克/常规治疗组病死率（%）＜70%，≥70%	总体：PMX-HP与低死亡风险相关；亚组：高死亡风险组（常规治疗组病死率≥70%），PMX-HP降低其病死率（中度异质性，证据质量偏低）

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Application and timing of hemoperfusion therapy for sepsis

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Application and timing of hemoperfusion therapy for sepsis