摘要
目的通过脉搏指示连续心排出量(PiCCO)监测作为治疗目标,评价感染性休克早期以PiCCO监测结果为优化目标的导向性治疗的意义。方法收集入住南京大学医学院附属鼓楼医院重症医学科的感染性休克患者的临床资料,经过以中心静脉压(CVP)为复苏目标的初始经验性容量复苏循环仍不稳定,则实施PiCCO监测血流动力学指标,共纳入80例患者。以胸腔内血容积指数(ITBVI)、心排指数(CI)和血管外肺水指数(EVLWI)为目标指导容量复苏,记录PiCCO目标导向治疗前(初始)、8 h及24 h的血流动力学和氧代谢指标,并采用多重回归分析逐步回归法,确定影响患者28 d预后的指标。结果 80例感染性休克患者经PiCCO目标导向治疗8 h和24 h后平均动脉压(MAP)[(73.6±13.4)和(75.1±10.2)mm Hg]、ITBVI[(843.5±168.9)和(891.5±232.9)mL/m2]和CI[(3.2±1.1)和(3.9±0.4)L.min-1.m-2]均较治疗前[(69.1±21.4)mm Hg,(781.2±146.7)mL/m2和(2.7±1.5)L.min-1.m-2]显著升高,动脉血乳酸[(2.0±1.4)和(1.1±1.0)mmol/L]和外周血管阻力指数(SVRI)[(1624.2±301.7)和(1543.6±435.4)d.s.m2.cm-5]则较治疗前[(119.7±11.6)次/min,(3.1±2.4)mmol/L和(1796.2±399.1)d.s.m2.cm-5)显著下降(P<0.05),容量复苏达标率(64.7%和66.9%)明显高于初始达标率(55.7%)(P<0.05)。根据患者预后分为存活组(54例)和死亡组(26例)。存活组初始及24 h容量复苏达标率(57.1%和71.3%)均明显高于死亡组(28.6%和39.3%)。以28 d预后为因变量进行多重回归分析,建立的多重线性回归方程有统计学意义(F=55.03,P<0.05)。通过逐层筛选,拟合方程,确定初始CI(R=0.431)和ITBVI(R=0.627)以及24 h的EVLWI(R=0.305)对28 d预后有显著影响。结论感染性休克早期采用脉搏指示连续心排出量优化目标导向性治疗可以提高容量复苏成功率,改善患者预后,而且CI、ITBVI和EVLWI是较好的判断患者预后的指标。
Objective To investigate the value of pulse indicator continuous cardiac output （PiCCO） monitoring in the treatment of septic shock. Methods Patients with septic shock were selected in intensive care unit （ICU）. After initial empirical resuscitating and using vasoactive drugs, the patients with circulation instability were connected with the PiCCO temperature probe to monitor hemodynamics and to resuscitate in the target of intrathoracic blood volume index （ITBVI）, cardiac index （CI）, extravascular lung water index （EVLWI）. Hemodynamic parameters, oxygen metabolic variability and 24h-fluid management after Oh （before） ,8h, 24h, the rate of implementing resuscitation goals, oxygen metabolic variability and fluid resuscitation at different times in the guidance of PiCCO parameters were compared. The data of age, APACHE lI score, central venous pressure （ CVP）, CI, ITBVI, mean arterial pressure （ MAP）, systemic vascular resistance index （SVRI） and EVLWI after Oh and 24h were substituted into the regression equationby the multiple linear regression,to determine the indexes which would affect the 28-day prognosis. Results A total of 80 patients with septic shock were recruited in the study. Comparing fluid resuscitation at different times in the guidance of PiCCO,MAP（73.6 ＋ 13.4 and 75.1 ＋ 10. 2 mm Hg） ,ITBVI （843.5 ± 168.9 and 891.5±232.9 mL/m2）and CI （3.2 ± 1.1 and 3.9 ±0.4 L min^1 . m^2） on 8h and 24h were significantly higher than that at Oh （69. 1 ± 21.4 mm Hg,781.2 ± 146. 7 mL/m2 and 2. 7 ~ 1.5 L min^1 m^2 ）, and Lac（2.0 ± 1.4 and 1.1 ＋1.0 retool/L） and SVRI （1 624.2±301.7 and 1 543.6±435.4 d . s. m^2 . cm^-5） were declined than that at 0h（3. 1 ±2.4 mmol/L and 1 796.2±399. 1 d . s. m^2. cm^-5）（P 〈0.05）. The rate of implementing resuscitation goals at 8h （64. 7% ） and 24h （66. 9% ） were significantly higher than that at Oh （55.7%） （P 〈 0. 05 ）, but there was no significant difference between 8h and 24h （ P 〉 0. 05 ）. All of the patients were divided into a survival group （ n = 54） and a death group （ n = 26）. The rate of implementing resuscitation goals at Oh and 24h in the survival group （57.1% and 71.3%） were significantly higher than that of the death group（28.6% and 39.3% ）. By the prognosis on 28-day as the dependent variability in the multiple linear regression, multiple linear regression equation were established, and there was significantly difference （ F = 55.03, P 〈 0.05 ）. By the layer-wise screening, equation was fitted, both the CI （ R = 0.431 ） and ITBVI （ R = 0. 627 ） at beginning and EVLWI （ R = 0.305 ） at 24h were determined to influence the 28-day prognosis. Conclusions The fluid resuscitation under the guidance of PiCCO can achieve the goal better and improve the prognosis. CI, ITBVI and EVLWI were useful goal directors for the prognosis evaluation in critical ill patients.
出处
《中国呼吸与危重监护杂志》
CAS
2013年第4期349-352,共4页
Chinese Journal of Respiratory and Critical Care Medicine
基金
南京市卫生局重点项目(编号:YKK06091)
关键词
脉搏指示连续心排出量
感染性休克
复苏
Pulse index continuous cardiac output
Septic shock
Resuscitation
