摘要
目的观察脓毒性休克患者的血流动力学特征及其与中医辨证分型之间的关系，以指导脓毒性休克的辨证论治。方法采用前瞻性观察性研究方法，选择2013年1月至2015年7月广东省中医院大德路总院重症医学科收治的68例脓毒性休克患者，使用脉搏指示连续心排血量监测系统（PiCCO）观察其血流动力学变化，测定心率（HR）、平均动脉压（MAP）、中心静脉压（CVP）、心排血指数（CI）、全心舒张期末容积指数（GEDVI）、血管外肺水指数（EvLwI）、左心室收缩指数（dPmax）及外周血管阻力指数（SVRI）等指标。按C1分为高CI组（CI≥50．0mL·s-1·m-1，34例）及低cI组（CI〈50．0mL·s-1·m-1，34例），比较两组患者的临床资料及血流动力学特征。采用“四证四法”对患者辨证分型，研究不同证型患者的血流动力学特征，寻找中医证候要素与血流动力学参数的关系。按预后分为存活组及死亡组，比较两组患者的临床资料及血流动力学特征。结果脓毒性休克低cI组急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分和血糖水平均明显高于高CI组[APACHEⅡ（分）：24．4±7．2比19．8±7．4，t=-2．279，P=O．023；血糖（mmol/L）：9．7（7．7，14．6）比6．7（5．6，10．0），z=-2．257，P=0．024]，CI、GEDVI均明显低于高CI组[CI（mL·s-1·m-2）：36．7±8．3比68．4±16．7，t=10．285，P=0．000；GEDVI（mL／m2）：689．0（566．0，883．8）比838．5（692．8，1247_3），χ2=2．711，P=O．007]，sVRI明显高于高CI组[kPa·s·L-1·m-2：248．7（202．1，324．5）比143．4（102．7，171．4），z=-5．336，P=O．000]。脓毒性休克患者中医辨证以兼夹证型为主，最常见的中医证候依次为气虚证（45例）、血瘀证（40例）、毒热证（37例）、腑实证（24例）及阴虚证（10例）。5种证型患者血流动力学参数无明显差异（均P〉O．05），仅气虚证cI明显低于毒热证（mL·s-1·m-2：48．3±18．3比58．3±21．7，P〈0．05）。祛除兼证的影响后分析显示，气虚证cI明显低于非气虚证（mL·s-1·m-2：48．3±18．3比61．7±21．7，t=-2．783，P=0．007），毒热证cI明显高于非毒热证（mL·s-1·m-2：58．3±21．7比48．3±16．7，t=2．133，P=O．037）；血瘀证EVLWI明显低于非血瘀证（mL／kg：10．0（7．0，15．1）比14．9（8．5，26．8），z=-2．075，P=0．038]。与存活组（38例）比较，死亡组（30例）APACHEⅡ评分升高（分：25．8±8．4比19．1±5．4，t=-3．940，P=O．000），行连续性肾脏替代治疗（CRRT）的比例更高[60．0％（18／30）比31．6％（12／38），χ2=5．493，P=0．019]，HR更快（次／min：118．5±20．5比98．1±19．9，t=-4．157，P=0．000），气虚证的比例更高[86．7％（26／30）比50．0％（19／38），χ2=10．070，P=0．002]。结论脓毒性休克患者按血流动力学可分为高排低阻型及低排高阻型，两者具有各自的血流动力学特征；“四证四法”辨证脓毒症切实可行，不同证型之间血流动力学表现不同，存在一定关系；使用PiCCO进行血流动力学监测是中医辨证的有益补充，有利于辨证施治。
Objective To observe hemodynamic characteristics and the correlation with syndrome types of traditional Chinese medicine （TCM） in patients with septic shock, so as to direct the treatment based on syndrome differentiation. Methods A prospective observation was conducted. Sixty-eight patients with septic shock admitted to the Department of Critical Care Medicine of Dade Road General Hospital of Guangdong Hospital of TCM from f January 2013 to July 2015 were enrolled. Pulse indicating continuous cardiac output （PiCCO） was used to monitor the hemodynamic changes, including heart rate （HR）, mean arterial pressure （MAP）, central venous pressure （CVP）, cardiac index （CI）, global end diastolic volμme index （GEDVI）, extravascular lung water index （EVLWI）, maximμm rate of the increase in pressure （dPmax） and systemic vascular resistance index （SVRI）, for assessment of hemodynamics. According to the CI, the patients were divided into two groups, i.e. high CI group （CI ≥50.0 mL·s-1·m-2, n = 34） and low CI group （CI 〈 50.0 mL·s-1·m-2, n = 34）, and the clinical and hemodynamic characteristics of two groups were investigated. The TCM differentiation was conducted with ＂four syndromes and four methods＂, and the hemodynamic characteristics of different syndrome types were investigated, the correlation between the TCM syndrome factors and hemodynamic parameters was analyzed. The patients were divided into survival group and death group, and clinical parameters and hemodynamic characteristics were compared between two groups. Results The acute physiology and chronic health evaluation H （APACHE II ） score and blood glucose of low CI group were higher than those of high CI group [APACHE lI score： 24.4±7.2 vs. 19.8±7.4, t = -2.279, P = 0.023; blood glucose （retool/L）： 9.7 （7.7, 14.6） vs. 6.7 （5.6, 10.0）, Z = -2.257, P = 0.024], CI and GEDVI were lowered [CI （ mL·s-1·m-2）： 36.7±8.3 vs. 68.4± 16.7, t = 10.285, P = 0.000; GEDVI （mL/m2）： 689.0 （566.0, 883.8） vs. 838.5 （692.8, 1247.3）, Z = -2.711, P = 0.007], while SVRI was increased [kPa mL·s-1·m-2： 248.7 （202.1, 324.5） vs. 143.4 （102.7, 171.4）, Z = -5.336, P = 0.000]. Accompanied symptoms were found to occur more commonly in septic shock patients, and the most common syndrome elements were Qi deficiency syndrome （n = 45）, blood stasis syndrome （n = 40）, heat-toxin syndrome （n = 37）, Fushi syndrome （n = 24） and Yin deficiency syndrome （n = 10）, respectively. There was no significant difference in hemodynamie parameters among patients with five types of syndrome （all P 〉 0.05）. However, only the CI of those with Qi deficiency syndrome was significantly lower than that of heat-toxin syndrome （ mL·s-1·m-2：48.3 ± 18.3 vs. 53.3± 21.7, P 〈 0.05）. While the results after removing the effect of accompanied symptoms showed that CI of Qi deficiency syndrome was significantly lower than that of non-Qi deficiency syndrome （ mL·s-1·m-2：48.3 ± 18.3 vs. 61.7±21.7, t = -2.783, P = 0.007）, CI of heat-toxin syndrome was significantly higher than that of non-heat-toxin syndrome （ mL·s-1·m-2：58.3 ± 21.7 vs. 48.3 ± 16.7, t = 2.133, P = 0.037）, EVLWI of blood stasis syndrome was significantly lower than that of non-blood stasis syndrome [mL/kg： 10.0 （7.0, 15.1） vs. 14.9 （8.5, 26.8）, Z = -2.075, P = 0.038]. Compared with survival group （n = 38）, APACHE II score in death group （n = 30） was increased （25.8 ± 8.4 vs. 19.1-± 5.4, t = -3.940, P = 0.000）, the proportion of continuous renal replacement therapy （CRRT） was increased [60.0% （18/30） vs. 31.6% （12/38）, X 2 = 5.493, P = 0.019], HR was increased （bpm： 118.5±20.5 vs. 98.1± 19.9, t = -4.157, P = 0.000）, and the proportion of Qi deficiency syndrome was increased [86.7% （26/30） vs. 50.0% （19/38）, X 2 = 10.070, P = 0.002]. Conclusions Patients with sepsis shock may be divided into high-output and low-resistance ＆ low-output and high-resistance groups according to hemodynamies, with respective hemodynamic characteristics. Hemodynamic performance differed among different syndrome types, and there was a certain relationship. Hemodynamic monitoring with PiCCO was a useful supplement of TCM, which was good for the evidence-based medieine.
出处
《中华危重病急救医学》
CAS
CSCD
北大核心
2016年第2期140-146,共7页
Chinese Critical Care Medicine
基金
广东省科技厅一广东省中医药科学院联合基金项目（2014A020221044）
中医药管理局“十二五”重点专科培育项目（2012-2-129）
国家临床重点专科（中医专业）建设项目（2014-122）
关键词
脓毒性休克
血流动力学
中医证型
Septic shock
Hemodynamics
Traditional Chinese medicine syndrome
