CAJ | 학술논문

目的观察动-静脉血二氧化碳分压差[ P(cv-a) CO2]在感染性休克患者早期目标指导治疗(EGDT)过程中的变化及其对EGDT效果及预后的评估价值.方法 2009年4月至2010年10月入住东南大学附属中大医院重症医学科的26例感染性休克患者纳入研究,根据6h复苏后EGDT达标情况,将患者分为EGDT达标组与未达标组,观察EGDT前后2组患者平均动脉压(MAP)、氧输送(DO2)、心脏指数(CI)、氧耗、氧摄取率、中心静脉血氧饱和度(ScvO2)、乳酸及P(cv-a) CO2的变化,比较2组患者急性生理和慢性健康(APACHE)Ⅱ评分、住院28 d病死率等指标.结果 26例感染性休克患者中EGDT达标组15例,EGDT未达标组11例,2组患者年龄、性别差异无统计学意义.EGDT未达标组患者入组时APACHEⅡ评分(21±5)及28 d病死率(9/11)均明显高于EGDT达标组(分别为16±3和6/15),差异有统计学意义(t=2.985,x2=4.547,P＜0.05).EGDT未达标组患者治疗前后MAP、CI、DO2、氧耗、氧摄取率、ScvO2、乳酸、P(cv-a) CO2均无明显变化；而EGDT达标组患者治疗后MAP[ (90 ±9) mmHg(1 mmHg =0.133 kPa)]、CI[(4.0±1.8)L· min-1·m-2]、DO2[(596±274) ml·min-1·m-2]、ScvO2 (76.9％ ±4.1％)均明显升高(t=-3.393、-2.985、- 2.103、-3.195,P＜0.05),O2ext有下降趋势,P(cv-a) CO2[(4.2±2.7) mmHg]明显下降(t =2.211,P＜0.05),而乳酸、氧耗无明显变化.以EGDT前后P(cv-a) CO2变化作为预后判断指标的ROC曲线下面积为0.839(P =0.004),以EGDT后P(cv-a) CO2升高为依据判断患者死亡的灵敏度为100％,特异度为60％.结论感染性休克患者EGDT后P(cv-a) CO2的升高可能提示组织灌注仍未改善,P (cv-a) CO2变化可作为评估感染性休克患者EGDT效果及患者预后的指标之一.
목적 관찰동-정맥혈이양화탄분압차[ P(cv-a) CO2]재감염성휴극환자조기목표지도치료(EGDT)과정중적변화급기대EGDT효과급예후적평고개치.방법 2009년4월지2010년10월입주동남대학부속중대의원중증의학과적26례감염성휴극환자납입연구,근거6h복소후EGDT체표정황,장환자분위EGDT체표조여미체표조,관찰EGDT전후2조환자평균동맥압(MAP)、양수송(DO2)、심장지수(CI)、양모、양섭취솔、중심정맥혈양포화도(ScvO2)、유산급P(cv-a) CO2적변화,비교2조환자급성생리화만성건강(APACHE)Ⅱ평분、주원28 d병사솔등지표.결과 26례감염성휴극환자중EGDT체표조15례,EGDT미체표조11례,2조환자년령、성별차이무통계학의의.EGDT미체표조환자입조시APACHEⅡ평분(21±5)급28 d병사솔(9/11)균명현고우EGDT체표조(분별위16±3화6/15),차이유통계학의의(t=2.985,x2=4.547,P＜0.05).EGDT미체표조환자치료전후MAP、CI、DO2、양모、양섭취솔、ScvO2、유산、P(cv-a) CO2균무명현변화；이EGDT체표조환자치료후MAP[ (90 ±9) mmHg(1 mmHg =0.133 kPa)]、CI[(4.0±1.8)L· min-1·m-2]、DO2[(596±274) ml·min-1·m-2]、ScvO2 (76.9％ ±4.1％)균명현승고(t=-3.393、-2.985、- 2.103、-3.195,P＜0.05),O2ext유하강추세,P(cv-a) CO2[(4.2±2.7) mmHg]명현하강(t =2.211,P＜0.05),이유산、양모무명현변화.이EGDT전후P(cv-a) CO2변화작위예후판단지표적ROC곡선하면적위0.839(P =0.004),이EGDT후P(cv-a) CO2승고위의거판단환자사망적령민도위100％,특이도위60％.결론 감염성휴극환자EGDT후P(cv-a) CO2적승고가능제시조직관주잉미개선,P (cv-a) CO2변화가작위평고감염성휴극환자EGDT효과급환자예후적지표지일.
Objective To detect the changes of central venous-to-arterial carbon dioxide difference (P(cv-a)CO2) during early goal-directed therapy (EGDT) in patients with septic shock and evaluate its' value in predicting adequate resuscitation and prognosis. Methods From April 2009 to October 2010,26 septic shock patients were enrolled in the study.EGDT was performed in all the patients immediately after enrollment.According to the whether they achieved early goal with in the 6 hour or not,patients were separated to EGDT achievement and un-achievement groups.At the onset and after the 6 hours EGDT,mean arterial pressure (MAP),cardiac index (CI),central venous oxygen saturation (ScvO2 ),oxygen delivery ( DO2 ),oxygen comsumption ( VO2 ),oxygen extraction ratio ( O2 ext ),lactate,P ( cv-a ) CO2 were recorded.The Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ ) score and 28 day mortality were compared between 2 groups. Results There were no significant difference of age and sex between the 15 patients who achieved early goals and 11 patients who did not. EGDT un-achievement patients had higher APACHE Ⅱ score (21±5) and 28 day mortality (9/11) when compared with EGDT achievement patients (t =2.985,x2 =4.547,P ＜ 0.05 ). In EGDT un-achievement group,MAP,CI,DO2,VO2,O2ext,ScvO2,Lac,P(cv-a) CO2 were comparable between the onset and 6 hours after EGDT.However,in EGDT achievement group,MAP ((90 ± 9) mmHg( 1 mmHg =0.133 kPa)),CI ((4.0 ±1.8) L · min 1 · m-2),DO2( (596± 274) ml · min-1 · m 2),ScvO2(76.9％ ±4.1％ ) increased,and P(ev-a) CO2 ( (4.2 ± 2.7 ) mmHg) decreased significantly after 6 hours of EGDT ( t values were - 3.393,-2.985, - 2.103 and - 3.195 respectively,all P ＜ 0.05 ).The changes of P(cv-a) CO 2 between the onset and 6 hours after EGDT,demonstrated high value for predictability of outeome,according to the area under the ROC curve (AUC) was O.839 ( P =0.004).As a predictor for death,increasing of P(cv-a) CO2 after 6 hours of EGDT has a sensibility of 100％ and specificity of 60％. Conclusions Increasing of P(ev-a)CO2 after EGDT purports inadequate tissue perfusion in patients with septic shock. Changes of P(cv-a) CO 2 during EGDT demonstrated a useful tool to evaluate adequate resuscitation and prognosis.