监测严重脓毒症患者舌下微循环对病情严重程度及预后判定的临床意义
감측엄중농독증환자설하미순배대병정엄중정도급예후판정적림상의의
The clinical significance of determining the severity and prognosis by monitoring the changes in sublingual microcircuiation in patients with severe sepsis
  • 万方数据
    中国危重病急救医学 중국위중병급구의학
    CHINESE CRITICAL CARE MEDICINE
    2012年 3期 158-161 ,共4页

    赵梦雅%李昂%庄海舟%董磊%李鑑%刘冲%翁以炳%张淑文%段美丽

    조몽아%리앙%장해주%동뢰%리감%류충%옹이병%장숙문%단미려

    脓毒症%微循环%旁流暗视野%急性生理学与慢性健康状况评分系统Ⅱ%28d病死率 膿毒癥%微循環%徬流暗視野%急性生理學與慢性健康狀況評分繫統Ⅱ%28d病死率
    농독증%미순배%방류암시야%급성생이학여만성건강상황평분계통Ⅱ%28d병사솔
    Sepsis%Microcirculation%Sidestream dark-field%Acute physiology and chronic health evaluation Ⅱ%28-day mortality
    目的 探讨动态监测严重脓毒症患者舌下微循环的变化对判断病情严重程度和预后的临床意义.方法 采用前瞻性研究方法,收集北京友谊医院重症医学科2010年6月至12月符合入选标准的住院患者65例,其中脓毒症30例,严重脓毒症35例；严重脓毒症患者进行早期目标导向液体复苏治疗；于治疗0(治疗前)、6、12、24、48、72 h,采用旁流暗视野技术测定各组患者舌下微循环总血管密度(TVD)、灌注血管密度(PVD)、灌注血管比例(PPV)、微血管流动指数(MFI),并记录急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、住重症监护病房(ICU)天数及28 d病死率.另以同期30例健康体检者作为健康对照组.结果 脓毒症组舌下微循环PPV、MFI较健康对照组明显降低[PPV:(73.60±16.77)％比(85.17±7.60)％；MFI:3.23±0.77比3.78±0.35,均P＜0.05]；严重脓毒症组PVD、PPV、MFI较脓毒症组明显降低[PVD(mm/mm2):7.53±4.38比12.15±2.88；PPV:(49.13±33.74)％比(73.60±16.77)％；MFI:2.21±1.41比3.23±0.77,均P＜0.05].严重脓毒症患者经早期目标导向液体复苏后,舌下微循环指标均较治疗前(0 h)明显改善,以12h最为明显[TVD(mm/mm2):5.76±2.25比6.72±4.37；PVD(mm/mm2):7.57±1.77比5.48±4.39；PPV:(69.47±19.24)％比(34.55±30.82)％；MFI:3.17±0.49比1.55±1.14,均P＜0.05].与脓毒症组比较,严重脓毒症组APACHEⅡ评分(分)有所增加(24.77±7.45比19.30±10.36,但P＞0.05),住ICU天数(d)明显延长(20.60±19.87比10.33±9.53,P＜0.05),28 d病死率有所升高(45.71％比36.36％,但P＞ 0.05).在严重脓毒症患者中,与存活组(19例)比较,死亡组(16例)舌下微循环PVD、PPV、MFI降低更明显[PVD(mm/mm2):6.70±5.15比8.53±3.13;PPV:(44.23±37.71)％比(54.96±28.41)％;MFI:1.89±1.65比2.58±0.98,P＜0.05或P＜0.01];APACHEⅡ评分(分:23.19±6.46比20.31±6.03)及住ICU天数(d:16.13±10.90比19.19±9.90)差异均无统计学意义(均P＞0.05).相关性分析显示:PPV与患者预后呈显著负相关(r=-0.374,P＜0.05).结论 严重脓毒症患者舌下微循环动态监测可用于判断病情严重程度,对指导预后有一定意义.
    목적 탐토동태감측엄중농독증환자설하미순배적변화대판단병정엄중정도화예후적림상의의.방법 채용전첨성연구방법,수집북경우의의원중증의학과2010년6월지12월부합입선표준적주원환자65례,기중농독증30례,엄중농독증35례；엄중농독증환자진행조기목표도향액체복소치료；우치료0(치료전)、6、12、24、48、72 h,채용방류암시야기술측정각조환자설하미순배총혈관밀도(TVD)、관주혈관밀도(PVD)、관주혈관비례(PPV)、미혈관류동지수(MFI),병기록급성생이학여만성건강상황평분계통Ⅱ(APACHEⅡ)평분、주중증감호병방(ICU)천수급28 d병사솔.령이동기30례건강체검자작위건강대조조.결과 농독증조설하미순배PPV、MFI교건강대조조명현강저[PPV:(73.60±16.77)％비(85.17±7.60)％；MFI:3.23±0.77비3.78±0.35,균P＜0.05]；엄중농독증조PVD、PPV、MFI교농독증조명현강저[PVD(mm/mm2):7.53±4.38비12.15±2.88；PPV:(49.13±33.74)％비(73.60±16.77)％；MFI:2.21±1.41비3.23±0.77,균P＜0.05].엄중농독증환자경조기목표도향액체복소후,설하미순배지표균교치료전(0 h)명현개선,이12h최위명현[TVD(mm/mm2):5.76±2.25비6.72±4.37；PVD(mm/mm2):7.57±1.77비5.48±4.39；PPV:(69.47±19.24)％비(34.55±30.82)％；MFI:3.17±0.49비1.55±1.14,균P＜0.05].여농독증조비교,엄중농독증조APACHEⅡ평분(분)유소증가(24.77±7.45비19.30±10.36,단P＞0.05),주ICU천수(d)명현연장(20.60±19.87비10.33±9.53,P＜0.05),28 d병사솔유소승고(45.71％비36.36％,단P＞ 0.05).재엄중농독증환자중,여존활조(19례)비교,사망조(16례)설하미순배PVD、PPV、MFI강저경명현[PVD(mm/mm2):6.70±5.15비8.53±3.13;PPV:(44.23±37.71)％비(54.96±28.41)％;MFI:1.89±1.65비2.58±0.98,P＜0.05혹P＜0.01];APACHEⅡ평분(분:23.19±6.46비20.31±6.03)급주ICU천수(d:16.13±10.90비19.19±9.90)차이균무통계학의의(균P＞0.05).상관성분석현시:PPV여환자예후정현저부상관(r=-0.374,P＜0.05).결론 엄중농독증환자설하미순배동태감측가용우판단병정엄중정도,대지도예후유일정의의.
    Objective To investigate the clinical significance of dynamic monitoring of changes in the sublingual microcirculation in patients with severe sepsis to determine the degree of severity of the clinical condition and prognosis.Methods A prospective study was conducted.Sixty-five patients in the intensive care unit(ICU)in Beijing Friendship Hospital were enrolled from June 2010 to December 2010,among whom there were 30 cases of sepsis,35 cases of severe sepsis.The severe sepsis patients received the early goal-directed resuscitation; and at 0(before treatment),6,12,24,48,72 hours after resuscitation,the technology of sidestream dark-field was used to measure the sublingual total vessel density(TVD),perfusing vessel density(PVD),proportion of perfused vessels(PPV),microvascular flow index(MFI)of sublingual microcirculation in patients and acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ)score,ICU days and 28-day mortality were recorded.Thirty healthy individuals were enrolled as the control group.Results The sublingual PPV and MFI were significantly lower in sepsis patients than those of the control group[PPV:(73.60 ± 16.77)％ vs.(85.17 ± 7.60)％; MFI:3.23 ± 0.77 vs.3.78 ± 0.35,both P＜0.05]; PVD,PPV,MFI in severe sepsis patients were not only significantly lower than those of the sepsis group[PVD (mm/mm2):7.53 ± 4.38 vs.12.15 ± 2.88; PPV:(49.13 ± 33.74)％ vs.(73.60 ± 16.77)％; MFI:2.21 ± 1.41 vs.3.23 ±0.77,all P＜0.05].After the early goal-directed fluid resuscitation,the sublingual microcirculation was improved significantly compared with that before treatment(0 hour),and they were remarkably apparent at 12 hours[TVD (mm/mm2):5.76 ± 2.25 vs.6.72 ± 4.37; PVD(mm/mm2):7.57 ± 1.77 vs.5.48 ± 4.39; PPV:(69.47 ± 19.24)％ vs.(34.55 ±30.82)％; MFI:3.17 ±0.49 vs.1.55 ± 1.14,all P＜0.05].Compared with the sepsis group,APACHE Ⅱ score of the severe sepsis group was elevated(24.77 ± 7.45 vs.19.30 ± 10.36,butP＞0.05),the length of stay in ICU (days)was longer(20.60 ± 19.87 vs.10.33 ±9.53,P＜0.05),and the 28-day mortality was higher(45.71％ vs.36.36％,but P＞0.05).In the severe sepsis group,compared with the survival group[19 cases),the sublingual microcirculation in the non-survival group(16 cases)PVD,PPV,MFI were significantly decreased[PVD(mm/mm2):6.70 ± 5.15 vs.8.53 ± 3.13; PPV:(44.23 ± 37.71)％ vs.(54.96 ± 28.41)％; MFI:1.89 ± 1.65 vs.2.58 ± 0.98,P＜0.05 or P＜0.01],but APACHE Ⅱ score and length of stay in ICU(days)were not significantly different(23.19 ± 6.46vs.20.31 ±6.03; 16.13 ± 10.90 vs.19.19 ±9.90,both P＞0.05).Correlation analysis showed that:PPV showed a significant negative correlation with the prognosis of the patients(r=-0.374,P＜0.05).Conclusion Sequential monitoring of the sublingual microcirculation in patients with severe sepsis can be used to determine the disease severity,and to forecast the outcome of the patient.
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