中华危重病急救医学
中華危重病急救醫學
중화위중병급구의학
Chinese Critical Care Medicine
2014年
1期
23-27
,共5页
感染性休克%集束化治疗%脉搏指示连续心排血量
感染性休剋%集束化治療%脈搏指示連續心排血量
감염성휴극%집속화치료%맥박지시련속심배혈량
Septic shock%Surviving sepsis bundles%Pulse indicated continuous cardiac output
目的 探讨脉搏指示连续心排血量(PiCCO)监测指导下的早期目标导向治疗(EDGT)对感染性休克患者的治疗效果.方法 选择2009年1月至2012年12月收住江苏省苏北人民医院的82例感染性休克患者,按随机数字表法分为传统集束化组(40例)和改良集束化组(42例)两组.传统集束化组按国际脓毒症指南标准给予常规EDGT集束化方案复苏.改良集束化组首先放置PiCCO导管,根据所测得的胸腔内血容量指数(ITBVI)指导液体复苏,使ITBVI达到850 ～1 000 mL/m2;并根据左心室收缩力指数(dPmax)和每搏量指数(SVI)等指标应用多巴酚丁胺调节心功能,使用去甲肾上腺素维持平均动脉压(MAP)≥65 mmHg(1 mmHg=0.133 kPa),同时监测血管外肺水指导液体选择和利尿剂的应用.观察两组患者治疗前后急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分和序贯器官衰竭评分(SOFA)、使用血管活性药物的例数、血清降钙素原(PCT)水平、动脉血乳酸、乳酸清除率、复苏液体量的变化及机械通气时间、住重症监护病房(ICU)时间、住院病死率.结果 两组患者治疗后APACHEⅡ评分、SOFA评分、使用血管活性药物的例数均较治疗前逐渐降低,且治疗72 h时改良集束化组显著低于传统集束化组[APACHEⅡ评分(分):13.1±6.5比20.9±7.5,SOFA评分(分):8.8±4.3比14.6±4.9,使用血管活性药物的例数:8比17,均P＜ 0.05].两组治疗后乳酸清除率均逐渐增加,改良集束化组各时间点乳酸清除率均明显高于传统集束化组[6 h:(18.2±8.3)％比(10.8±7.5)％,t=-6.036,P=0.001;12 h:(22.6-7.3)％比(12.4±8.1)％,t=-4.536,P=0.001;24 h:(27.8±5.6)％比(16.4±9.5)％,t=-5.882,P=0.000].改良集束化组6h内使用复苏液体量明显多于传统集束化组(mL:3 608±715比2 809±795,t=-3.865,P=0.033),而24、48和72 h复苏液体量均较传统集束化组明显减少,以72 h为最低(mL:918± 351比1805±420,t=5.907,P=0.037).改良集束化组机械通气时间(h:98.4±20.3比143.3±29.6,t=9.766,P=0.001)、住ICU时间(d:7.1±3.1比9.5±2.5,t=2.993,P=0.004)也较传统集束化组明显缩短,但住院病死率略低于传统集束化组[16.7％(7/42)比17.5％(7/40),x2=0.010,P=0.920].结论 以PiCCO指导的改良集束化治疗能降低感染性休克患者的疾病严重程度,更准确地指导液体复苏、减少肺水,缩短机械通气和住ICU时间,具有很大的临床意义.
目的 探討脈搏指示連續心排血量(PiCCO)鑑測指導下的早期目標導嚮治療(EDGT)對感染性休剋患者的治療效果.方法 選擇2009年1月至2012年12月收住江囌省囌北人民醫院的82例感染性休剋患者,按隨機數字錶法分為傳統集束化組(40例)和改良集束化組(42例)兩組.傳統集束化組按國際膿毒癥指南標準給予常規EDGT集束化方案複囌.改良集束化組首先放置PiCCO導管,根據所測得的胸腔內血容量指數(ITBVI)指導液體複囌,使ITBVI達到850 ～1 000 mL/m2;併根據左心室收縮力指數(dPmax)和每搏量指數(SVI)等指標應用多巴酚丁胺調節心功能,使用去甲腎上腺素維持平均動脈壓(MAP)≥65 mmHg(1 mmHg=0.133 kPa),同時鑑測血管外肺水指導液體選擇和利尿劑的應用.觀察兩組患者治療前後急性生理學與慢性健康狀況評分繫統Ⅱ(APACHEⅡ)評分和序貫器官衰竭評分(SOFA)、使用血管活性藥物的例數、血清降鈣素原(PCT)水平、動脈血乳痠、乳痠清除率、複囌液體量的變化及機械通氣時間、住重癥鑑護病房(ICU)時間、住院病死率.結果 兩組患者治療後APACHEⅡ評分、SOFA評分、使用血管活性藥物的例數均較治療前逐漸降低,且治療72 h時改良集束化組顯著低于傳統集束化組[APACHEⅡ評分(分):13.1±6.5比20.9±7.5,SOFA評分(分):8.8±4.3比14.6±4.9,使用血管活性藥物的例數:8比17,均P＜ 0.05].兩組治療後乳痠清除率均逐漸增加,改良集束化組各時間點乳痠清除率均明顯高于傳統集束化組[6 h:(18.2±8.3)％比(10.8±7.5)％,t=-6.036,P=0.001;12 h:(22.6-7.3)％比(12.4±8.1)％,t=-4.536,P=0.001;24 h:(27.8±5.6)％比(16.4±9.5)％,t=-5.882,P=0.000].改良集束化組6h內使用複囌液體量明顯多于傳統集束化組(mL:3 608±715比2 809±795,t=-3.865,P=0.033),而24、48和72 h複囌液體量均較傳統集束化組明顯減少,以72 h為最低(mL:918± 351比1805±420,t=5.907,P=0.037).改良集束化組機械通氣時間(h:98.4±20.3比143.3±29.6,t=9.766,P=0.001)、住ICU時間(d:7.1±3.1比9.5±2.5,t=2.993,P=0.004)也較傳統集束化組明顯縮短,但住院病死率略低于傳統集束化組[16.7％(7/42)比17.5％(7/40),x2=0.010,P=0.920].結論 以PiCCO指導的改良集束化治療能降低感染性休剋患者的疾病嚴重程度,更準確地指導液體複囌、減少肺水,縮短機械通氣和住ICU時間,具有很大的臨床意義.
목적 탐토맥박지시련속심배혈량(PiCCO)감측지도하적조기목표도향치료(EDGT)대감염성휴극환자적치료효과.방법 선택2009년1월지2012년12월수주강소성소북인민의원적82례감염성휴극환자,안수궤수자표법분위전통집속화조(40례)화개량집속화조(42례)량조.전통집속화조안국제농독증지남표준급여상규EDGT집속화방안복소.개량집속화조수선방치PiCCO도관,근거소측득적흉강내혈용량지수(ITBVI)지도액체복소,사ITBVI체도850 ～1 000 mL/m2;병근거좌심실수축력지수(dPmax)화매박량지수(SVI)등지표응용다파분정알조절심공능,사용거갑신상선소유지평균동맥압(MAP)≥65 mmHg(1 mmHg=0.133 kPa),동시감측혈관외폐수지도액체선택화이뇨제적응용.관찰량조환자치료전후급성생이학여만성건강상황평분계통Ⅱ(APACHEⅡ)평분화서관기관쇠갈평분(SOFA)、사용혈관활성약물적례수、혈청강개소원(PCT)수평、동맥혈유산、유산청제솔、복소액체량적변화급궤계통기시간、주중증감호병방(ICU)시간、주원병사솔.결과 량조환자치료후APACHEⅡ평분、SOFA평분、사용혈관활성약물적례수균교치료전축점강저,차치료72 h시개량집속화조현저저우전통집속화조[APACHEⅡ평분(분):13.1±6.5비20.9±7.5,SOFA평분(분):8.8±4.3비14.6±4.9,사용혈관활성약물적례수:8비17,균P＜ 0.05].량조치료후유산청제솔균축점증가,개량집속화조각시간점유산청제솔균명현고우전통집속화조[6 h:(18.2±8.3)％비(10.8±7.5)％,t=-6.036,P=0.001;12 h:(22.6-7.3)％비(12.4±8.1)％,t=-4.536,P=0.001;24 h:(27.8±5.6)％비(16.4±9.5)％,t=-5.882,P=0.000].개량집속화조6h내사용복소액체량명현다우전통집속화조(mL:3 608±715비2 809±795,t=-3.865,P=0.033),이24、48화72 h복소액체량균교전통집속화조명현감소,이72 h위최저(mL:918± 351비1805±420,t=5.907,P=0.037).개량집속화조궤계통기시간(h:98.4±20.3비143.3±29.6,t=9.766,P=0.001)、주ICU시간(d:7.1±3.1비9.5±2.5,t=2.993,P=0.004)야교전통집속화조명현축단,단주원병사솔략저우전통집속화조[16.7％(7/42)비17.5％(7/40),x2=0.010,P=0.920].결론 이PiCCO지도적개량집속화치료능강저감염성휴극환자적질병엄중정도,경준학지지도액체복소、감소폐수,축단궤계통기화주ICU시간,구유흔대적림상의의.
Objective To explore the effect of early goal-directed therapy (EGDT) according to pulse indicated continuous cardiac output (PiCCO) on septic shock patients.Methods Eighty-two septic shock patients in Subei People's Hospital of Jiangsu Province from January 2009 to December 2012 were enrolled and randomly divided into two groups using a random number table,standard surviving sepsis bundle group (n=40) and modified surviving sepsis bundles group (n =42).The patients received the standard EGDT bundles in standard surviving sepsis bundle group.PiCCO catheter was placed in modified surviving sepsis bundles group.Fluid resuscitation was guided by intrathoracic blood volume index (ITBVI) with the aim of 850-1 000 mL/m2.Dobutamine was used to improve the heart function according to left ventricular contractile index (dPmax) and stroke volume index (SVI).The mean arterial blood pressure (MAP) was maintained 65 mmHg (1 mmHg=0.133 kPa) or above with norepinephrine.Extra-vascular lung water was monitored for the titration of liquid and diuretics.The acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score,sequential organ failure assessment (SOFA) score,the number of patients needed vasopressor,serum procalcitonin (PCT),lactic acid and lactate extraction ratio,the amount of fluid resuscitation,duration of mechanical ventilation,duration of intensive care unit (ICU) stay,hospital mortality were recorded in both groups.Results After treatment,the APACHE Ⅱ score,SOFA score and the number of patients needed vasopressor were gradually reduced in both groups,and those in modified surviving sepsis bundle group were significantly lower than those of standard sepsis bundle group at 72 hours (APACHE Ⅱ score:13.1 ± 6.5 vs.20.9 ± 7.5,SOFA score:8.8 ± 4.3 vs.14.6 ± 4.9,the number of patients needed vasopressor:8 vs.17,all P＜0.05).Arterial blood lactate clearance rate was gradually increased after treatment in both groups.Lactate clearance rate in modified surviving sepsis bundle group was significantly higher than that of standard surviving sepsis bundle group [6 hours:(18.2 ± 8.3)％ vs.(10.8 ± 7.5)％,t=-6.036,P=0.001 ; 12 hours:(22.6 ± 7.3)％ vs.(12.4 ± 8.1)％,t=-4.536,P=0.001 ; 24 hours:(27.8 ± 5.6)％ vs.(16.4 ± 9.5)％,t=-5.882,P=0.000].The amount of fluid resuscitation within 6 hours in modified surviving sepsis bundle group increased significantly compared with standard surviving sepsis bundle group (mL:3 608 ± 715 vs.2 809 ± 795,t=-3.865,P=0.033).The amount of fluid resuscitation within 24,48 and 72 hours in modified surviving sepsis bundle group was significantly less than that of standard modified surviving sepsis bundle group with the nadir at 72 hours (mL:918 ± 351 vs.1 805 ± 420,t=5.907,P=0.037).Duration of mechanical ventilation (hours:98.4 ± 20.3 vs.143.3 ± 29.6,t=9.766,P=0.001) and ICU stay (days:7.1 ± 3.1 vs.9.5 ± 2.5,t=2.993,P=0.004) were significantly reduced in modified surviving sepsis bundle group compared with standard surviving sepsis bundle group.The hospital mortality in modified surviving sepsis bundle group was slightly lower than that in standard surviving sepsis bundle group [16.7％(7/42)比 17.5％(7/40),x2=0.010,P=0.920].Conclusions Modified surviving sepsis bundle treatment according PiCCO can reduce the severity of disease in patients with septic shock,can make more accurately guide fluid resuscitation,and can reduce lung water and duration of mechanical ventilation and ICU stay.It has great clinical significance.
