目的 观察早期应用神经肌肉阻断剂(NMBA)治疗严重脓毒症合并急性呼吸窘迫综合征(ARDS)的临床效果.方法 采用前瞻性临床研究方法,选择2012年7月至2013年9月广西壮族自治区柳州市人民医院重症监护病房(ICU)收治的96例严重脓毒症合并ARDS患者,根据ARDS柏林定义分为重度ARDS组(48例)及中度ARDS组(48例),各组再按随机数字表法分为治疗组与对照组,每组24例.所有患者按照2008年国际严重脓毒症与感染性休克治疗指南给予综合治疗,并在镇静,镇痛基础上行气管插管机械通气;治疗组在机械通气开始时给予负荷剂量维库溴铵0.1 mg/kg后以0.05 mg· kg-1·h-1持续静脉泵入24 ～ 48 h.比较两组患者治疗前和治疗48 h后急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、序贯器官衰竭评分(SOFA)、氧合指数(paO2/FiO2)、中心静脉血氧饱和度(ScvO2)、动脉血乳酸(Lac)、C-反应蛋白(CRP)水平及21d病死率.结果 在中度或重度ARDS患者中,治疗组与对照组治疗前APACHEⅡ评分、SOFA评分、PaO2/FiO2、ScvO2、Lac、CRP比较差异均无统计学意义.在重度ARDS患者中,治疗组治疗48 h后APACHEⅡ评分、SOFA评分、PaO2/FiO2、ScvO2、Lac的改善均较对照组明显[APACHEⅡ评分(分):16.58±2.41比19.79±3.52,t=3.679,P=0.010; SOFA评分(分):12.04±2.17比14.75±3.26,t=3.385,P=0.010;PaOJFiO2(mmHg,1mmHg=0.133 kPa):159.31±22.57比131.81±34.93,t=3.239,P=0.020; ScvO2:0.673±0.068比0.572±0.142,t=3.137,P=0.030;Lac(mmol/L):3.10±1.01比4.39±1.72,t=3.161,P=0.030],而CRP差异无统计学意义(mg/L:180.91±37.14比174.66±38.46,t=0.572,P=0.570);且治疗组21d病死率明显低于对照组[20.8％ (5/24)比50.0％(12/24),x2=4.463,P=0.035].在中度ARDS患者中,治疗组与对照组治疗48 h后,除CRP无明显变化外,各指标均有所改善,但两组间各项指标比较差异无统计学意义(均P＞0.05);治疗组21d病死率略低于对照组,但差异也无统计学意义[16.7％(4/24)比25.0％(6/24),x2=0.505,P=0.477].结论 早期使用NMBA治疗严重脓毒症合并重度ARDS患者,不仅能有效改善病情严重程度,且能够降低21d病死率.
目的 觀察早期應用神經肌肉阻斷劑(NMBA)治療嚴重膿毒癥閤併急性呼吸窘迫綜閤徵(ARDS)的臨床效果.方法 採用前瞻性臨床研究方法,選擇2012年7月至2013年9月廣西壯族自治區柳州市人民醫院重癥鑑護病房(ICU)收治的96例嚴重膿毒癥閤併ARDS患者,根據ARDS柏林定義分為重度ARDS組(48例)及中度ARDS組(48例),各組再按隨機數字錶法分為治療組與對照組,每組24例.所有患者按照2008年國際嚴重膿毒癥與感染性休剋治療指南給予綜閤治療,併在鎮靜,鎮痛基礎上行氣管插管機械通氣;治療組在機械通氣開始時給予負荷劑量維庫溴銨0.1 mg/kg後以0.05 mg· kg-1·h-1持續靜脈泵入24 ～ 48 h.比較兩組患者治療前和治療48 h後急性生理學與慢性健康狀況評分繫統Ⅱ(APACHEⅡ)評分、序貫器官衰竭評分(SOFA)、氧閤指數(paO2/FiO2)、中心靜脈血氧飽和度(ScvO2)、動脈血乳痠(Lac)、C-反應蛋白(CRP)水平及21d病死率.結果 在中度或重度ARDS患者中,治療組與對照組治療前APACHEⅡ評分、SOFA評分、PaO2/FiO2、ScvO2、Lac、CRP比較差異均無統計學意義.在重度ARDS患者中,治療組治療48 h後APACHEⅡ評分、SOFA評分、PaO2/FiO2、ScvO2、Lac的改善均較對照組明顯[APACHEⅡ評分(分):16.58±2.41比19.79±3.52,t=3.679,P=0.010; SOFA評分(分):12.04±2.17比14.75±3.26,t=3.385,P=0.010;PaOJFiO2(mmHg,1mmHg=0.133 kPa):159.31±22.57比131.81±34.93,t=3.239,P=0.020; ScvO2:0.673±0.068比0.572±0.142,t=3.137,P=0.030;Lac(mmol/L):3.10±1.01比4.39±1.72,t=3.161,P=0.030],而CRP差異無統計學意義(mg/L:180.91±37.14比174.66±38.46,t=0.572,P=0.570);且治療組21d病死率明顯低于對照組[20.8％ (5/24)比50.0％(12/24),x2=4.463,P=0.035].在中度ARDS患者中,治療組與對照組治療48 h後,除CRP無明顯變化外,各指標均有所改善,但兩組間各項指標比較差異無統計學意義(均P＞0.05);治療組21d病死率略低于對照組,但差異也無統計學意義[16.7％(4/24)比25.0％(6/24),x2=0.505,P=0.477].結論 早期使用NMBA治療嚴重膿毒癥閤併重度ARDS患者,不僅能有效改善病情嚴重程度,且能夠降低21d病死率.
목적 관찰조기응용신경기육조단제(NMBA)치료엄중농독증합병급성호흡군박종합정(ARDS)적림상효과.방법 채용전첨성림상연구방법,선택2012년7월지2013년9월엄서장족자치구류주시인민의원중증감호병방(ICU)수치적96례엄중농독증합병ARDS환자,근거ARDS백림정의분위중도ARDS조(48례)급중도ARDS조(48례),각조재안수궤수자표법분위치료조여대조조,매조24례.소유환자안조2008년국제엄중농독증여감염성휴극치료지남급여종합치료,병재진정,진통기출상행기관삽관궤계통기;치료조재궤계통기개시시급여부하제량유고추안0.1 mg/kg후이0.05 mg· kg-1·h-1지속정맥빙입24 ～ 48 h.비교량조환자치료전화치료48 h후급성생이학여만성건강상황평분계통Ⅱ(APACHEⅡ)평분、서관기관쇠갈평분(SOFA)、양합지수(paO2/FiO2)、중심정맥혈양포화도(ScvO2)、동맥혈유산(Lac)、C-반응단백(CRP)수평급21d병사솔.결과 재중도혹중도ARDS환자중,치료조여대조조치료전APACHEⅡ평분、SOFA평분、PaO2/FiO2、ScvO2、Lac、CRP비교차이균무통계학의의.재중도ARDS환자중,치료조치료48 h후APACHEⅡ평분、SOFA평분、PaO2/FiO2、ScvO2、Lac적개선균교대조조명현[APACHEⅡ평분(분):16.58±2.41비19.79±3.52,t=3.679,P=0.010; SOFA평분(분):12.04±2.17비14.75±3.26,t=3.385,P=0.010;PaOJFiO2(mmHg,1mmHg=0.133 kPa):159.31±22.57비131.81±34.93,t=3.239,P=0.020; ScvO2:0.673±0.068비0.572±0.142,t=3.137,P=0.030;Lac(mmol/L):3.10±1.01비4.39±1.72,t=3.161,P=0.030],이CRP차이무통계학의의(mg/L:180.91±37.14비174.66±38.46,t=0.572,P=0.570);차치료조21d병사솔명현저우대조조[20.8％ (5/24)비50.0％(12/24),x2=4.463,P=0.035].재중도ARDS환자중,치료조여대조조치료48 h후,제CRP무명현변화외,각지표균유소개선,단량조간각항지표비교차이무통계학의의(균P＞0.05);치료조21d병사솔략저우대조조,단차이야무통계학의의[16.7％(4/24)비25.0％(6/24),x2=0.505,P=0.477].결론 조기사용NMBA치료엄중농독증합병중도ARDS환자,불부능유효개선병정엄중정도,차능구강저21d병사솔.
Objective To observe the clinical effects of early use of neuromuscular blocking agents (NMBA) in patients with severe sepsis and acute respiratory distress syndrome (ARDS).Methods A prospective study was conducted.96 patients with severe sepsis and ARDS admitted from July 2012 to September 2013 to intensive care unit (ICU) of Liuzhou People's Hospital in Guangxi Zhuang Autonomous Region were enrolled and divided into severe ARDS group (n=48) and moderate ARDS group (n=48) according to the Berlin definition of ARDS.Then patients in each group were randomly divided into treatment group (n =24) and control group (n=24).All patients with diagnosis in accordance with the 2008 international septic shock and severe sepsis treatment guidelines were provided with comprehensive treatment and mechanical ventilation on the basis of analgesia and sedation.The patients in treatment group were given a loading dose of vecuronium during mechanical ventilation,started with 0.l mg/kg up to 0.05 mg ·kg 1 ·h 1 for continuous intravenous infusion for 24-48 hours.The acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score,sequential organ failure assessment (SOFA),arterial oxygenation index (PaOfFiO2),central venous oxygen saturation (ScvO2),arterial blood lactate (Lac),C-reactive protein (CRP) levels of two groups were compared before treatment and 48 hours after treatment,and 21-day mortality rate was finally compared.Results In moderate or severe ARDS group,there were no statistically significant difference in APACHE Ⅱ score,SOFA score,PaO2/FiO2,ScvO2,Lac and CRP before treatment between two groups.APACHE Ⅱ score,SOFA score,PaO2/FiO2,ScvO2,and Lac 48 hours after treatment were significantly improved in severe ARDS group compared with control group [APACHE Ⅱ score:16.58 ± 2.41 vs.19.79 ± 3.52,t=3.679,P=0.010; SOFA score:12.04 ± 2.17 vs.14.75 ±3.26,t=3.385,P=0.010; PaO2/FiO2 (mmHg,1 mmHg=0.133 kPa):159.31 ±22.57 vs.131.81 ± 34.93,t=3.239,P=0.020; ScyO2:0.673 ± 0.068 vs.0.572 ± 0.142,t=3.137,P=0.030; Lac (mmol/L):3.10 ± 1.01 vs.4.39 ± 1.72,t=3.161,P=0.030],while the value of CRP (mg/L) showed no significant difference (180.91 ±37.14 vs.174.66 ± 38.46,t=0.572,P=0.570).21-day mortality in treatment group was significantly lower than that in control group [20.8％ (5/24) vs.50.0％ (12/24),x2=4.463,P=0.035].In moderate ARDS group,each of the above clinical parameters were improved in both groups expect for CRP at 48 hours after treatment,but the indexes showed no statistically significant difference between two groups (all P＞0.05).21-day mortality rate in the treatment group was slightly lower than that in the control group which showed no statistically significant difference [16.7％ (4/24) vs.25.0％(6/24),x2=0.505,P=0.477].Conclusion The early use of NMBA treatment of patients with severe sepsis and severe ARDS cannot only improve the severity but also reduce 21-day mortality.
