中华急诊医学杂志
中華急診醫學雜誌
중화급진의학잡지
CHINESE JOURNAL OF EMERGENCY MEDICINE
2013年
4期
346-351
,共6页
卢院华%刘玲%邱晓华%于晴%杨毅%邱海波
盧院華%劉玲%邱曉華%于晴%楊毅%邱海波
로원화%류령%구효화%우청%양의%구해파
经皮氧分压%经皮二氧化碳分压%微循环%感染性休克%早期目标导向治疗%组织灌注%氧代谢%旁流暗视野成像
經皮氧分壓%經皮二氧化碳分壓%微循環%感染性休剋%早期目標導嚮治療%組織灌註%氧代謝%徬流暗視野成像
경피양분압%경피이양화탄분압%미순배%감염성휴극%조기목표도향치료%조직관주%양대사%방류암시야성상
Transcutaneous pressure of oxygen%Transcutaneous pressure of carbon dioxide%Microcirculation%Septic shock%Early goal directed therapy%Tissue perfusion%Tissue oxygenation%Sidestream dark field imaging
目的 探讨早期目标导向治疗(EGDT)对感染性休克患者组织灌注、微循环和氧代谢的影响.方法 前瞻性观察性研究,选取2009年9月至2011年5月东南大学附属中大医院ICU收治的早期感染性休克(＜24 h)患者,并且EGDT未达标(四项指标中至少一项未达标),排除脑血管意外、颅脑外伤、合并其他类型休克、重度心衰、急性心梗、未成年人、妊娠、疾病终末期、心搏呼吸骤停、大面积烧伤、口腔毁损或出血、张口极度困难、感染性休克发病时间大于24h等患者,按照EGDT流程对患者进行治疗,监测血流动力学、经皮氧分压(PtcO2)和二氧化碳分压(PtcCO2),用旁流暗视野成像仪(SDF)监测舌下微循环,观察同一患者EGDT达标前后血流动力学、组织氧和舌下微循环变化.符合正态性分布者自身比较用配对t检验,不符合者用Wilcoxon符号秩和检验,变量相关性采用Pearson相关分析.结果 20例患者进入本研究,1例患者EGDT未达标,未纳入分析,最终共有19例患者EGDT达标并监测了组织氧,其中4例患者同时监测了患者舌下微循环.(1)与治疗前相比,EGDT达标后PtcO2[(8.0±30.9) mm Hgvs.(62.7±24.0)mm Hg,P＜0.05,1 mm Hg =0.133 kPa],组织氧合指数(PtcO2/FiO2)[(141.6±78.2) mmHgvs.(110.7 ±60.4) mm Hg,P＜0.05]显著增加,PtcCO2和经皮-动脉二氧化碳分压差(PCO2 gap) (P ＜0.05)显著降低.(2) EGDT达标后灌注血管比例(PPV) (P =0.051)、微循环血流量指数(MFI) (P =0.074)均较治疗前有增加趋势.(3) PtcO2、组织氧合指数、PtcCO2与中心静脉血氧饱和度、乳酸、氧输送、氧耗差异均无统计学意义(P＞0.05).结论 EGDT能改善感染性休克患者局部组织灌注和微循环,感染性休克EGDT达标前后全身组织灌注的指标可能不能反映局部组织灌注.
目的 探討早期目標導嚮治療(EGDT)對感染性休剋患者組織灌註、微循環和氧代謝的影響.方法 前瞻性觀察性研究,選取2009年9月至2011年5月東南大學附屬中大醫院ICU收治的早期感染性休剋(＜24 h)患者,併且EGDT未達標(四項指標中至少一項未達標),排除腦血管意外、顱腦外傷、閤併其他類型休剋、重度心衰、急性心梗、未成年人、妊娠、疾病終末期、心搏呼吸驟停、大麵積燒傷、口腔燬損或齣血、張口極度睏難、感染性休剋髮病時間大于24h等患者,按照EGDT流程對患者進行治療,鑑測血流動力學、經皮氧分壓(PtcO2)和二氧化碳分壓(PtcCO2),用徬流暗視野成像儀(SDF)鑑測舌下微循環,觀察同一患者EGDT達標前後血流動力學、組織氧和舌下微循環變化.符閤正態性分佈者自身比較用配對t檢驗,不符閤者用Wilcoxon符號秩和檢驗,變量相關性採用Pearson相關分析.結果 20例患者進入本研究,1例患者EGDT未達標,未納入分析,最終共有19例患者EGDT達標併鑑測瞭組織氧,其中4例患者同時鑑測瞭患者舌下微循環.(1)與治療前相比,EGDT達標後PtcO2[(8.0±30.9) mm Hgvs.(62.7±24.0)mm Hg,P＜0.05,1 mm Hg =0.133 kPa],組織氧閤指數(PtcO2/FiO2)[(141.6±78.2) mmHgvs.(110.7 ±60.4) mm Hg,P＜0.05]顯著增加,PtcCO2和經皮-動脈二氧化碳分壓差(PCO2 gap) (P ＜0.05)顯著降低.(2) EGDT達標後灌註血管比例(PPV) (P =0.051)、微循環血流量指數(MFI) (P =0.074)均較治療前有增加趨勢.(3) PtcO2、組織氧閤指數、PtcCO2與中心靜脈血氧飽和度、乳痠、氧輸送、氧耗差異均無統計學意義(P＞0.05).結論 EGDT能改善感染性休剋患者跼部組織灌註和微循環,感染性休剋EGDT達標前後全身組織灌註的指標可能不能反映跼部組織灌註.
목적 탐토조기목표도향치료(EGDT)대감염성휴극환자조직관주、미순배화양대사적영향.방법 전첨성관찰성연구,선취2009년9월지2011년5월동남대학부속중대의원ICU수치적조기감염성휴극(＜24 h)환자,병차EGDT미체표(사항지표중지소일항미체표),배제뇌혈관의외、로뇌외상、합병기타류형휴극、중도심쇠、급성심경、미성년인、임신、질병종말기、심박호흡취정、대면적소상、구강훼손혹출혈、장구겁도곤난、감염성휴극발병시간대우24h등환자,안조EGDT류정대환자진행치료,감측혈류동역학、경피양분압(PtcO2)화이양화탄분압(PtcCO2),용방류암시야성상의(SDF)감측설하미순배,관찰동일환자EGDT체표전후혈류동역학、조직양화설하미순배변화.부합정태성분포자자신비교용배대t검험,불부합자용Wilcoxon부호질화검험,변량상관성채용Pearson상관분석.결과 20례환자진입본연구,1례환자EGDT미체표,미납입분석,최종공유19례환자EGDT체표병감측료조직양,기중4례환자동시감측료환자설하미순배.(1)여치료전상비,EGDT체표후PtcO2[(8.0±30.9) mm Hgvs.(62.7±24.0)mm Hg,P＜0.05,1 mm Hg =0.133 kPa],조직양합지수(PtcO2/FiO2)[(141.6±78.2) mmHgvs.(110.7 ±60.4) mm Hg,P＜0.05]현저증가,PtcCO2화경피-동맥이양화탄분압차(PCO2 gap) (P ＜0.05)현저강저.(2) EGDT체표후관주혈관비례(PPV) (P =0.051)、미순배혈류량지수(MFI) (P =0.074)균교치료전유증가추세.(3) PtcO2、조직양합지수、PtcCO2여중심정맥혈양포화도、유산、양수송、양모차이균무통계학의의(P＞0.05).결론 EGDT능개선감염성휴극환자국부조직관주화미순배,감염성휴극EGDT체표전후전신조직관주적지표가능불능반영국부조직관주.
Objective To observe the effect of early goal directed therapy (EGDT) on tissue perfusion,microcirculation and tissue oxygenation in patients with septic shock.Methods A prospective observational study was carried out in 20 patients with early septic shock admitted to ICU within 24 hours after onset.Patients with one of following conditions,including stroke,brain injury,other types of shock,severe heart failure,acute myocardium infarction,ages below 18,pregnancy,terminal stage of disease,cardiac arrest,extensive bums,mouth bleeding,oromandiblular dyetonia (difficult to open the mouth),and the time elapsed over 24 hours after onset of septic shock,were excluded.The eligible patients were treated with the standard procedure of EGDT.The partial pressure of transcutaneous oxygen and carbon dioxide (PtcO2,PtcCO2) was monitored and hemodynamic data were recorded.Sidestream dark field imaging device was applied to detect the sublingual microcirculation.Hemodynamics,tissue oxygen,and sublingual microcirculation were compared before treatment and after EGDT.When the variables met the normal distribution,t test was applied.Otherwise,Wilcoxon test was used.Correlation between variables was analyzed with Pearson Correlation Analysis.Results Of 20 patients,19 met all 4 elements in criteria of EGDT after treatment and were eligible for study.PtcO2 and PtcCO2 were monitored in 19 patients.Sublingual microcirculation was obtained in four of them.(1) After the criteria of EGDT were entirely met,PtcO2 increased from (62.7 ± 24.0) mm Hg to (78.0 ± 30.9) mm Hg (P ＜ 0.05) ; tissue oxygenation index (PtcO2/FiO2) was (110.7 ± 60.4) mm Hg before treatment and (141.6 ± 78.2) mm Hg after EGDT (P ＜ 0.05).PtcCO2 and PaCO2 gap (difference between PtcCO2 and PaCO2) decreased significantly after EGDT (P ＜ 0.05).(2) Both proportion of small vessels with perfusion (PVP) and microcirculatory flow index of small vessels (MFI) showed a trend of increase after EGDT,but there were no significant differences between pre-and post-EGDT (P was 0.051 and 0.074 respectively).(3) PtcO2,PtcO2/FiO2,and PtcCO2 were not linearly related to central venous saturation,lactate,oxygen delivery,and oxygen consumption (All P ＞ 0.05).Conclusions Peripheral perfusion improved after EGDT in patients with septic shock but those hemodynamic variables might not exactly reflect the authenticity of global perfusion.
