脉搏指示连续心排血量监测下脓毒性休克患者心功能变化的前瞻性研究
맥박지시련속심배혈량감측하농독성휴극환자심공능변화적전첨성연구
Value of pulse indicator continuous cardiac output monitoring of cardiac function in septic shock patients:a prospective study
  • 万方数据
    中华危重病急救医学 중화위중병급구의학
    Chinese Critical Care Medicine
    2015年 1期 22-27 ,共6页

    伊敏%么改琦%郭向阳

    이민%요개기%곽향양

    脓毒性休克%心功能%脉搏指示连续心排血量监测 膿毒性休剋%心功能%脈搏指示連續心排血量鑑測
    농독성휴극%심공능%맥박지시련속심배혈량감측
    Septic shock%Cardiac function%Pulse indicator continuous cardiac output monitoring
    目的 探讨脉搏指示连续心排血量(PiCCO)监测指导下病情极危重脓毒性休克患者的心功能变化.方法 采用前瞻性观察性研究方法,选择2011年8月至2013年12月北京大学第三医院危重医学科收治的脓毒性休克患者36例.根据患者病情危重程度,按是否需要PiCCO监测分为PiCCO监测组和常规监测组,应用PiCCO监测的血流动力学指标指导液体复苏及血管收缩药物和正性肌力药物的使用.观察PiCCO监测组患者入重症加强治疗病房(ICU)1 d、3d时的心排血指数(CI)、全心射血分数(GEF)、左心室压力上升最大速率(dp/dt max)、超声心动图指标及血清肌钙蛋白T(TnT)、B型钠尿肽(BNP)变化.比较是否使用米力农两组患者的中心静脉压(CVP)、平均动脉压(MAP)水平和达标时间,以及去甲肾上腺素及3 d液体入量的差异.比较PiCCO监测和常规监测两组患者的病情程度及治疗结局.结果 36例患者中PiCCO监测组15例,常规监测组21例.①使用PiCCO监测的15例患者中,入ICU 1 d时心脏收缩功能指标CI、GEF、dp/dt max降低者分别占40.0％、93.3％、33.3％;入 ICU 3 d时,CI、GEF、dp/dt max降低者分别占60.0％、93.3％、60.0％,提示入ICU 3 d时CI、GEF、dp/dt max降低无明显改善.超声心动图显示,入ICU 1 d时,35.7％的患者左室射血分数(LVEF)低于正常,分别有71.4％、71.4％的患者二尖瓣舒张早期血流速度/运动速度比值(E/Em)、左心室舒张早期/舒张晚期最大血流比值(E/A)减低;入ICU 3 d时,有80％入ICU 1 d LVEF低于正常的患者LVEF恢复至正常,有50％入 ICU 1 d舒张功能减低的患者舒张功能较前好转.入ICU 1 d时,有92.9％的患者血清TnT升高,100％的患者BNP升高;入ICU 3 d时,分别有71.4％的患者TnT和78.6％的患者BNP较1d时下降.②使用PiCCO监测患者中,米力农组(8例)与非米力农组(7例)入ICU初始CVP、MAP水平及其达标时间,以及去甲肾上腺素用量差异均无统计学意义,但3d液体入量较非米力农组显著增加(mL:8 324±3 962比4 372±2 081,t=-2.362,P=0.034).③与常规监测组比较,PiCCO监测组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)、机械通气时间、ICU住院时间及住院28 d病死率均显著增加[APACHEⅡ(分):20.67±6.15比14.71±4.67,t=-3.304,P=0.002;SOFA(分):9.53±3.00比7.52±1.97,t=-2.433,P=0.020;机械通气时间(h):132 (54 ～ 310)比63(14 ～ 284),Z=-2.295,P=0.022;ICU住院时间(d):7(4～15)比5(1～14),Z=-2.360,P=0.018;住院28 d病死率:26.7％比0,P=0.023].结论 对极危重脓毒性休克患者使用PiCCO监测血流动力学,可以更全面地进行血容量、全身血管阻力和心功能监测,科学指导患者液体复苏、血管收缩药物和正性肌力药物的应用.
    목적 탐토맥박지시련속심배혈량(PiCCO)감측지도하병정겁위중농독성휴극환자적심공능변화.방법 채용전첨성관찰성연구방법,선택2011년8월지2013년12월북경대학제삼의원위중의학과수치적농독성휴극환자36례.근거환자병정위중정도,안시부수요PiCCO감측분위PiCCO감측조화상규감측조,응용PiCCO감측적혈류동역학지표지도액체복소급혈관수축약물화정성기력약물적사용.관찰PiCCO감측조환자입중증가강치료병방(ICU)1 d、3d시적심배혈지수(CI)、전심사혈분수(GEF)、좌심실압력상승최대속솔(dp/dt max)、초성심동도지표급혈청기개단백T(TnT)、B형납뇨태(BNP)변화.비교시부사용미력농량조환자적중심정맥압(CVP)、평균동맥압(MAP)수평화체표시간,이급거갑신상선소급3 d액체입량적차이.비교PiCCO감측화상규감측량조환자적병정정도급치료결국.결과 36례환자중PiCCO감측조15례,상규감측조21례.①사용PiCCO감측적15례환자중,입ICU 1 d시심장수축공능지표CI、GEF、dp/dt max강저자분별점40.0％、93.3％、33.3％;입 ICU 3 d시,CI、GEF、dp/dt max강저자분별점60.0％、93.3％、60.0％,제시입ICU 3 d시CI、GEF、dp/dt max강저무명현개선.초성심동도현시,입ICU 1 d시,35.7％적환자좌실사혈분수(LVEF)저우정상,분별유71.4％、71.4％적환자이첨판서장조기혈류속도/운동속도비치(E/Em)、좌심실서장조기/서장만기최대혈류비치(E/A)감저;입ICU 3 d시,유80％입ICU 1 d LVEF저우정상적환자LVEF회복지정상,유50％입 ICU 1 d서장공능감저적환자서장공능교전호전.입ICU 1 d시,유92.9％적환자혈청TnT승고,100％적환자BNP승고;입ICU 3 d시,분별유71.4％적환자TnT화78.6％적환자BNP교1d시하강.②사용PiCCO감측환자중,미력농조(8례)여비미력농조(7례)입ICU초시CVP、MAP수평급기체표시간,이급거갑신상선소용량차이균무통계학의의,단3d액체입량교비미력농조현저증가(mL:8 324±3 962비4 372±2 081,t=-2.362,P=0.034).③여상규감측조비교,PiCCO감측조급성생이학여만성건강상황평분계통Ⅱ(APACHEⅡ)평분、서관기관쇠갈평분(SOFA)、궤계통기시간、ICU주원시간급주원28 d병사솔균현저증가[APACHEⅡ(분):20.67±6.15비14.71±4.67,t=-3.304,P=0.002;SOFA(분):9.53±3.00비7.52±1.97,t=-2.433,P=0.020;궤계통기시간(h):132 (54 ～ 310)비63(14 ～ 284),Z=-2.295,P=0.022;ICU주원시간(d):7(4～15)비5(1～14),Z=-2.360,P=0.018;주원28 d병사솔:26.7％비0,P=0.023].결론 대겁위중농독성휴극환자사용PiCCO감측혈류동역학,가이경전면지진행혈용량、전신혈관조력화심공능감측,과학지도환자액체복소、혈관수축약물화정성기력약물적응용.
    Objective To investigate the value of employing pulse indicator continuous cardiac output (PiCCO) for cardiac function monitoring in patients with severe septic shock.Methods A prospective observation was conducted.Thirty-six septic shock patients in Department of Critical Care Medicine of Peking University Third Hospital admitted from August 2011 to December 2013 were enrolled.According to the degree of severity,the patients were divided into PiCCO monitor group and routine monitor group.The PiCCO monitor provided a continuous assessment of fluid resuscitation,vasopressors and inotropes infusion in the patients with severe septic shock.The following cardiac function parameters were assessed in severe septic shock patients on the 1st and 3rd day after intensive care unit (ICU)admission:cardiac index (CI),global ejection fraction (GEF),rate of left ventricular pressure increase (dp/dt max),echocardiography,and blood troponin T (TNT) and B-type natriuretic peptide (BNP).The central venous pressure (CVP),mean arterial pressure (MAP) and the time reaching their standard values,and the norepinephrine dosage and 3-day fluid balance in severe septic shock patients were compared between milrinone and non-milrinone usage groups.The severity degree and outcome were compared between PiCCO monitor group and routine monitor group.Results There were 15 patients in PiCCO monitor group and 21 in routine monitor group among 36 septic shock patients.① In 15 patients with PiCCO monitoring,the patients with decreased CI,GEF,and dp/dt max accounted for 40.0％,93.3％,and 33.3％ at 1 day after ICU admission,and accounted for 60.0％,93.3％,and 60.0％ at 3 days after ICU admission,and it showed that CI,GEF,and dp/dt max was not improved at 3 days after ICU admission.Echocardiography showed that 35.7％ patients had lower left ventricular ejection fraction (LVEF) at 1 day after ICU admission,71.4％ and 71.4％ of patients,respectively,had lower early diastolic mitral flow velocity/early diastolic myocardial velocity (E/Em) and early diastolic mitral flow velocity/end diastolic mitral flow velocity (E/A).Three days after ICU admission,80％ of patients with low LVEF value turned to normal,and diastolic dysfunction was ameliorated in 50％ patients.At 1 day after ICU admission,higher TNT was found in 92.9％ of patients,higher BNP in 100％ of patients,and 3 days after ICU admission,71.4％ and 78.6％ patients showed a decrease in TNT and BNP,respectively.② In PiCCO monitor group,there were no significant differences in initial CVP,MAP and their time reaching standard values,norepinephrine dosage between milrinone group (n =8) and non-milrinone group (n =7).However,3-day intake of liquid in milrinone group was significantly higher than that in non-milrinone group (mL:8 324±3 962 vs.4 372±2 081,t =-2.362,P =0.034).③ Compared with routine monitor group,there was a significant elevation in acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score,sequential organ failure assessment (SOFA) score,duration of mechanical ventilation,length of ICU stay and 28-day hospital mortality in PiCCO monitor group [APACHE Ⅱ score:20.67 ± 6.15 vs.14.71 ±4.67,t =-3.304,P =0.002; SOFA score:9.53±3.00 vs.7.52± 1.97,t =-2.433,P =0.020; duration of mechanical ventilation (hours):132 (54-310) vs.63 (14-284),Z =-2.295,P =0.022; length of ICU stay (days):7 (4-15) vs.5 (1-14),Z =-2.360,P =0.018; 28-day hospital mortality:26.7％ vs.0,P =0.023].Conclusion With the use of the PiCCO hemodynamic monitoring in patients with severe septic shock,more comprehensive values of blood volume,systemic vascular resistance and cardiac function can be obtained for guiding fluid resuscitation and selection of vasopressor and inotropic drugs.
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