目的 探讨感染性休克患者不同时期进行液体负荷试验对机体的影响.方法 采用前瞻性研究方法,选择2010年3月至2014年3月沈阳市第四人民医院重症医学科收治42例接受机械通气治疗的感染性休克患者,在诊断感染性休克0、24、48、72 h进行液体负荷试验,记录液体负荷试验前后采用脉搏指示连续心排血量仪(PiCCO)监测的心排血量(CO)、每搏量(SV)、血管外肺水指数(EVLWI),采血检测动脉血氧分压(PaO2)等指标.以液体负荷后SV增加值(△SV)≥15％定义为容量反应阳性;EVLWI增加且＞7 mL/kg定义为肺水增加;氧合指数(PaO2/FiO2)较前下降定义为氧合下降.分析不同时间点感染性休克患者的容量反应性、血管外肺水及氧合情况.结果 42例患者共进行168次液体负荷试验.与液体负荷试验前比较,确诊0、24、48 h时液体负荷试验后患者心率(HR)明显下降,平均动脉压(MAP)、CO、SV均明显增加(均P＜0.01),72 h时无明显变化.确诊各时间点EVLWI均增加,其中0h、24 h时EVLWI＜7 mL/kg,而48 h、72 h时EVLWI＞7 mL/kg[EVLWI (mL/kg) 0h:6.0±1.5比4.7±1.5,t=-4.183,P=0.000;24 h:6.5±1.5比5.6±1.3,t=-6.000,P=0.000;48h:8.1±2.2比6.1±1.7,t=-7.246,P=0.000;72h:9.0±2.4比6.2±1.5,t=-7.524,P=0.000];而PaO2/FiO2在0h、24 h明显上升,48 h无明显变化,72 h明显下降[PaO2/FiO2 (mmHg,1 mmHg=0.133 kPa)0 h:189.6±34.5比183.2±36.6,t=-3.644,P=0.002;24h:194.6±35.7比190.7±37.5,t =-4.594,P=0.000;48 h:201.8±30.2比200.8±33.0,t=-0.793,P=0.437;72h:201.7±24.8比206.2±26.9,t=2.243,P=0.036].诊断0、24、48、72 h时患者容量反应阳性率逐渐降低,分别为85.7％、80.9％、42.8％、28.6％;肺水增加发生率逐渐增高,分别为9.8％、14.3％、42.8％、61.9％;氧合下降发生率逐渐增高,分别为9.5％、11.9％、19.0％、33.3％.与0h相比,48 h起容量反应阳性率减少、肺水增加发生率增高的差异即有统计学意义(P＜0.05或P＜0.01),72 h时氧合下降发生率增高差异有统计学意义(P＜0.01).结论 感染性休克患者发病48～ 72 h可能是发生液体过负荷的关键时期,此时期限制液体输注可减少肺水肿发生.
目的 探討感染性休剋患者不同時期進行液體負荷試驗對機體的影響.方法 採用前瞻性研究方法,選擇2010年3月至2014年3月瀋暘市第四人民醫院重癥醫學科收治42例接受機械通氣治療的感染性休剋患者,在診斷感染性休剋0、24、48、72 h進行液體負荷試驗,記錄液體負荷試驗前後採用脈搏指示連續心排血量儀(PiCCO)鑑測的心排血量(CO)、每搏量(SV)、血管外肺水指數(EVLWI),採血檢測動脈血氧分壓(PaO2)等指標.以液體負荷後SV增加值(△SV)≥15％定義為容量反應暘性;EVLWI增加且＞7 mL/kg定義為肺水增加;氧閤指數(PaO2/FiO2)較前下降定義為氧閤下降.分析不同時間點感染性休剋患者的容量反應性、血管外肺水及氧閤情況.結果 42例患者共進行168次液體負荷試驗.與液體負荷試驗前比較,確診0、24、48 h時液體負荷試驗後患者心率(HR)明顯下降,平均動脈壓(MAP)、CO、SV均明顯增加(均P＜0.01),72 h時無明顯變化.確診各時間點EVLWI均增加,其中0h、24 h時EVLWI＜7 mL/kg,而48 h、72 h時EVLWI＞7 mL/kg[EVLWI (mL/kg) 0h:6.0±1.5比4.7±1.5,t=-4.183,P=0.000;24 h:6.5±1.5比5.6±1.3,t=-6.000,P=0.000;48h:8.1±2.2比6.1±1.7,t=-7.246,P=0.000;72h:9.0±2.4比6.2±1.5,t=-7.524,P=0.000];而PaO2/FiO2在0h、24 h明顯上升,48 h無明顯變化,72 h明顯下降[PaO2/FiO2 (mmHg,1 mmHg=0.133 kPa)0 h:189.6±34.5比183.2±36.6,t=-3.644,P=0.002;24h:194.6±35.7比190.7±37.5,t =-4.594,P=0.000;48 h:201.8±30.2比200.8±33.0,t=-0.793,P=0.437;72h:201.7±24.8比206.2±26.9,t=2.243,P=0.036].診斷0、24、48、72 h時患者容量反應暘性率逐漸降低,分彆為85.7％、80.9％、42.8％、28.6％;肺水增加髮生率逐漸增高,分彆為9.8％、14.3％、42.8％、61.9％;氧閤下降髮生率逐漸增高,分彆為9.5％、11.9％、19.0％、33.3％.與0h相比,48 h起容量反應暘性率減少、肺水增加髮生率增高的差異即有統計學意義(P＜0.05或P＜0.01),72 h時氧閤下降髮生率增高差異有統計學意義(P＜0.01).結論 感染性休剋患者髮病48～ 72 h可能是髮生液體過負荷的關鍵時期,此時期限製液體輸註可減少肺水腫髮生.
목적 탐토감염성휴극환자불동시기진행액체부하시험대궤체적영향.방법 채용전첨성연구방법,선택2010년3월지2014년3월침양시제사인민의원중증의학과수치42례접수궤계통기치료적감염성휴극환자,재진단감염성휴극0、24、48、72 h진행액체부하시험,기록액체부하시험전후채용맥박지시련속심배혈량의(PiCCO)감측적심배혈량(CO)、매박량(SV)、혈관외폐수지수(EVLWI),채혈검측동맥혈양분압(PaO2)등지표.이액체부하후SV증가치(△SV)≥15％정의위용량반응양성;EVLWI증가차＞7 mL/kg정의위폐수증가;양합지수(PaO2/FiO2)교전하강정의위양합하강.분석불동시간점감염성휴극환자적용량반응성、혈관외폐수급양합정황.결과 42례환자공진행168차액체부하시험.여액체부하시험전비교,학진0、24、48 h시액체부하시험후환자심솔(HR)명현하강,평균동맥압(MAP)、CO、SV균명현증가(균P＜0.01),72 h시무명현변화.학진각시간점EVLWI균증가,기중0h、24 h시EVLWI＜7 mL/kg,이48 h、72 h시EVLWI＞7 mL/kg[EVLWI (mL/kg) 0h:6.0±1.5비4.7±1.5,t=-4.183,P=0.000;24 h:6.5±1.5비5.6±1.3,t=-6.000,P=0.000;48h:8.1±2.2비6.1±1.7,t=-7.246,P=0.000;72h:9.0±2.4비6.2±1.5,t=-7.524,P=0.000];이PaO2/FiO2재0h、24 h명현상승,48 h무명현변화,72 h명현하강[PaO2/FiO2 (mmHg,1 mmHg=0.133 kPa)0 h:189.6±34.5비183.2±36.6,t=-3.644,P=0.002;24h:194.6±35.7비190.7±37.5,t =-4.594,P=0.000;48 h:201.8±30.2비200.8±33.0,t=-0.793,P=0.437;72h:201.7±24.8비206.2±26.9,t=2.243,P=0.036].진단0、24、48、72 h시환자용량반응양성솔축점강저,분별위85.7％、80.9％、42.8％、28.6％;폐수증가발생솔축점증고,분별위9.8％、14.3％、42.8％、61.9％;양합하강발생솔축점증고,분별위9.5％、11.9％、19.0％、33.3％.여0h상비,48 h기용량반응양성솔감소、폐수증가발생솔증고적차이즉유통계학의의(P＜0.05혹P＜0.01),72 h시양합하강발생솔증고차이유통계학의의(P＜0.01).결론 감염성휴극환자발병48～ 72 h가능시발생액체과부하적관건시기,차시기한제액체수주가감소폐수종발생.
Objective To explore the influence of fluid loading at different stages in patients with septic shock.Methods A prospective study was conducted.Forty-two mechanically ventilated patients in septic shock were enrolled in the Department of Critical Care Medicine of the Fourth People's Hospital of Shenyang from March 2010 to March 2014.Fluid loading was performed at 0,24,48 and 72 hours after the diagnosis of septic shock.The hemodynamic parameters including cardiac output (CO),stroke volume (SV),and extravascular lung water index (EVLWI) were measured by pulse indicator continuous cardiac output (PiCCO),and arterial partial pressure (PaO2)was determined.Positive responders were defined as SV increased by more than 15％ after fluid loading.Increase of lung water was defined as EVLWI increased after fluid loading and its value was more than 7 mL/kg.Oxygenation descend was defined when oxygenation index (PaO2/FiO2) lowered.Fluid responsiveness,extravascular lung water,and oxygenation were analyzed and recorded at different stages in patients with septic shock.Results Fluid loading test was conducted for a total of 168 times in 42 patients.Compared with those before fluid loading test,the heart rate (HR) was lowered,and mean arterial pressure (MAP),CO,and SV were increased after fluid loading at 0,24,48 hours (all P ＜ 0.01),unchanged at 72 hours.EVLWI levels at all time points were increased including an increase of EVLWI less than 7 mL/kg at 0 hour and 24 hours,and higher than 7 mL/kg at 48 hours and 72 hours [EVLWI (mL/kg)at 0 hour:6.0 ± 1.5 vs.4.7 ± 1.5,t =-4.183,P =0.000; 24 hours:6.5 ± 1.5 vs.5.6 ± 1.3,t =-6.000,P =0.000; 48 hours:8.1±2.2 vs.6.1±1.7,t =-7.246,P =0.000; 72 hours:9.0±2.4 vs.6.2±1.5,t =-7.524,P =0.000].After fluid loading,PaO2/FiO2 was increased remarkably at 0 hour and 24 hours,unchanged at 48 hours,and decreased significantly at 72 hours [PaO2/FiO2 (mmHg,1 mmHg =0.133 kPa) at 0 hour:189.6±34.5 vs.183.2±36.6,t =-3.644,P =0.002; 24 hours:194.6±35.7 vs.190.7±37.5,t =-4.594,P =0.000; 48 hours:201.8±30.2 vs.200.8 ± 33.0,t =-0.793,P=0.437; 72 hours:201.7 ± 24.8 vs.206.2 ± 26.9,t =2.243,P =0.036].The rate of positive response gradually decreased:85.7％,80.9％,42.8％,28.6％ at 0,24,48,and 72 hours,the rate of lung water increased was gradually elevated:9.8％,14.3％,42.8％,61.9％ at 0,24,48,and 72 hours,and there was an increase of rate of lowering oxygenation with elapse of time (9.5％,11.9％,19.0％,33.3％ at 0,24,48 and 72 hours).Compared with 0 hour,the rate of positive response decreased and rate of lung water increased were increased from 48 hours on (P ＜ 0.05or P ＜ 0.01),and rate of lowering oxygenation was increased at 72 hours (P ＜ 0.01).Conclusions 48 to 72 hours might be the crucial period of occurrence of volume overload in patients with septic shock.Curtailing fluid infusion during this period might reduce the occurrence of pulmonary edema.
