中华危重病急救医学
中華危重病急救醫學
중화위중병급구의학
Chinese Critical Care Medicine
2015年
6期
443-447
,共5页
陈志%杨春丽%贺慧为%何招辉
陳誌%楊春麗%賀慧為%何招輝
진지%양춘려%하혜위%하초휘
脓毒性休克%糖皮质激素%血流动力学%血糖变异度
膿毒性休剋%糖皮質激素%血流動力學%血糖變異度
농독성휴극%당피질격소%혈류동역학%혈당변이도
Septic shock%Corticosteroids%Hemodynamics%Glucose variability
目的：探讨不同方法补充小剂量糖皮质激素对顽固性脓毒性休克患者血流动力学、血糖波动及预后的影响。方法采用前瞻性单盲随机对照研究方法，选择2013年4月1日至2014年10月31日江西省人民医院重症医学科住院的脓毒性休克患者。按随机数字表编码法将患者分为对照组和研究组。所有患者均进行常规脓毒性休克治疗；对照组给予氢化可的松200 mg/d缓慢静脉滴注2 h，研究组持续静脉微量泵入氢化可的松8.33 mg/h，两组均连续5 d。观察两组患者入组时及入组6 h、24 h、48 h、5 d时的心率（HR）、平均动脉压（MAP）、中心静脉压（CVP）、动脉血乳酸变化；佩戴动态血糖监测仪，监测平均血糖水平（MBG）、最大血糖波动幅度（LAGE）、血糖波动系数（GV），统计高血糖时间窗；记录两组患者休克持续时间、重症加强治疗病房（ICU）住院时间、总住院时间和28 d病死率。结果共有79例脓毒性休克患者入选，对照组41例，研究组38例。与对照组相比，研究组患者入组6 h MAP明显降低〔mmHg（1 mmHg＝0.133 kPa）：66.31±4.38比68.58±4.86， t＝1.062，P＝0.033〕，其他时间点两组患者HR、MAP、CVP、乳酸清除率及去甲肾上腺素（NE）使用率差异均无统计学意义。研究组患者MBG与对照组相比差异无统计学意义（mmol/L：8.69±2.14比9.95±3.87，t＝1.771，P＝0.080），但研究组患者LAGE、GV、高血糖时间窗均明显低于对照组〔LAGE（mmol/L）：17.18±8.97比22.71±11.80，t＝2.331，P＝0.022；GV（mmol/L）：2.57±1.05比3.16±1.37，t＝2.136，P＝0.036；高血糖时间窗：（43.1±11.7）%比（49.4±15.3）%，t＝2.044，P＝0.044〕。研究组与对照组患者休克持续时间（d：3.47±0.98比3.61±1.07，t＝0.605，P＝0.547）、ICU住院时间（d：8.74±3.12比9.97±3.37，t＝1.543，P＝0.120）、总住院时间（d：18.34±9.27比19.58±9.83，t＝0.576，P＝0.566）及28 d病死率（23.68%比26.83%，χ2＝0.103，P＝0.748）差异均无统计学意义。结论对于顽固性脓毒性休克患者，持续微量注射泵补充小剂量氢化可的松较单次静脉缓慢滴注更能稳定患者血糖波动幅度，更有利于维护机体代谢平衡；但在稳定血流动力学、缩短休克持续时间、减少ICU及总住院时间、降低28 d病死率等方面两组无显著差异。
目的：探討不同方法補充小劑量糖皮質激素對頑固性膿毒性休剋患者血流動力學、血糖波動及預後的影響。方法採用前瞻性單盲隨機對照研究方法，選擇2013年4月1日至2014年10月31日江西省人民醫院重癥醫學科住院的膿毒性休剋患者。按隨機數字錶編碼法將患者分為對照組和研究組。所有患者均進行常規膿毒性休剋治療；對照組給予氫化可的鬆200 mg/d緩慢靜脈滴註2 h，研究組持續靜脈微量泵入氫化可的鬆8.33 mg/h，兩組均連續5 d。觀察兩組患者入組時及入組6 h、24 h、48 h、5 d時的心率（HR）、平均動脈壓（MAP）、中心靜脈壓（CVP）、動脈血乳痠變化；珮戴動態血糖鑑測儀，鑑測平均血糖水平（MBG）、最大血糖波動幅度（LAGE）、血糖波動繫數（GV），統計高血糖時間窗；記錄兩組患者休剋持續時間、重癥加彊治療病房（ICU）住院時間、總住院時間和28 d病死率。結果共有79例膿毒性休剋患者入選，對照組41例，研究組38例。與對照組相比，研究組患者入組6 h MAP明顯降低〔mmHg（1 mmHg＝0.133 kPa）：66.31±4.38比68.58±4.86， t＝1.062，P＝0.033〕，其他時間點兩組患者HR、MAP、CVP、乳痠清除率及去甲腎上腺素（NE）使用率差異均無統計學意義。研究組患者MBG與對照組相比差異無統計學意義（mmol/L：8.69±2.14比9.95±3.87，t＝1.771，P＝0.080），但研究組患者LAGE、GV、高血糖時間窗均明顯低于對照組〔LAGE（mmol/L）：17.18±8.97比22.71±11.80，t＝2.331，P＝0.022；GV（mmol/L）：2.57±1.05比3.16±1.37，t＝2.136，P＝0.036；高血糖時間窗：（43.1±11.7）%比（49.4±15.3）%，t＝2.044，P＝0.044〕。研究組與對照組患者休剋持續時間（d：3.47±0.98比3.61±1.07，t＝0.605，P＝0.547）、ICU住院時間（d：8.74±3.12比9.97±3.37，t＝1.543，P＝0.120）、總住院時間（d：18.34±9.27比19.58±9.83，t＝0.576，P＝0.566）及28 d病死率（23.68%比26.83%，χ2＝0.103，P＝0.748）差異均無統計學意義。結論對于頑固性膿毒性休剋患者，持續微量註射泵補充小劑量氫化可的鬆較單次靜脈緩慢滴註更能穩定患者血糖波動幅度，更有利于維護機體代謝平衡；但在穩定血流動力學、縮短休剋持續時間、減少ICU及總住院時間、降低28 d病死率等方麵兩組無顯著差異。
목적：탐토불동방법보충소제량당피질격소대완고성농독성휴극환자혈류동역학、혈당파동급예후적영향。방법채용전첨성단맹수궤대조연구방법，선택2013년4월1일지2014년10월31일강서성인민의원중증의학과주원적농독성휴극환자。안수궤수자표편마법장환자분위대조조화연구조。소유환자균진행상규농독성휴극치료；대조조급여경화가적송200 mg/d완만정맥적주2 h，연구조지속정맥미량빙입경화가적송8.33 mg/h，량조균련속5 d。관찰량조환자입조시급입조6 h、24 h、48 h、5 d시적심솔（HR）、평균동맥압（MAP）、중심정맥압（CVP）、동맥혈유산변화；패대동태혈당감측의，감측평균혈당수평（MBG）、최대혈당파동폭도（LAGE）、혈당파동계수（GV），통계고혈당시간창；기록량조환자휴극지속시간、중증가강치료병방（ICU）주원시간、총주원시간화28 d병사솔。결과공유79례농독성휴극환자입선，대조조41례，연구조38례。여대조조상비，연구조환자입조6 h MAP명현강저〔mmHg（1 mmHg＝0.133 kPa）：66.31±4.38비68.58±4.86， t＝1.062，P＝0.033〕，기타시간점량조환자HR、MAP、CVP、유산청제솔급거갑신상선소（NE）사용솔차이균무통계학의의。연구조환자MBG여대조조상비차이무통계학의의（mmol/L：8.69±2.14비9.95±3.87，t＝1.771，P＝0.080），단연구조환자LAGE、GV、고혈당시간창균명현저우대조조〔LAGE（mmol/L）：17.18±8.97비22.71±11.80，t＝2.331，P＝0.022；GV（mmol/L）：2.57±1.05비3.16±1.37，t＝2.136，P＝0.036；고혈당시간창：（43.1±11.7）%비（49.4±15.3）%，t＝2.044，P＝0.044〕。연구조여대조조환자휴극지속시간（d：3.47±0.98비3.61±1.07，t＝0.605，P＝0.547）、ICU주원시간（d：8.74±3.12비9.97±3.37，t＝1.543，P＝0.120）、총주원시간（d：18.34±9.27비19.58±9.83，t＝0.576，P＝0.566）급28 d병사솔（23.68%비26.83%，χ2＝0.103，P＝0.748）차이균무통계학의의。결론대우완고성농독성휴극환자，지속미량주사빙보충소제량경화가적송교단차정맥완만적주경능은정환자혈당파동폭도，경유리우유호궤체대사평형；단재은정혈류동역학、축단휴극지속시간、감소ICU급총주원시간、강저28 d병사솔등방면량조무현저차이。
Objective To discuss the influence of different ways of low-dose corticosteroids infusion on hemodynamics, changes in blood glucose level and prognosis in patients with refractory septic shock. Methods A prospective single-blind randomized controlled trial was conducted. Refractory septic shock patients admitted to the Department of Critical Care Medicine of Jiangxi Provincial People's Hospital from April 1st, 2013 to October 31st, 2014 were enrolled for the study. The patients were divided into control group and research group by random number table. Besides conventional treatment for septic shock, patients in control group were given 200 mg/d hydrocortisone intravenous infusion lasting for 2 hours, while those of research group were given 8.33 mg/h hydrocortisone per hour with an intravenous pump. Treatment lasted for 5 continuous days for both groups. The changes in heart rate ( HR ), mean arterial pressure ( MAP ), central venous pressure ( CVP ) and arterial blood lactic acid in both groups were observed at the time of enroldment and 6 hours, 24 hours, 48 hours, and 5 days after the treatment. With a dynamic blood glucose monitor, mean blood glucose ( MBG ) level, largest amplitude of glycemic excursions ( LAGE ), glucose variability ( GV ), and the ratio of hyperglycaemia time were recorded. The duration of shock, length of intensive care unit ( ICU ) stay, total length of hospital stay, and 28-day mortality of both groups were recorded. Results Seventy-nine septic shock patients were assigned to the treatment, with 41 in control group, and 38 in research group. Compared with control group, 6-hour MAP in research group was obviously lowered [ mmHg ( 1 mmHg=0.133 kPa ):66.31±4.38 vs. 68.58±4.86, t=1.062, P=0.033 ], but there were no significant differences in HR, MAP, CVP, lactic acid clearance and norepinephrine ( NE ) utilization rates at other time points between two groups. No significant difference in MBG was found between research group and control group ( mmol/L:8.69±2.14 vs. 9.95±3.87, t=1.771, P=0.080 ), but LAGE, GV, the ratio of hyperglycemia time in research group were significantly lower than those of the control group [ LAGE ( mmol/L ): 17.18±8.97 vs. 22.71±11.80, t = 2.331, P = 0.022; GV ( mmol/L ): 2.57±1.05 vs. 3.16±1.37, t=2.136, P=0.036;the ratio of hyperglycemia time:( 43.1±11.7 )%vs. ( 49.4±15.3 )%, t=2.044, P=0.044 ]. There was no statistical difference in the following features between research group and control group, such as the duration of shock ( days:3.47±0.98 vs. 3.61±1.07, t=0.605, P=0.547 ), length of ICU stay ( days:8.74±3.12 vs. 9.97±3.37, t = 1.543, P = 0.120 ), total length of hospital stay ( days: 18.34±9.27 vs. 19.58±9.83, t = 0.576, P = 0.566 ) and 28-day mortality rate ( 23.68%vs. 26.83%,χ2=0.103, P=0.748 ). Conclusions Compared with slow intravenous infusion, a continuous intravenous supplementation of small amount of hydrocortisone to patients with refractory septic shock could stabilize blood glucose levels and maintain metabolic balance efficiently. However, in both groups there was no significant difference in the efficiency in stabilizing hemodynamics, shortening shock duration, reducing ICU or hospital days and decreasing 28-day mortality.
