中国急救医学
中國急救醫學
중국급구의학
Chinese Journal of Critical Care Medicine
2015年
9期
787-793
,共7页
吴文%李敏%吴海鹰%聂昆%赵有芳%陈涛%张毅%余涛%钱传云
吳文%李敏%吳海鷹%聶昆%趙有芳%陳濤%張毅%餘濤%錢傳雲
오문%리민%오해응%섭곤%조유방%진도%장의%여도%전전운
中心静脉-动脉血二氧化碳分压差(Pcv-aCO2)%感染性休克%微循环衰竭%血液净化
中心靜脈-動脈血二氧化碳分壓差(Pcv-aCO2)%感染性休剋%微循環衰竭%血液淨化
중심정맥-동맥혈이양화탄분압차(Pcv-aCO2)%감염성휴극%미순배쇠갈%혈액정화
Central venous -to-arterial carbon dioxide difference(Pcv-aCO2)%Septic shock%Microcirculatory failure%Blood purification
目的:探讨中心静脉-动脉血二氧化碳分压差( Pcv-aCO2)对血液净化治疗顽固性感染性休克的预测价值。方法采用前瞻性观察研究方法,选择2011-06~2014-06在葛洲坝中心医院重症医学科治疗的55例接受血液净化治疗的顽固性感染性休克患者,将血液净化治疗48 h后去甲肾上腺素(NE)剂量及血乳酸(Lac)下降≥30%的患者定义为治疗有反应,反之为治疗无反应,对应将患者分为有反应组及无反应组。记录两组患者在血液净化治疗前和治疗后48 h循环灌注指标,包括Pcv-aCO2、中心静脉血氧饱和度( ScvO2)、血Lac;观察器官功能指标,包括血肌酐(Cr)、N末端脑钠肽前体(NT-proBNP)、血清降钙素原(PCT)、氧合指数(PaO2/FiO2)及急性生理学与慢性健康状况评分系统Ⅱ( APACHEⅡ)评分、序贯器官衰竭评分系统( SOFA)评分。通过Logistic回归分析,评价各指标与治疗反应的关系,通过受试者工作特征( ROC)曲线评估各个参数对治疗反应的预测能力。结果与治疗有反应组比较,治疗无反应组Pcv-aCO2、PCT明显升高[Pcv-aCO2(mm Hg):9(8,12)比8(6,8),Z=-4.551,P=0.000;PCT(ng/mL):6.0(4.0,9.0)比4.5(3.0,6.0),Z=-2.442,P=0.015],7 d SOFA评分变化[ΔSOFA (D1~D7)评分]明显恶化[ΔSOFA (D1~D7)评分(分):-1(-2,0)比3(2,4),Z=-3.743,P=0.000],住院病死率比有反应组升高[60.87%(14/23)比25.00%(8/32),P=0.007]。相关分析显示,入组48 h后Pcv-aCO2与血Lac(r=0.494,P=0.000)呈明显正相关。对单因素分析中有统计学意义的 Pcv-aCO2和PCT进行多因素Logistic回归分析发现,Pcv-aCO2水平升高[ OR=3.198,95% CI 1.487~6.877,P=0.003]是血液净化治疗反应差的独立危险因素。 Pcv-aCO2预测血液净化治疗无反应的ROC曲线下面积( AUC)为0.855,最佳临界值为8 mm Hg 时,敏感度为69.57%,特异度为84.37%,高于血清PCT、血Lac及ScvO2的预测价值。联合Pcv-aCO2和血清PCT共同预测治疗反应,AUC为0.873,敏感度为73.91%,特异度为93.75%。结论 Pcv-aCO2可预测血液净化治疗顽固性感染性休克的治疗反应。
目的:探討中心靜脈-動脈血二氧化碳分壓差( Pcv-aCO2)對血液淨化治療頑固性感染性休剋的預測價值。方法採用前瞻性觀察研究方法,選擇2011-06~2014-06在葛洲壩中心醫院重癥醫學科治療的55例接受血液淨化治療的頑固性感染性休剋患者,將血液淨化治療48 h後去甲腎上腺素(NE)劑量及血乳痠(Lac)下降≥30%的患者定義為治療有反應,反之為治療無反應,對應將患者分為有反應組及無反應組。記錄兩組患者在血液淨化治療前和治療後48 h循環灌註指標,包括Pcv-aCO2、中心靜脈血氧飽和度( ScvO2)、血Lac;觀察器官功能指標,包括血肌酐(Cr)、N末耑腦鈉肽前體(NT-proBNP)、血清降鈣素原(PCT)、氧閤指數(PaO2/FiO2)及急性生理學與慢性健康狀況評分繫統Ⅱ( APACHEⅡ)評分、序貫器官衰竭評分繫統( SOFA)評分。通過Logistic迴歸分析,評價各指標與治療反應的關繫,通過受試者工作特徵( ROC)麯線評估各箇參數對治療反應的預測能力。結果與治療有反應組比較,治療無反應組Pcv-aCO2、PCT明顯升高[Pcv-aCO2(mm Hg):9(8,12)比8(6,8),Z=-4.551,P=0.000;PCT(ng/mL):6.0(4.0,9.0)比4.5(3.0,6.0),Z=-2.442,P=0.015],7 d SOFA評分變化[ΔSOFA (D1~D7)評分]明顯噁化[ΔSOFA (D1~D7)評分(分):-1(-2,0)比3(2,4),Z=-3.743,P=0.000],住院病死率比有反應組升高[60.87%(14/23)比25.00%(8/32),P=0.007]。相關分析顯示,入組48 h後Pcv-aCO2與血Lac(r=0.494,P=0.000)呈明顯正相關。對單因素分析中有統計學意義的 Pcv-aCO2和PCT進行多因素Logistic迴歸分析髮現,Pcv-aCO2水平升高[ OR=3.198,95% CI 1.487~6.877,P=0.003]是血液淨化治療反應差的獨立危險因素。 Pcv-aCO2預測血液淨化治療無反應的ROC麯線下麵積( AUC)為0.855,最佳臨界值為8 mm Hg 時,敏感度為69.57%,特異度為84.37%,高于血清PCT、血Lac及ScvO2的預測價值。聯閤Pcv-aCO2和血清PCT共同預測治療反應,AUC為0.873,敏感度為73.91%,特異度為93.75%。結論 Pcv-aCO2可預測血液淨化治療頑固性感染性休剋的治療反應。
목적:탐토중심정맥-동맥혈이양화탄분압차( Pcv-aCO2)대혈액정화치료완고성감염성휴극적예측개치。방법채용전첨성관찰연구방법,선택2011-06~2014-06재갈주패중심의원중증의학과치료적55례접수혈액정화치료적완고성감염성휴극환자,장혈액정화치료48 h후거갑신상선소(NE)제량급혈유산(Lac)하강≥30%적환자정의위치료유반응,반지위치료무반응,대응장환자분위유반응조급무반응조。기록량조환자재혈액정화치료전화치료후48 h순배관주지표,포괄Pcv-aCO2、중심정맥혈양포화도( ScvO2)、혈Lac;관찰기관공능지표,포괄혈기항(Cr)、N말단뇌납태전체(NT-proBNP)、혈청강개소원(PCT)、양합지수(PaO2/FiO2)급급성생이학여만성건강상황평분계통Ⅱ( APACHEⅡ)평분、서관기관쇠갈평분계통( SOFA)평분。통과Logistic회귀분석,평개각지표여치료반응적관계,통과수시자공작특정( ROC)곡선평고각개삼수대치료반응적예측능력。결과여치료유반응조비교,치료무반응조Pcv-aCO2、PCT명현승고[Pcv-aCO2(mm Hg):9(8,12)비8(6,8),Z=-4.551,P=0.000;PCT(ng/mL):6.0(4.0,9.0)비4.5(3.0,6.0),Z=-2.442,P=0.015],7 d SOFA평분변화[ΔSOFA (D1~D7)평분]명현악화[ΔSOFA (D1~D7)평분(분):-1(-2,0)비3(2,4),Z=-3.743,P=0.000],주원병사솔비유반응조승고[60.87%(14/23)비25.00%(8/32),P=0.007]。상관분석현시,입조48 h후Pcv-aCO2여혈Lac(r=0.494,P=0.000)정명현정상관。대단인소분석중유통계학의의적 Pcv-aCO2화PCT진행다인소Logistic회귀분석발현,Pcv-aCO2수평승고[ OR=3.198,95% CI 1.487~6.877,P=0.003]시혈액정화치료반응차적독립위험인소。 Pcv-aCO2예측혈액정화치료무반응적ROC곡선하면적( AUC)위0.855,최가림계치위8 mm Hg 시,민감도위69.57%,특이도위84.37%,고우혈청PCT、혈Lac급ScvO2적예측개치。연합Pcv-aCO2화혈청PCT공동예측치료반응,AUC위0.873,민감도위73.91%,특이도위93.75%。결론 Pcv-aCO2가예측혈액정화치료완고성감염성휴극적치료반응。
Objective To approach the predictive value of central venous -to-arterial carbon dioxide difference ( Pcv-aCO2 ) in refractory septic shock patients receiving blood purification therapy . Methods A prospective observational study was conducted .Fifty-five refractory septic shock patients admitted to Department of Critical Care Medicine of Gezhouba Central Hospital from January 2011 to March 2014 were enrolled .After all patients received blood purification therapy at least 48 h, they were divided into responders group and non -responders group .Patients were considered responders if they stabilized MAP with ≥30% decrease in both norepinephrine requirements and lactate , otherwise they were considered non -responders .The following data were collected at 0 and 48 hours ( T0 , T48 ) after enrolled:perfusion parameters [Pcv -aCO2,ScvO2, serum lactate (Lac)], organ function -related parameters [ serum creatinine ( Cr ) , oxygenation index ( PaO2/FiO2 ) , N-terminal prohormone brain natriuretic peptide (NT -proBNP)], APACHEⅡ score, SOFA score, and hospital mortality.The independent risk factors of the response to the blood purification therapy were analyzed by univariate and multivariable Logistic regression .Receiver operating characteristic curve ( ROC) was plotted to evaluate the value of Pcv -aCO2 in predicting the response to HVHF .Results Compared with responders group, the non -responders group showed significantly elevated Pcv -aCO2 and PCT [ Pcv -aCO2 (mm Hg):9 (8,12) vs 8 (6,8), Z=-4.551, P=0.000;PCT (ng/mL):6.0 (4.0,9.0) vs 4.5 (3.0,6.0), Z=-2.442, P=0.015], significantly worse 7 d SOFA score changes [ΔSOFA (D1~D7) score] [ΔSOFA (D1 ~D7) score (points): -1( -2,0) vs 3 (2,4), Z=-3.743, P=0.000], and significantly higher hospital mortality [25.00% (8/32) vs 60.87% (14/23), P =0.007].Correlation analysis showed that the Pcv -aCO2 and Lac ( r =0.494, P =0.000 ) were positively correlated at T 48 .Pcv -aCO2 and PCT were founded statistical significance in univariate analysis when analyzed by multivariable logistic regression .High Pcv-aCO2 at admission [ odds ratio (OR)=3.198, 95%confidence interval (95%CI)=1.487~6.877, P=0.003] was the independent prognostic factors for the poor response to HVHF .The area under the ROC curve of Pcv -aCO2 was 0.855, the optimal critical value of Pcv -aCO2 was 8 mm Hg, the sensitivity was 69.57%, and specificity was 84.37%, the levels of Pcv -aCO2 was better in predicting the response to blood purification therapy than PCT , Lac and ScvO 2 in refactory septic shock patients .The AUC of Pcv-aCO2 combined PCT was 0.873, the sensitivity was 73.91% and specificity was 93.75%.Conclusion Central venous -arterial carbon dioxide difference ( Pcv -aCO2 ) can predict the response to blood purification treatment of refractory septic shock .