胸腔内血容积指数和血管外肺水指数指导的液体管理方案在重症急性胰腺炎患者液体治疗中的应用价值
흉강내혈용적지수화혈관외폐수지수지도적액체관리방안재중증급성이선염환자액체치료중적응용개치
Clinical observation of fluid management strategy guided by intrathoracic blood volume index and extravascular lung water index in patients with severe acute pancreatitis
  • 万方数据
    中国医药 중국의약
    China Medicine
    2015年 10期 1466-1471 ,共6页

    周森%邢柏%王小智%王日兴

    주삼%형백%왕소지%왕일흥

    重症急性胰腺炎%胸腔内血容量指数%血管外肺水指数%液体管理 重癥急性胰腺炎%胸腔內血容量指數%血管外肺水指數%液體管理
    중증급성이선염%흉강내혈용량지수%혈관외폐수지수%액체관리
    Severe acute pancreatitis%Intrathoracic blood volume index%Extravascular lung water index%Fluid management
    目的 探讨胸腔内血容积指数(ITBVI)和血管外肺水指数(EVLWI)指导的液体管理方案在重症急性胰腺炎(SAP)患者液体治疗中的应用价值.方法 选择海南省农垦总医院重症监护室(ICU)2010年12月至2015年2月收治的58例SAP患者,采用随机数字表法分为观察组(31例)和对照组(27例).观察组以脉波指示剂连续心排血量(PiCCO)技术测定ITBVI和EVLWI指导液体管理;对照组以中心静脉压(CVP)指导液体管理.比较2组患者入ICU后72 h内不同时点液体出入量和平衡量、入ICU后6、24 h液体复苏达标率、入ICU后不同时点(0、6、24、48、72 h)血流动力学参数、治疗第1～3天急性生理与慢性健康(APACHEⅡ)评分、血乳酸、血肌酐、血管活性药物评分以及血管活性药物使用时间、机械通气率、机械通气时间、ICU住院时间及28 d病死率.结果 观察组入ICU后6h液体复苏达标率明显高于对照组[80.6％(25/31)比51.9％(14/27)],差异有统计学意义(x2=5.431,P=0.026),而24 h达标率与对照组比较差异无统计学意义(P =0.489).观察组患者0～6h液体入量及平衡量明显多于对照组[(1 925±558)ml比(1 359±386)ml,(1 497±356) ml比(976 ±328)ml],48 ～72 h液体出量明显多于对照组[(2 578±439) ml比(1 944 ±729)ml],液体平衡量明显少于对照组[(539±246)ml比(1 058±519)ml],差异均有统计学意义(均P＜0.05),其余时点2组患者液体出入量及平衡量差异均无统计学意义(均P＞0.05).观察组不同时点ITBVI、EVLWI比较差异均无统计学意义(均P＞0.05).2组患者不同时点CVP、平均动脉压、心率比较,差异均无统计学意义(均P＜0.05).2组患者入ICU 48、72 h后,平均动脉压均高于0h,心率均低于0h[观察组:(86±13)、(89±15)mmHg(1 mmHg =0.133 kPa)比(62±18) mmHg,(106±26)、(102±27)次/min比(129±24)次/min;对照组:(85±14)、(88±14) mmHg比(65±17) mmHg,(107±27)、(106±25)次/min比(132±26)次/min],差异均有统计学意义(均P＜0.05).观察组第3天的APACHEⅡ评分、血乳酸水平和血管活性药物评分均低于对照组[(19±5)分比(24±7)分、(3.1±2.7) mmol/L比(5.8±3.5) mmol/L、(12±6)分比(17±8)分],差异均有统计学意义(均P＜0.05).观察组机械通气率、机械通气时间、血管活性药物使用时间、ICU住院时间、28 d病死率均低于对照组[29.0％(9/31)比51.9％ (14/27)、(6.9±3.0)d比(8.5±2.6)d、(66±29)h比(85±28)h、(8.5±3.4)d比(10.4±2.8)d、16.1％(5/31)比40.7％(11/37)],差异均有统计学意义(均P＜0.05).结论 ITBVI和EVLWI指导的液体管理方案可以精确评估和指导SAP患者的液体管理,减少机械通气时间和ICU住院时间,降低病死率.
    목적 탐토흉강내혈용적지수(ITBVI)화혈관외폐수지수(EVLWI)지도적액체관리방안재중증급성이선염(SAP)환자액체치료중적응용개치.방법 선택해남성농은총의원중증감호실(ICU)2010년12월지2015년2월수치적58례SAP환자,채용수궤수자표법분위관찰조(31례)화대조조(27례).관찰조이맥파지시제련속심배혈량(PiCCO)기술측정ITBVI화EVLWI지도액체관리;대조조이중심정맥압(CVP)지도액체관리.비교2조환자입ICU후72 h내불동시점액체출입량화평형량、입ICU후6、24 h액체복소체표솔、입ICU후불동시점(0、6、24、48、72 h)혈류동역학삼수、치료제1～3천급성생리여만성건강(APACHEⅡ)평분、혈유산、혈기항、혈관활성약물평분이급혈관활성약물사용시간、궤계통기솔、궤계통기시간、ICU주원시간급28 d병사솔.결과 관찰조입ICU후6h액체복소체표솔명현고우대조조[80.6％(25/31)비51.9％(14/27)],차이유통계학의의(x2=5.431,P=0.026),이24 h체표솔여대조조비교차이무통계학의의(P =0.489).관찰조환자0～6h액체입량급평형량명현다우대조조[(1 925±558)ml비(1 359±386)ml,(1 497±356) ml비(976 ±328)ml],48 ～72 h액체출량명현다우대조조[(2 578±439) ml비(1 944 ±729)ml],액체평형량명현소우대조조[(539±246)ml비(1 058±519)ml],차이균유통계학의의(균P＜0.05),기여시점2조환자액체출입량급평형량차이균무통계학의의(균P＞0.05).관찰조불동시점ITBVI、EVLWI비교차이균무통계학의의(균P＞0.05).2조환자불동시점CVP、평균동맥압、심솔비교,차이균무통계학의의(균P＜0.05).2조환자입ICU 48、72 h후,평균동맥압균고우0h,심솔균저우0h[관찰조:(86±13)、(89±15)mmHg(1 mmHg =0.133 kPa)비(62±18) mmHg,(106±26)、(102±27)차/min비(129±24)차/min;대조조:(85±14)、(88±14) mmHg비(65±17) mmHg,(107±27)、(106±25)차/min비(132±26)차/min],차이균유통계학의의(균P＜0.05).관찰조제3천적APACHEⅡ평분、혈유산수평화혈관활성약물평분균저우대조조[(19±5)분비(24±7)분、(3.1±2.7) mmol/L비(5.8±3.5) mmol/L、(12±6)분비(17±8)분],차이균유통계학의의(균P＜0.05).관찰조궤계통기솔、궤계통기시간、혈관활성약물사용시간、ICU주원시간、28 d병사솔균저우대조조[29.0％(9/31)비51.9％ (14/27)、(6.9±3.0)d비(8.5±2.6)d、(66±29)h비(85±28)h、(8.5±3.4)d비(10.4±2.8)d、16.1％(5/31)비40.7％(11/37)],차이균유통계학의의(균P＜0.05).결론 ITBVI화EVLWI지도적액체관리방안가이정학평고화지도SAP환자적액체관리,감소궤계통기시간화ICU주원시간,강저병사솔.
    Objective To investigate the effect of fluid management strategy guided by intrathoracic blood volume index and extravascular lung water index in patients with severe acute pancreatitis (SAP) using intrathoracic blood volume index (ITBVI) and extravascular lung water index (EVLWI).Methods Fifty-eight patients with SAP in intensive care unit (ICU) from December 2010 to February 2015 were randomly divided into observation group (31 cases) and control group (27 cases).Observation group received fluid management guided by ITBVI and EVLWI through pulse indicator continuous output (PiCCO) monitoring;control group received traditional fluid management guided by central venous pressure (CVP).The following data were analyzed between the two groups:fluid output and intake,fluid balance volume in different periods within 72 hours after admission to ICU,compliance rate of early goal directed therapy (EGDT) 6 and 24 h after admission to ICU,hemodynamic parameters at different time points (0,6,24,48,72 h) after admission to ICU,acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score,serum lactic acid,serum creatinine,vasopressor score 1-3 days after treatment,duration of vasopressor,mechanical ventilation ratio,duration of mechanical ventilation,ICU stay and 28-day mortality.Results The compliance rate of EGDT 6 hours after admission to ICU in observation group was significantly higher than that in control group[80.6％ (25/31) vs 51.9％ (14/27)] (x2 =5.431,P =0.026),but no significant difference was found 6 hours after admission to ICU [x2 =0.878,P =0.489].The fluid intake and fluid balance volume during 0-6 hours period were significantly greater in observation group than those in control group [(1 925±558) mlvs (1 359±386) ml,(1 497±356) mlvs (976±328) ml] (P＜0.05);the fluid output during 48-72 hours was significantly greater in observation group than that in control group [(2 578 ±439) ml vs (1 944 ± 729) ml] (P ＜ 0.05);the fluid balance volume was significantly lower in observation group than that in control group [(539 ± 246) ml vs (1 058 ± 519) ml] (P ＜ 0.05);the fluid output and intake,and the fluid balance of other periods showed no difference between both groups (P ＞ 0.05).The ITBVI and EVLWI at different time points in observation group showed no difference compared with those in control group;the CVP,mean arterial pressure and heart rate at different time points also showed no differences between both groups (P ＞ 0.05).The mean arterial pressure was significantly increased,and the heart rate was significantly reduced 48 and 72 h after admission to ICU compared with those before admission in observation group [(86 ± 13),(89 ± 15) mmHg vs (62 ± 18) mmHg,(106 ± 26),(102 ± 27) times/min vs (129 ± 24) times/min] and control group:[(85±14),(88±14) mmHg vs (65±17) mmHg,(107±27),(106±25) times/min vs (132±26) times/min] (P ＜ 0.05).The APACHE Ⅱ,serum lactic acid and vasopressor score in observation group were significantly lower than those in control group 3 days after treatment[(19 ± 5) scores vs (24 ± 7) scores,(3.1 ± 2.7) mmol/L vs (5.8 ± 3.5) mmol/L,(12 ± 6) scores vs (17 ± 8) scores] (P ＜ 0.05).The mechanical ventilation ratio,duration of mechanical ventilation,duration of vasopressor,ICU stay and 28-days morality in observation group were significantly lower than those in control group [29.0％ (9/31) vs 51.9％ (14/27),(6.9±3.0) d vs (8.5 ±2.6) d,(66 ±29) h vs (85 ±28) h,(8.5 ±3.4) d vs (10.4 ±2.8) d,16.1％(5/31) vs 40.7％ (11/37)] (P＜0.05).Conclusion Fluid management strategy guided by ITBVI and EVLWI can accurately assess and guide fluid management in SAP,with less duration of mechanical ventilation,ICU stay and mortality.
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