目的 探讨艾司洛尔对感染性休克患者容量反应性及血流动力学的影响.方法 采用前瞻性自身前后对照研究,选择2015年1月至8月弋矶山医院重症医学科收治的15例行机械通气感染性休克患者为研究对象.所有患者均按照2012年美国胸科医师协会/危重病医学会重症感染和感染性休克指南给予相应治疗;静脉输注艾司洛尔,起始速率为6 mg·kg-1·h-1,调整输注速率使目标心率较基础值下降约10％.于艾司洛尔给药前及给药后2h,采用脉搏指示连续心排血量监测仪(PiCCO)监测患者的血流动力学和全身氧代谢指标,以每搏量变异度(SVV)评估患者的容量反应性,SVV≥10％为容量反应性阳性.结果 15例患者中男性9例、女性6例;年龄(65±16)岁;肺感染10例、腹腔感染5例;急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分为(21±9)分,序贯器官衰竭评分(SOFA)为(8±4)分;28d病死率为40.0％.与给药前相比,艾司洛尔给药后SVV[(14±5)％比(17±7)％,t=2.400,P=0.031]、心率[HR(次/min):100±4比112±8,t=8.161,P=0.000]、心排血量[CO (L/min):6.13±1.45比7.88±1.82,t=4.046,P=0.001]、心排血指数[CI(mL·s-1·m-2):51.51±11.00比66.18±11.48,t=4.131,P=0.001]、每搏量指数[SI(mL/m2):31.0±6.4比35.4±6.5,t=2.577,P=0.020]、左室内压上升最大速率[dp/dt max(mmHg/s):927±231比1 194±294,t=3.775,P=0.002]、全心射血分数(GEF:0.21±0.05比0.24±0.06,t=3.091,P=0.008)、心功能指数(CFI:5.03±1.37比6.59±1.92, t=4.769,P=0.000)均显著下降,中心静脉压[CVP (mmHg,1 mmHg=0.133 kPa):9±3比8±3,t=-3.617,P=0.003]、舒张压[DBP (mmHg):69±15比66±13,t=-2.656,P=0.019]以及外周血管阻力指数[SVRI (kPa·s·L-1·m-2):206.8±69.8比157.7±46.7, t=-3.255,P=0.006]均显著上升,而收缩压[SBP (mmHg):120±25比123±18,t=0.678,P=0.509]、平均动脉压[MAP (mmHg):86±18比85±14,t=-0.693,P=0.500]、全心舒张期末容积指数[GEDVI(mL/m2):614±84比618±64,t=0.218,P=0.830]、血管外肺水指数[EVLWI(mL/kg):5.99±1.50比5.73±1.14,t=-1.329,P=0.205]以及组织灌注指标中心静脉血氧饱和度(ScvO2:0.711±0.035比0.704±0.048,t=-0.298,P=0.773)、动脉血乳酸[Lac(mmol/L):3.1±0.3比3.0±0.4,t=-0.997,P=0.345]、中心静脉-动脉血二氧化碳分压差[Pcv-aCO2(mmHg):4.1±0.9比4.7±0.5,t=1.445,P=0.182]均无明显改变.结论 艾司洛尔能够降低感染性休克患者的容量反应性,降低心肌收缩功能、减慢心率、使CO下降,但对组织灌注无明显影响.
目的 探討艾司洛爾對感染性休剋患者容量反應性及血流動力學的影響.方法 採用前瞻性自身前後對照研究,選擇2015年1月至8月弋磯山醫院重癥醫學科收治的15例行機械通氣感染性休剋患者為研究對象.所有患者均按照2012年美國胸科醫師協會/危重病醫學會重癥感染和感染性休剋指南給予相應治療;靜脈輸註艾司洛爾,起始速率為6 mg·kg-1·h-1,調整輸註速率使目標心率較基礎值下降約10％.于艾司洛爾給藥前及給藥後2h,採用脈搏指示連續心排血量鑑測儀(PiCCO)鑑測患者的血流動力學和全身氧代謝指標,以每搏量變異度(SVV)評估患者的容量反應性,SVV≥10％為容量反應性暘性.結果 15例患者中男性9例、女性6例;年齡(65±16)歲;肺感染10例、腹腔感染5例;急性生理學與慢性健康狀況評分繫統Ⅱ(APACHEⅡ)評分為(21±9)分,序貫器官衰竭評分(SOFA)為(8±4)分;28d病死率為40.0％.與給藥前相比,艾司洛爾給藥後SVV[(14±5)％比(17±7)％,t=2.400,P=0.031]、心率[HR(次/min):100±4比112±8,t=8.161,P=0.000]、心排血量[CO (L/min):6.13±1.45比7.88±1.82,t=4.046,P=0.001]、心排血指數[CI(mL·s-1·m-2):51.51±11.00比66.18±11.48,t=4.131,P=0.001]、每搏量指數[SI(mL/m2):31.0±6.4比35.4±6.5,t=2.577,P=0.020]、左室內壓上升最大速率[dp/dt max(mmHg/s):927±231比1 194±294,t=3.775,P=0.002]、全心射血分數(GEF:0.21±0.05比0.24±0.06,t=3.091,P=0.008)、心功能指數(CFI:5.03±1.37比6.59±1.92, t=4.769,P=0.000)均顯著下降,中心靜脈壓[CVP (mmHg,1 mmHg=0.133 kPa):9±3比8±3,t=-3.617,P=0.003]、舒張壓[DBP (mmHg):69±15比66±13,t=-2.656,P=0.019]以及外週血管阻力指數[SVRI (kPa·s·L-1·m-2):206.8±69.8比157.7±46.7, t=-3.255,P=0.006]均顯著上升,而收縮壓[SBP (mmHg):120±25比123±18,t=0.678,P=0.509]、平均動脈壓[MAP (mmHg):86±18比85±14,t=-0.693,P=0.500]、全心舒張期末容積指數[GEDVI(mL/m2):614±84比618±64,t=0.218,P=0.830]、血管外肺水指數[EVLWI(mL/kg):5.99±1.50比5.73±1.14,t=-1.329,P=0.205]以及組織灌註指標中心靜脈血氧飽和度(ScvO2:0.711±0.035比0.704±0.048,t=-0.298,P=0.773)、動脈血乳痠[Lac(mmol/L):3.1±0.3比3.0±0.4,t=-0.997,P=0.345]、中心靜脈-動脈血二氧化碳分壓差[Pcv-aCO2(mmHg):4.1±0.9比4.7±0.5,t=1.445,P=0.182]均無明顯改變.結論 艾司洛爾能夠降低感染性休剋患者的容量反應性,降低心肌收縮功能、減慢心率、使CO下降,但對組織灌註無明顯影響.
목적 탐토애사락이대감염성휴극환자용량반응성급혈류동역학적영향.방법 채용전첨성자신전후대조연구,선택2015년1월지8월익기산의원중증의학과수치적15례행궤계통기감염성휴극환자위연구대상.소유환자균안조2012년미국흉과의사협회/위중병의학회중증감염화감염성휴극지남급여상응치료;정맥수주애사락이,기시속솔위6 mg·kg-1·h-1,조정수주속솔사목표심솔교기출치하강약10％.우애사락이급약전급급약후2h,채용맥박지시련속심배혈량감측의(PiCCO)감측환자적혈류동역학화전신양대사지표,이매박량변이도(SVV)평고환자적용량반응성,SVV≥10％위용량반응성양성.결과 15례환자중남성9례、녀성6례;년령(65±16)세;폐감염10례、복강감염5례;급성생이학여만성건강상황평분계통Ⅱ(APACHEⅡ)평분위(21±9)분,서관기관쇠갈평분(SOFA)위(8±4)분;28d병사솔위40.0％.여급약전상비,애사락이급약후SVV[(14±5)％비(17±7)％,t=2.400,P=0.031]、심솔[HR(차/min):100±4비112±8,t=8.161,P=0.000]、심배혈량[CO (L/min):6.13±1.45비7.88±1.82,t=4.046,P=0.001]、심배혈지수[CI(mL·s-1·m-2):51.51±11.00비66.18±11.48,t=4.131,P=0.001]、매박량지수[SI(mL/m2):31.0±6.4비35.4±6.5,t=2.577,P=0.020]、좌실내압상승최대속솔[dp/dt max(mmHg/s):927±231비1 194±294,t=3.775,P=0.002]、전심사혈분수(GEF:0.21±0.05비0.24±0.06,t=3.091,P=0.008)、심공능지수(CFI:5.03±1.37비6.59±1.92, t=4.769,P=0.000)균현저하강,중심정맥압[CVP (mmHg,1 mmHg=0.133 kPa):9±3비8±3,t=-3.617,P=0.003]、서장압[DBP (mmHg):69±15비66±13,t=-2.656,P=0.019]이급외주혈관조력지수[SVRI (kPa·s·L-1·m-2):206.8±69.8비157.7±46.7, t=-3.255,P=0.006]균현저상승,이수축압[SBP (mmHg):120±25비123±18,t=0.678,P=0.509]、평균동맥압[MAP (mmHg):86±18비85±14,t=-0.693,P=0.500]、전심서장기말용적지수[GEDVI(mL/m2):614±84비618±64,t=0.218,P=0.830]、혈관외폐수지수[EVLWI(mL/kg):5.99±1.50비5.73±1.14,t=-1.329,P=0.205]이급조직관주지표중심정맥혈양포화도(ScvO2:0.711±0.035비0.704±0.048,t=-0.298,P=0.773)、동맥혈유산[Lac(mmol/L):3.1±0.3비3.0±0.4,t=-0.997,P=0.345]、중심정맥-동맥혈이양화탄분압차[Pcv-aCO2(mmHg):4.1±0.9비4.7±0.5,t=1.445,P=0.182]균무명현개변.결론 애사락이능구강저감염성휴극환자적용량반응성,강저심기수축공능、감만심솔、사CO하강,단대조직관주무명현영향.
Objective To study the effects of esmolol on fluid responsiveness and hemodynamic parameters in patients with septic shock.Methods A prospective self-control study was conducted.Fifteen septic shock patients undergoing mechanical ventilation admitted to Department of Critical Care Medicine of Yijishan Hospital from January 2015 to August 2015 were enrolled.All patients enrolled in this study were given the treatment based on American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) Consensus 2012.Esmolol was intravenously injected at a beginning rate of 6 mg·kg-1·h-1, and then the dose was adjusted to reduce heart rate by 10％ from baseline.The changes in hemodynamic and systemic oxygen metabolism indexes were monitored by pulse indicator continuous cardiac output (PiCCO) before and 2 hours after the esmolol administration, and the fluid responsiveness was evaluated by stroke volume variation (SVV).SVV ≥ 10％ was considered to be a positive fluid responsiveness.Results In 15 patients, 9 were male and 6 female, with an age of 65 ± 16.Among them 10 patients suffered from pulmonary infection, and 5 patients with abdominal infection.Acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score was 21 ±9;sequential organ failure score (SOFA) was 8 ±4.28-day mortality was 40.0％.SVV was significantly decreased after esmolol infusion as compared with baseline [(14 ± 5)％ vs.(17 ±7)％, t =2.400, P =0.031].Heart rate [HR (bpm): 100±4 vs.112±8, t =8.161, P =0.000], cardiac output [CO (L/min):6.13 ± 1.45 vs.7.88 ± 1.82, t =4.046, P =0.001], cardiac index [CI (mL·s-1·m-2): 51.51 ± 11.00 vs.66.18 ± 11.48, t =4.131, P =0.001], stroke volume index [SVI (mL/m2): 31.0 ± 6.4 vs.35.4 ± 6.5, t =2.577, P =0.020], the maximum rate of left ventricular pressure rise [dp/dt max (mmHg/s): 927±231 vs.1 194±294, t =3.775, P =0.002], global ejection fraction (GEF: 0.21 ±0.05 vs.0.24±0.06, t =3.091, P =0.008), cardiac function index (CFI: 5.03 ± 1.37 vs.6.59 ± 1.92, t =4.769, P =0.000) showed significant decrease during esmolol infusion.On the other hand, central venous pressure [CVP (mmHg, 1 mmHg =0.133 kPa): 9±3 vs.8±3, t =-3.617, P =0.003], diastolic blood pressure (DBP, mmHg: 69± 15 vs.66± 13, t =-2.656, P =0.019), systemic vascular resistance index (SVRI, kPa·s·L-1·m-2:206.8±69.8 vs.206.8±69.8, t =-3.255, P =0.006) were significantly increased during esmolol infusion.No significant difference was found in systolic blood pressure [SBP (mmHg): 120 ± 25 vs.123 ± 18, t =0.678, P =0.509],mean arterial pressure [MAP (mmHg): 86 ± 18 vs.85 ± 14, t =-0.693, P =0.500], global end diastolic volume index [GEDVI (mL/m2): 614 ± 84 vs.618 ± 64, t =0.218, P =0.830], extravascular lung water index [EVLWI (mL/kg):5.99±1.50 vs.5.73±1.14, t =-1.329, P =0.205], central venous oxygen saturation (ScvO2: 0.711±0.035 vs.0.704 ± 0.048, t =-0.298, P =0.773), arterial blood lactate [Lac (mmol/L): 3.1± 0.3 vs.3.0 ± 0.4, t =-0.997, P =0.345],and difference of central venous-arterial carbon dioxide partial pressure [Pcv-aCO2 (mmHg): 4.1 ± 0.9 vs.4.7 ± 0.5,t =1.445, P =0.182] as compared with those before esmolol treatment.Conclusion Heart rate control with esmolol infusion may reduce fluid responsiveness, cardiac function, heart rate and cardiac output without adverse effect on systemic perfusion in septic shock patients.
