血管外肺水和容量指标在感染性休克患者呼吸机撤离中的临床意义  

Clinical value of extravascular lung water and preload parameters in weaning of mechanical ventilation in patients with septic shock

作　　者：方明[1] 陈淼[1] 郑崇伟[1] 邓医宇[1] 胡北[1] 柳学[1] 黄伟平[1] 龙怡[1] 蒋文新[1] 曾红科[1] 

机构地区：[1]广东省人民医院(广东省医学科学院)急危重症医学部,广州510080

出　　处：《中华危重病急救医学》2013年第1期28-31,共4页Chinese Critical Care Medicine

基　　金：广东省科技计划项目（20108031600110）

摘　　要：目的探讨血管外肺水及容量指标在感染性休克患者呼吸机撤离过程中变化的临床价值。方法采用前瞻性研究，选择2010年1月至2012年7月52例需呼吸机支持的感染性休克患者，在脉搏指示连续心排血量（PiCCO）技术监测下治疗，达到撤机标准后循序进行自主呼吸试验（SBT）、拔管。根据48h内撤机结局分为撤机成功组（38例）与撤机失败组（14例），比较两组撤机前、撤机后0．5h、拔管后0．5h、撤机失败时或撤机48h的血管外肺水指数（EVLWI）、容量指标[如全心舒张期末容量指数（GEDVI）、胸腔内血容量指数（ITBVI）、肺血管渗透性指数（PVPI）]和N末端脑钠肽前体（NT-proBNP）的差异。对撤机失败者进行PVPI分层，比较高PVPI组（PVPI≥1．5ml/m2）和低PVPI组（PVPI〈1．5ml/m2）NT-proBNP、肺内血容量（PBV）差异。结果两组撤机前容量指标和EVLWI、NT-proBNP差异均无统计学意义。两组撤机和拔管后EvLwI、GEDVI、ITBVI、PVPI和logNT-proBNP均进行性升高，其中撤机失败组在观察终点EVLWI（ml／kg）、PvPI（ml／m。）、logNT-proBNP均明显高于撤机成功组（EVLwI：12．81±2．13比8．48±1．53，PVPI：2．79±1．29比2．19±0．94，logNT-proBNP：3．72±0．35比3．44±0．28，P〈0．05或P〈0．01）；在拔管后0．5h和观察终点，撤机失败组GEDVI（ml/m2）、ITBVI（ml/m2）均明显高于撤机成功组（拔管后0．5h：GEDVI986．29±166．44比856．47±149．15，ITBVI：1171．07±167．03比1045．79±146．09；观察终点：GEDVI957．00±67．25比816．86±27．58，ITBVI：1184．29±209．68比993．79±168．90，P〈0．05或P〈0．01）。分层分析显示，撤机失败者观察终点低PVPI组logNT-proBNP、PBV均明显高于高PVPI组（bgNT-proBNP：4．02±0．11比3．71±0．23，PBV：507．19±25．72比347．85±47．52，P〈0．05和P〈0．01）。结论感染性休克患者撤机拔管过程可增加容量负荷�Objective To investigate the values of extravascular lung water and preload parameters of weaning from mechanical ventilation on patients with septic shock. Methods A prospective study was conducted. A total of 52 septic shock patients with mechanical ventilation were enrolled from January 2010 to July 2012. All patients were treated and monitored by pulse induced continuous cardiac output （PiCCO） till they reached weaning criteria, and then spontaneous breathing trial （SBT）, weaning, and extubation were performed in turn. The enrolled patients were divided into two groups including successful weaning group （n = 38 ） and weaning failure group （n = 14 ） according to clinical manifestations during 48 hours after weaning. Extravascular lung water index （EVLWI）, preload parameters such as global end diastolic volume index （GEDVI） and intra-thoracic blood volume index （ITBVI）, pulmonary vascular permeability index （PVPI） and N-terminal pro-B-type natriuretic peptide （NT-proBNP） were compared at the time before weaning, 0.5 hour after weaning, 0.5 hour after extubatiou, and time of weaning failure or 48 hours after weaning. The patients in weaning failure group were sub-divided into high PVPI group （PVPI ≥ 1.5 ml/m2） and low PVPI group （PVPI〈1.5 ml/m2）, the NT-proBNP and pulmonary blood volume （PBV） were compared between two groups. Results Before weaning, there was no statistical difference in NT-proBNP, volume parameters and EVLWI between two groups. EVLWI, GEDVI, ITBVI, PVPI and log NT-proBNP were gradually increased after weaning and extubation in two groups. The EVLWI （ml/kg）, PVPI （ml/m2） and log NT-proBNP were significantly higher at end point of observation in weaning failure group compared with those in successful weaning group （EVLWI： 12.81 ± 2.13 vs. 8.48 ± 1.53, PVPI： 2.79 ± 1.29 vs. 2.19 ± 0.94, log NT-proBNP： 3.72 ± 0.35 vs. 3.44± 0.28, P〈0.05 or P〈0.01 ）. GEDVI （ml/m2）, ITBVI （ml/m2） at 0.5 hour after weaning and end

关 键 词：感染性休克 机械通气 撤机 脉搏指示连续心排血量技术 N末端脑钠肽前体 

分 类 号：R631.4[医药卫生—外科学]