监测液体复苏前后血流动力学参数对脓毒性休克短期预后的早期预测价值  

Early predictive value of hemodynamic parameters during fluid resuscitation in patients with sepsis shock

作　　者：陈炜[1] 臧学峰[1] 牛素平[1] 吕超[1] 赵磊[1] 盛博[1] 古旭云[1] 张静姝[1] 

机构地区：[1]首都医科大学附属北京世纪坛医院重症医学科,北京100038

出　　处：《中华危重病急救医学》2015年第1期43-47,共5页Chinese Critical Care Medicine

基　　金：北京市自然科学基金（7123219）;北京市中医管理局重点项目（2014-ZYJ01）

摘　　要：目的观察脓毒性休克患者液体复苏前后血流动力学参数对其短期预后的影响。方法回顾性分析2013年1月至2014年10月入住北京世纪坛医院重症医学科76例脓毒性休克并行液体复苏患者的临床资料，所有患者入科后立即用脉搏指示连续心排血量仪（PiCCO）监测血流动力学参数，记录液体复苏前及复苏后6h的平均动脉压（MAP）、每搏量指数（SVI）、心排血指数（CI）、全心射血分数（GEF）、全心舒张期末容积指数（GEDVI）、胸腔内血容量指数（ITBVI）、血管外肺水指数（EVLWI）、外周血管阻力指数（SVRI）、肺毛细血管通透性指数（PVPI）等。根据7d预后将患者分为生存组（42例）和死亡组（34例）。比较两组血流动力学参数的差异，并绘制受试者工作特征曲线（ROC），分析复苏前及复苏后6h各参数对患者早期预后的预测价值。采用多因素logistic回归分析脓毒性休克患者7d预后的预测因素。结果①与液体复苏前比较，存活组复苏后6h的EVLWI、PVPI均明显下降[EVLWI（mL／kg）：7．33±1．72比9．07±2．81，PVPI：1．39±0．34比1．74±0．50，均P〈0．01]；死亡组复苏后6h的EVLWI、PVPI均明显升高[EVLWI（mL／kg）：12．62±3．58比8．97±2．74，PVPI：2．36±0．81比1．73±0．60，均P〈0．01]，而MAP进一步下降（MAP（mmHg，1mmHg=0．133kPa）：70．53±12．12比77．06±13．48，P〈0．01]。②ROC曲线显示，液体复苏后6h EVLWI的ROC曲线下面积（AUC）为0．914，临界值为9．50mL/kg时的敏感度为82．4％，特异度为88．1％；PVPI的AUC为0．890，临界值为1．75时的敏感度为73．5％，特异度为92．9％。③多因素logistic回归分析显示，液体复苏后6h的EVLWI是脓毒性休克患者7d预后的独立预测因素（优势比（OR）=0．546，95％可信区间（95％CI）=0．852～0．976，P=0．006]。结论PiCCO监测的血流动力学参数EVLWI、PVPI、MAP与脓�Objective To investigate the short term predictive value of hemodynamic parameters during fluid resuscitation in patients with septic shock. Methods Data of 76 patients with septic shock admitted to Department of Critical Care Medicine of Beijing Shijitan Hospital from January 2013 to October 2014 were retrospectively analyzed. The hemodynamic parameters were monitored by pulse indicator continuous cardiac output （ PiCCO ）, including mean arterial pressure （MAP）, stroke volume index （SVI）, cardiac index （CI）, global ejection fraction （GEF）, global end diastolic volume index （GEDVI）, intrathoracic blood volume index （ITBVI）, extravascular lung water index （EVLWI）, systemic vascular resistance index （SVRI）, and pulmonary vascular permeability index （PVPI）. They were recorded before and 6 hours after fluid resuscitation. According to the prognosis on the 7th day, the patients were divided into survival group （n = 42） and death group （n = 34）. The PiCCO records between two groups were compared and a receiver operating characteristic （ROC） curve for predicting the outcome was plotted to find the cut-off point value for each PiCCO record before and 6 hours after fluid resuscitation. The factors for predicting 7-day prognosis of patients with septic shock were analyzed by multivariate logistic regression analysis. Results ① Compared with those before fluid resuscitation, EVLWI and PVPI were significantly decreased at 6 hours after fluid resuscitation in the survival group [EVLWI （mL/kg）： 7.33±1.72 vs. 9.07±2.81, PVPh 1.39±0.34 vs. 1.74±0.50, both P〈0.01 ] but they were significantly increased in the death group [ EVLWI （mL/kg）： 12.62±3.58 vs. 8.97±2.74, PVPI： 2.36 ± 0.81 vs. 1.73± 0.60, both P〈0.01 ], and MAP in the death group decreased after fluid resuscitation [MAP （mmHg, 1 mmHg = 0.133 kPa）： 70.53±12.12 vs. 77.06±13.48, P〈0.01 ]. ② ROC curve showed that the area under ROC curve （AUC） of EVLWI at 6 hours after fluid resusc

关 键 词：脓毒性休克 血管外肺水指数 肺毛细血管通透性指数 平均动脉压 预后 

分 类 号：R459.7[医药卫生—急诊医学]