感染性休克患者平均动脉压改变对全身血流动力学及舌下微循环变化的影响  

The Influence of the Changes of Mean Arterial Pressure in Patients with Septic Shock on Systemic Hemodynamics and sublingual Microcirculation

作　　者：马四清[1] 何宗钊[1] 李欣慧[1] 徐静媛[2] 邱海波[2] 

机构地区：[1]青海省人民医院,810007 [2]东南大学附属东大医院,210009

出　　处：《高原医学杂志》2015年第3期4-9,共6页Journal of High Altitude Medicine

基　　金：青海省(应用)基础研究计划项目;编号2012-Z-713

摘　　要：目的：观察应用去甲肾上腺素提高感染性休克患者平均动脉压至平时水平时对全身血流动力学及舌下微循环的影响,探讨其相关变化关系。方法：本研究为单中心、前瞻性、干预性研究。根据Rivers提出早期目标导向性治疗（Early Goal-Directed Therapy,EGDT）,给予积极液体复苏或联合应用血管活性药物,使中心静脉压（Central Venous Pressure,CVP）达8mm Hg后,平均动脉压（Mean Arterial Pressure,MAP）达65mm Hg,应用NICOM系统（Cheetah Medical,Portland,OR）无创血流动力学监测仪监测心输出量（Cardiac Output,CO）、每搏量（Stroke Volume,SV）、总外周血管阻力指数（Systemic Vascular Resistance Index,SVRI）,应用旁流暗视野成像技术（Sidestream dark field,SDFMicroscan,Micro Vision Medical,Amsterdam,Netherlands）观察舌下微循环：总血管密度（Total Vascular Density,TVD）、灌注血管密度（Perfused Vascular Density,PVD）、灌注血管比例（Proportion of Perfused Vascular,PPV）,微血管流动指数（Microvascular Flow Index,MFI）。增加剂量滴定至患者MAP至平时水平,再次监测上述血流动力学指标和微循环指标。结果：共纳入20名诊断感染性休克24小时以内的患者,男14例,女6例,利用去甲肾上腺素滴定平均动脉压至平时水平可以明显提高CVP[（11±4）mm Hg至（13±4）mm Hg,P=0.002],CO[（5.4±1.4）L/min至（6.4±2.1）L/min,P=0.002],增加SVRI（1 587dyn·s·m^-2·cm^-5～1 890dyn·s·m^-2·cm^-5,P=0.004）和中心静脉血氧饱和度[Scv O2（81±7）%至（83±7）%,P=0.001]。血乳酸在血压滴定前后未有显著变化。与MAP滴定前相比,SDF观察到血压滴定后舌下PVD[（10.96±2.98）vessels/mm^2至（11.99±2.55）vessels/mm^2,P=0.009],PPV[（85±18）%至（92±14）%,P=0.002]均明显增加,MFI（2.45±0.61至2.80±0.68,P=0.009）明显增加。结论：应用去甲肾上腺素滴定感染性休克患者MAP至平时水平可以改善全身血流动力学和舌下微循�Objective： To observe the influence of the changes of mean arterial pressure applied Norepinephrine in patients with septic shock on systemic hemodynamics and sublingual microcirculation and clarity the corresponding relationship. Methods： This is a single- center,open- label study. hypertensive patients with septic shock for less than 24 hours after adequate fluid resuscitation and requiring Norepinephrine to maintain a mean arterial pressure of 65 mm Hg were enrolled. Mean arterial pressure was then titrated by Norepinephrine from 65 mm Hg to the normal level of the patient. In addition to hemodynamic variables sublingual microcirculation was evaluated by side- stream dark field imaging. Results： Twenty patients were enrolled in the study. Increasing mean arterial pressure from 65 mm Hg to normal levels was associated with increased central venous pressure[CVP,from（ 11 ± 4） mm Hg to（ 13 ± 4） mm Hg,P = 0. 002],cardiac output [CO,from（ 5. 4 ± 1. 4） L/min to（ 6. 4 ± 2. 1） L/min,P = 0. 001],systemic vascular resistance index[SVRI,（ 1 587 to 1 890dyn·s·m^-2·cm^-5,P = 0. 004） and central venous oxygen saturation [Scv O2,from（ 81 ± 7） % to（ 83 ± 7） %,P = 0. 001]. There were significant increases in small perfused vessel density[PVD,（ 10. 96 ± 2. 98） ～（ 11. 99 ± 2. 55）,P = 0. 009 ],proportion of small perfused vessels[PPV,from（ 85 ± 18） % to（ 92 ± 14） %,P = 0. 002],and small micro- vascular flow index[MFI,from（ 2. 45 ± 0. 61） % to（ 2. 80 ± 0. 68） %,P = 0. 009],when compared with a mean arterial pressure of 65 mm Hg. Conclusions： Increasing mean arterial pressure 65 mm Hg to normal levels is associated with microcirculation improving in hypertensive septic shock patients.

关 键 词：感染性休克 血流动力学 微循环 去甲肾上腺素 高原 

分 类 号：R459.7[医药卫生—急诊医学]