血管外肺水联合P(cv-a)CO_2/C(a-cv)O_2在脓毒性休克早期治疗中的应用研究  

Clinical value of extravascular lung water combined with central venous-to-arterial carbon dioxide difference/arterial-to-venous oxygen difference ratio in early treatment of patients with septic shock

作　　者：罗真春 刘祺[2] 李世琪[2] 但伶[2] 田泽丹[2] 黄燕[2] Luo Zhenchun;Liu Qi;Li Shiqi;Dan Lin;Tian Ze dan;Huang Yan(Department of Emergency & Critical Care Me die ine , Chongq ing Traditional Chinese Medical Hospital;Department of A nesthesiology, the Second Affiliated Hospital of Chongqing Medical University)

机构地区：[1]重庆市中医院急诊-重症医学科,重庆400021 [2]重庆医科大学附属第二医院麻醉科,重庆400001

出　　处：《重庆医科大学学报》2019年第3期365-369,共5页Journal of Chongqing Medical University

基　　金：重庆市卫生计生委医学科研面上资助项目(编号:2015MSXM021)

摘　　要：目的:探讨血管外肺水(extravascular lung water,EVLW)联合中心静脉-动脉二氧化碳分压差/动脉-中心静脉氧含量差比值[central venous-to-arterial carbon dioxide difference/arterial-to-venous oxygen difference ratio,P(cv-a)CO_2/C(a-cv)O_2]在指导脓毒性休克早期治疗中的临床价值。方法:选择在2015至2017年重庆医科大学附二院和重庆市中医院中心ICU入住的脓毒性休克患者50例,采用随机分组的原则将患者分为早期目标导向性治疗组(EGDT组,n=28)和EVLW联合P(cv-a)CO2/C(a-cv)O2组(P/C组,n=22)。监测指标:(1)所有患者持续监测平均动脉压(MAP)、心率(HR)及中心静脉压(CVP),并抽取动脉血和中心静脉血行血气分析,通过血气分析测定患者Pa CO2、Pcv CO2、Pcv O2、Scv O2、Hbcv、Pa O2、Sa O2、Hba以及入ICU时和复苏6 h后血乳酸值。计算P(cv-a)CO2/C(a-cv)O2。其中Ca O2=1.34×Hba×Sa O2+0.003×Pa O2;Ccv O2=1.34×Hbcv×Scv O2+0.003×Pcv O2;C(acv)O2=Ca O2-Ccv O2;(2)P/C组通过脉搏指示连续心排血量技术(Pi CCO),采用经肺热稀释法测血管外肺水(EVLW),每3 h 1次,连续测量3次取平均值;(3)乳酸清除率(乳酸清除率=(入ICU时血乳酸值-6 h后血乳酸值)/入ICU时血乳酸值×100%;(4)6 h内血管活性药物去甲肾上腺素用量比较;(5)统计患者28 d病死率。比较2组患者液体复苏后各指标的差异。结果:复苏6 h后MAP、Scv O2、复苏6 h达标率2组间无统计学差异(P>0.05);P/C组复苏6 h后的乳酸清除率和每小时尿量均明显高于EGDT组(P<0.05);复苏液体量、CVP、P(cv-a)CO_2/C(a-cv)O_2、血管活性药物用量均明显低于EGDT组(P<0.05);2组患者28 d病死率无统计学差异(P>0.05)。结论:血管外肺水联合P(cv-a)CO_2/C(a-cv)O_2联合指导下脓毒性休克早期目标导向治疗,能尽早且更准确地判断脓毒性休克患者的组织灌注状态和容量负荷状态,指导临床合理的液体治疗和血管活性药物的使用。Objective:To investigate the clinical value of extravascular lung water(EVLW)combined with central venous-arterial partial pressure of carbon dioxide/arterial-central venous oxygen content difference ratio[P(cv-a)CO2/C(a-cv)O2] in the early treatment of septic shock. Methods:A total of 50 patients with septic shock who were admitted to the intensive care unit(ICU)of The Second Affiliated Hospital of Chongqing Medical University and Chongqing Hospital of Traditional Chinese Medicine from 2015 to 2017 were enrolled and randomly divided into early goal-directed therapy(EGDT)group with 28 patients and EVLW+P(cv-a)CO2/C(a-cv)O2 group with 22 patients(P/C group). Mean arterial pressure(MAP),heart rate(HR),and central venous pressure(CVP)were continuously monitored for all patients,and arterial blood samples and central venous blood samples were collected for blood gas analysis to measure Pa CO2,Pcv CO2,Pcv O2,Scv O2,Hbcv,Pa O2,Sa O2,Hba,and blood lactate at the time of ICU admission and at 6 hours after resuscitation. P(cv-a)CO2/C(a-cv)O2 was calculated;Ca O2=1.34×Hba×Sa O2+0.003×Pa O2,Ccv O2=1.34×Hbcv× Scv O2+0.003×Pcv O2,and C(a-cv)O2=Ca O2-Ccv O2. For patients in the P/C group,extravascular lung water(EVLW)was measured by pulse-induced contour cardiac output(Pi CCO),once every 3 hours,and the mean value of three consecutive measurements was recorded.Lactate clearance rate was calculated according to the following equation:lactate clearance rate =(blood lactate value at the time of ICU admission-blood lactate value at 6 hours after resuscitation)/blood lactate value at the time of ICU admission×100%. The dose of the vasoactive agent norepinephrine within 6 hours after resuscitation was compared between the two groups. The 28-day mortality rate was calculated. Related indices after fluid resuscitation were compared between the two groups. Results:There were no significant differences between the two groups in MAP,Scv O2,and the proportion of patients achieving EGDT target at 6 hours after fluid resuscitation(P>

关 键 词：血管外肺水 中心静脉-动脉二氧化碳分压差/动脉-中心静脉氧含量差 早期目标导向性治疗 脓毒性休克 

分 类 号：R459.7[医药卫生—急诊医学]