感染性休克患者容量负荷试验后反应性评估时间的选择  

Choice of assessment time after fluid challenge in patients with septic shock

作　　者：黄惠斌 刘光云 许彪 杨婷 杜斌 Huang Huibin;Liu Guangyun;Xu Biao;Yang Ting;Du Bin(Department of MICU,Peking Union Medical College Hospital,Peking Union Medical College and Chinese Academy of Medical Sciences,Beijing 100730,China;Department of Respiratory and Critical Care Medicine,Peking Chaoyang Hospital,Beijing 100020,China;Critical Care Medicine Center,the Fifth Medical Center of PLA General Hospital,Beijing 100039,China)

机构地区：[1]中国医学科学院北京协和医院MICU,100730 [2]北京朝阳医院呼吸与危重病医学科,100020 [3]解放军总医院第五医学中心重症医学中心,北京100039

出　　处：《中华危重病急救医学》2019年第4期407-412,共6页Chinese Critical Care Medicine

基　　金：国家科技支撑计划项目(2012BAI11B05).

摘　　要：目的评估感染性休克患者使用胶体液或晶体液进行容量负荷试验(扩容试验)后短期内血流动力学变化特点,探讨判断容量反应性的恰当时机。方法采用前瞻性观察研究方法,选择北京协和医院内科重症加强治疗病房(ICU)2016年7月至2018年12月收治的接受肺动脉漂浮导管监测的感染性休克患者并进行扩容试验。按使用的扩容液体类型将患者分为晶体组(500mL的生理盐水)和胶体组(500mL的4%琥珀酰明胶),扩容液的选择由主治医师决定。记录扩容前及扩容后0(即刻)、10、30、45、60、90和120min的血流动力学指标,包括心排血指数(CI)、心率(HR)、平均动脉压(MAP)、中心静脉压(CVP)及肺动脉楔压(PAWP)等。以扩容试验后CI增加值(ΔCI)≥10%定义为容量反应阳性。分析不同类型扩容液体组患者和有无容量反应性患者的血流动力学指标变化趋势。结果研究纳入40例患者,胶体组和晶体组患者各20例。26例患者容量反应阳性,其中胶体组12例,晶体组14例;容量反应阴性患者14例,其中胶体组8例,晶体组6例。①与扩容前比较,胶体组和晶体组扩容即刻CI(mL·s^-1·m^-2)即显著增加(71.7±16.7比65.0±16.7,68.3±25.0比63.3±23.3,均P<0.05),其中胶体组CI在扩容后30min达峰值(76.7±18.3),至120min(70.0±16.7)仍显著高于扩容前(P<0.05),ΔCI≥10%持续至扩容后60min;晶体组CI在扩容后10min达峰值(73.3±28.3),于60min时恢复到基线水平,ΔCI≥10%持续至扩容后10min。两组扩容后各时间点ΔCI差异均无统计学意义。②对于无容量反应性的患者,无论是在晶体组或是胶体组,扩容前后CI均无显著变化。对于有容量反应性的患者,CI与扩容前相比有差异的时间点及达峰时间点与两组患者整体变化趋势相同;但胶体组有容量反应性的患者ΔCI≥10%可持续至120min,而晶体组有容量反应性的患者ΔCI≥10%持续至30min。此外,胶体组有容量反应性的患者扩容后30�Objective To explore the short-term hemodynamic change of fluid challenge (FC) with crystalloid or colloid and define fluid responsiveness at the optimal time in patients with septic shock. Methods A prospective observational study was conducted. Septic shock patients monitored with pulmonary catheters admitted to medical intensive care unit (ICU) of the Peking Union Medical College Hospital from July 2016 to December 2018 were enrolled. All included patients received FC and were divided into two groups according to the type of fluid used, i.e. crystalloid group (normal saline for 500 mL) and colloid group (4% succinyl gelatin for 500 mL). The choice of fluid type was decided by the attending physician. Hemodynamic variables were measured at baseline, and 0 (immediately), 10, 30, 45, 60, 90, 120 minutes after FC, included cardiac index (CI), heart rate (HR), mean artery pressure (MAP), central venous pressure (CVP) and pulmonary arterial wedge pressure (PAWP). Fluid responsiveness was defined as CI increased by more than 10% after FC. The data were analyzed by repeated measurements of variance between the two groups as well as responders and nonresponders. Results Forty patients were included, 20 cases each in colloid group and crystalloid group;of whom 26 were fluid responders with 12 of colloid group and 14 of crystalloid group. Of the 14 nonresponders, 8 were of colloid group and 6 of crystalloid group.① Compared with before FC, CI (mL·s-1·m-2) was significantly increased in crystalloid and colloid groups after FC (71.7±16.7 vs. 65.0±16.7, 68.3±25.0 vs. 63.3±23.3, both P < 0.05). In the colloid group, volume expansion increased the CI to maximum (76.7±18.3) at 30 minutes after FC, at 120 minutes after FC, a significantly higher CI (70.0±16.7) was also observed (P < 0.05), an increased in CI≥10% was observed at 60 minutes after FC. In the crystalloid group, CI was increased to maximum at 10 minutes (73.3±28.3) and decreased to baseline at 60 minutes, an increased in CI≥10% was also observed at 10

关 键 词：容量负荷试验 晶体液 胶体液 感染性休克 血流动力学 

分 类 号：R459.7[医药卫生—急诊医学]