重症超声指导脓毒性休克患儿液体管理的临床研究  

Clinical study of fluid management in children with septic shock guided by ultrasound

作　　者：罗勇[1] 金萍 刘纯义 谢红波 张玉明[2] Luo Yong;Jin Ping;Liu Chunyi;Xie Hongbo;Zhang Yuming(Department of PICU,Shenzhen Bao′an Maternal and Child Health Hospital Affiliated to Jinan University,Shenzhen 518102,China;Department of Pediatrics,Nanfang Hospital,Southern Medical University,Guangzhou 510515,China)

机构地区：[1]暨南大学附属深圳市宝安区妇幼保健院PICU,518102 [2]南方医科大学南方医院小儿科,广州510515

出　　处：《中国小儿急救医学》2020年第1期40-44,共5页Chinese Pediatric Emergency Medicine

摘　　要：目的探讨由儿童重症监护病房(PICU)医生操作的重症超声在PICU脓毒性休克患儿液体管理中的应用价值。方法深圳市宝安区妇幼保健院4位PICU医生通过中国重症超声协作组规范培训,获得合格证书阶段为过渡期。过渡期后2年即2017年1月至2018年12月,在我院PICU住院的脓毒性休克患儿为CCUE组(n=22)。在过渡期前2年即2014年1月至2015年12月我院PICU住院的脓毒性休克患儿为对照组(n=18)。两组患儿均按照脓毒性休克指南给予抗休克、抗感染、机械通气治疗。对照组按照传统方案对患儿进行液体管理。CCUE组患儿在对照组治疗基础上,给予重症急会诊超声检查(critical care chest ultrasonic examination in emergency consultation,CCUE)流程,动态评估血流动力学状态,以调整液体管理方案。结果CCUE组患儿机械通气时间,入院后48 h内液体入量、液体出量均少于对照组[(4.68±2.06)d比(7.33±0.49)d,(6.34±1.85)ml/(kg·h)比(8.55±0.39)ml/(kg·h),(2.47±1.22)ml/(kg·h)比(6.18±1.72)ml/(kg·h);P均<0.05];而CCUE组患儿入院后48 h内液体正平衡量,咪哒唑仑、芬太尼用量均多于对照组,差异有统计学意义[(3.87±2.33)ml/(kg·h)比(2.37±2.10)ml/(kg·h),(5.62±2.39)μg/(kg·min)比(1.68±0.82)μg/(kg·min),(1.41±0.39)μg/(kg·h)比(0.95±0.56)μg/(kg·h);P均<0.05]。CCUE组患儿平均48 h血管活性药物评分、呋塞米用量、PICU住院时间两组间差异无统计学意义(P>0.05)。CCUE组容量复苏1 h后插管率为54.5%(12/22)、病死率为8.3%(2/24),均高于对照组[33.33%(6/18)、5.3%(1/19)],但差异无统计学意义(P>0.05)。结论应用CCUE流程对PICU脓毒性休克患儿进行动态检查评估,可优化液体管理方案,减少机械通气时间。Objective To investigate the effects of critical care chest ultrasonic examination(CCUE)by intensive care physician on fluid management among septic shock patients in pediatric intensive care unit(PICU).Methods Forty children from PICU who were diagnosed as septic shock in Shenzhen Bao′an Maternal and Child Health Hospital were included in this study.Twenty-two of them who were hospitalized in PICU during January 2017 to December 2018,under the care of 4 PICU physicians who had certificates of the Chinese Critical Ultrasound Study Group(CCUSG)were defined as CCUE group.Eighteen PICU patients from January 2014 to December 2015 having no access to CCUE were recruited as control group.Both groups were treated according to the septic shock management guidelines with routine anti-shock and anti-infection therapy,as well as mechanical ventilation.Fluid management following conventional protocol was performed in the control group.While in the CCUE group,CCUE was applied to monitor the hemodynamic status for adjustment in fluid management.Results Compared with the control group,the CCUE group had shorter mechanical ventilation time as well as less fluid intake and output within 48 hours after admission[(4.68±2.06)d vs.(7.33±0.49)d,(6.34±1.85)ml/(kg·h)vs.(8.55±0.39)ml/(kg·h),(2.47±1.22)ml/(kg·h)vs.(6.18±1.72)ml/(kg·h)](P<0.05).The CCUE group also had a more positive fluid balance and larger dosage of midazolam and fentanyl administration[(3.87±2.33)ml/(kg·h)vs.(2.37±2.10)ml/(kg·h),(5.62±2.39)μg/(kg·min)vs.(1.68±0.82)μg/(kg·min),(1.41±0.39)μg/(kg·h)vs.(0.95±0.56)μg/(kg·h)](P<0.05).The two groups showed no differences in vasoactive-inotropic score within 48 h(11.11±6.08 vs.9.90±4.12),dosage of furosemide[(1.07±0.52)mg/(kg.d)vs.(0.94±0.15)mg/(kg·d)],length of PICU stay[(10.73±7.48)d vs.(10.00±2.91)d],intubation rate after 1 hour of volume resuscitation[54.5%(12/22)vs.33.33%(6/18)]or mortality[8.3%(2/24)vs.5.3%(1/19)](P>0.05).Conclusion Application of CCUE helps to optimize fluid management

关 键 词：脓毒性休克 液体管理 重症急会诊超声检查流程 

分 类 号：R7[医药卫生—临床医学]