血乳酸联合Pcv-aCO2/Ca-cvO2及下腔静脉直径扩张指数指导脓毒症休克早期液体复苏治疗的价值  

Value of arterial lactate combined with central venous-to-arterial carbon dioxide difference/arterial-central venous oxygen content difference ratio and inferior vena cava diameter distensibility index to guide early fluid resuscitation treatment in septic shock patients

作　　者：王雪婷[1] 高雪花[1] 曹雯[1] 关银[1] 罗延年[1] 何囡囡 李培杰[1] Wang Xue-ting;Gao Xue-hua;Cao Wen;Guan Yin;Luo Yan-nian;He Nan-nan;Li Pei-jie(Department of Critical Care Medicine,Lanzhou University Second Hospital,Lanzhou 730030,China)

机构地区：[1]兰州大学第二医院重症医学科,甘肃兰州730030

出　　处：《中国急救医学》2020年第8期703-708,共6页Chinese Journal of Critical Care Medicine

基　　金：甘肃省自然科学基金(18JR3RA313)。

摘　　要：目的明确血乳酸(Lac)联合中心静脉-动脉血二氧化碳分压差与动脉-中心静脉血氧含量差比值(Pcv-aCO2/Ca-cvO2)及下腔静脉直径扩张指数(dIVC)指导脓毒症休克早期液体复苏治疗的价值.方法纳入兰州大学第二医院重症医学科2018年1月至2019年6月收治的脓毒症休克合并有创机械通气患者共54例.根据复苏前dIVC和复苏6h的Pcv-aCO2/Ca-cvO2分组,分为对照组(dIVC≤18%)和实验组(dIVC>18%,Pcv-aCO2/Ca-cvO2<1),收集患者复苏前(T0)、复苏6 h(T6)的桡动脉和上腔静脉血气分析结果,计算Pcv-aCO2/Ca-cvO2.收集吸气末下腔静脉直径最大值(IVCmax)、呼气末下腔静脉直径最小值(IVCmin),计算dIVC.比较两组脓毒症休克患者的一般临床指标、急性生理与慢性健康状况Ⅱ评分(APACHEⅡ评分)、序贯器官衰竭评分(SOFA评分)、6h补液量、6h乳酸清除率(LCR)、下腔静脉直径扩张指数变化(△dIVC)、ICU住院时间以及复苏前后血流动力学及氧代谢指标;采用Kaplan-Meier法绘制两组患者28 d生存曲线;通过受试者工作特征(ROC)曲线评价血Lac+Pcv-aCO2/Ca-cvO2+dIVC和血Lac对脓毒症休克患者28 d病死率的预测价值.结果①两组患者基线资料比较差异无统计学意义,与对照组比较,实验组6h补液量少(L:2.96-±0.30 vs.2.65±0.20,P=0.000),6hLCR高(20.24±13.62 vs.32.67±12.02,P=0.001),△dIVC高(6.42±4.93 vs.10.19±4.05,P=0.005);②与对照组比较,实验组复苏前MAP高(52.39±4.97 vs.56.38±2.87,P=0.002),dIVC高(20.24±7.33 vs.25.48±4.62,P=0.005),血Lac低(4.98±0.92 vs.4.21±0.69,P=0.002),Pcv-aGO2低(6.52±1.48 vs.5.38±1.28,P=0.006),Pcv-aCO2/Ca-cvO2低(1.70±0.27 vs.1.42±0.18,P=0.000);与对照组比较,实验组复苏6h的MAP高(69.33±5.28 vs.72.57±5.05,P=0.030),血Lac低(4.02±1.16 vs.2.85±0.76,P=0.001),Pcv-aCO2低(6.36±1.71 vs.3.52±1.08,P=0.000),Pcv-aCO2/Ca-cvO2低(1.67±0.44 vs.1.08±0.10,P=0.000);③实验组病死率低于对照组[log-rank(Mantel-Cox=5.809),P=0.016];④Lac+Pcv-aCO2/Ca-cvO2+dIObjective To study the value of arterial lactate(Lac)combined with central venous-to-arterial carbon dioxide difference/arterial-central venous oxygen content difference ratio(Pev-aCO2/Ca-cvO2)and inferior vena cava diameter distensibility index(dIVC)to guide early fluid resuscitation therapy for septic shock.Methods A total of 54 patients with septic shock and invasive mechanical ventilation who were admitted to the Department of Critical Care Medicine of Lanzhou University Second Hospital from January 2018 to June 2019 were enrolled in this study.They were divided into control group(dIVC≤18%)and experimental group(dIVC>18%,Pev-aCO2/Ca-cvO2<1)according to the dIVC before recovery and Pcv-aCO2/Ca-cvO2 after 6-hour recovery.The Pcv-aCO2/Ca-cvO2 was calculated from blood gas analysis of radial artery and superior vena cava which was performed before resuscitation(T0)and after 6-hour resuscitation(T6).The inferior vena cava diameter distensibility index(dIVC)was calculated by the maximum inferior vena cava diameter at the end-inspiratory(IVCmax)and the minimum inferior vena cava diameter at the end-expiratory(IVCmin)which were measured by ultrasound.The baseline data,acute physiology and chronic health evaluation score I(APACHE II)score,sequential organ failure score(SOFA)score,the time of stay in the intensive care unit(ICU),fluid replacement at 6 h and lactate clearance rate(LCR)at 6 h,the change of inferior vena cava diameter distensibility index(SdIVC),hemodynamics and oxygen metabolism indexes before and after resuscitation were compared between the two groups.Kaplan-Meier was used to draw 28-day survival curve of two groups.The receiver-operating characteristic curve(ROC)was plotted to evaluate the predictive value of Lac±Pev-aCO2/Ca-cvO2±dIVC and Lac for 28-day mortality with septic shock patients.Results①There was no difference in baseline data between the two groups.Compared with the control group,patients in the experimental group had less fluid replacement at the 6th hour(L:2.96±0.30 vs.2.65±0.20,

关 键 词：脓毒症休克 中心静脉-动脉血二氧化碳分压差与动脉-中心静脉氧含量差比值(Pcv-aCO2/Ca-cvO2) 乳酸(Lac) 下腔静脉扩张指数(dIVC) 

分 类 号：R459.7[医药卫生—急诊医学]