NICaS监测下多巴酚丁胺负荷试验中感染性休克患者血流动力学变化与预后的关系  

Relationship between hemodynamics change and prognosis in the patients with septic shock under dobutamine stress test monitored with NICaS

作　　者：朱妍 吉猛 袁晓伟 林兆奋 Zhu Yan;Ji Meng;Yuan Xiao-wei;Lin Zhao-fen(ICU of Emergency Department,Shanghai Changzheng Hospital,Shanghai 200003,China)

机构地区：[1]上海长征医院急救科ICU,上海200003 [2]上海市杨浦区市东医院消化内科,上海200003

出　　处：《中国急救医学》2020年第9期858-863,共6页Chinese Journal of Critical Care Medicine

摘　　要：目的以无创全身阻抗法心输出量监测系统(noninvasive cardiac output monitoring system,NICaS)为监测手段,了解感染性休克患者心血管系统的反应性在预后判断中的作用.方法选择本院ICU收治的感染性休克患者96例,按28 d临床结局分为存活组和死亡组.收集患者入组时的一般资料,使用NICaS测量补液后多巴酚丁胺负荷试验前(基线数据)和多巴酚丁胺注射30 min后的血流动力学参数.结果两组患者基线各指标中仅血小板计数(P=0.00)、SOFA评分(P=0.01)和APACHEⅡ评分(P=0.01)差异有统计学意义.基线血流动力学数据中,死亡组心率(HR)快于存活组(P<0.05),而格兰夫-高尔指数(GGI)、氧输送指数(DO2I)和总外周血管阻力指数(TPRI)低于存活组(P<0.05),余两组间参数如平均动脉压(MBP)、心脏指数(CI)、每搏输出量指数(SI)、心脏做功指数(CPI)等差异均无统计学意义(P>0.05).多巴酚丁胺负荷前及负荷30 min后ΔMAP两组间比较差异无统计学意义(P>0.05),生存组使用多巴酚丁胺前后ΔSVI、ΔCI、ΔCPI、ΔGGI的升高较死亡组更明显(P<0.05);ΔTPRI降低较死亡组更明显(P<0.05).经多因素Logistic回归分析显示,心脏指数变化值(ΔCI)是感染性休克患者存活的独立预测因子、总外周血管阻力指数变化值(ΔTPRI)是死亡的独立预测因子.将两组多巴酚丁胺负荷试验前后血流动力学参数变化值与预后行ROC曲线分析,结果显示,ΔCI、ΔDO2 I、ΔCPI、ΔGGI预测感染性休克患者存活的曲线下面积分别为0.86、0.61、0.64、0.66,其中ΔCI是用于预测患者存活的最佳指标.以约登指数最大的一点为临界值,当ΔCI界值为1.05 L/(min·m^2)时,ROC曲线预测患者存活的敏感度为93.8%,特异度为65.6%.而当ΔTPRI界值为-427 dyn/(s·cm^2·m^2)时,ROC曲线预测患者死亡的敏感度为100%,特异度为71.9%,ROC曲线下面积为0.91.结论多巴酚丁胺负荷试验下心血管系统的反应性比初始血流动力学指标更�Objective To investigate the role of cardiovascular system reactivity in prog nosis of septic shock patients with noninvasive cardiac output monitoring system(NICaS)monitoring.Methods 96 septic shock patients from ICU were selected and were divided into survival group and death group according to the clinical outcome of 28 days.General data of patients were collected at the time of enrollment,and baseline hemodynamic data were measured after fluid rehydration and before dobutamine stress test by using NICaS.Results The difference in the baseline platelet count(P=0.00),SOFA score(P=0.01)and APACHE Ⅱ score(P=0.01)was statistically significant.In the death group,the baseline HR was faster than that in the survival group(P<0.05). Otherwise,GGI,oxygen transport index(DO2I)and total peripheral vascular resistance index(TPRI)were lower than those in the survival group(P<0.05).There were no significant differences in mean arterial pressure(MBP),cardiac index(CI),output per stroke index(SI),and cardiac work index(CPI)between the two groups(P>0.05).Before dobutamine load and after dobutamine load for 30 min,AMAP had no difference between the two groups(P>0.05),ΔSVI,ΔCI,ΔCPI,ΔGGI increased more significantly in the survival group than those in the death group(P<0.05);ΔTPRI decrease was more significant in the survival group than in the death group(P<0.05).The multivariate Logistic regression analysis showed that ΔCI was an independent predictor of survival in the patients with septic shock and ΔTPRI was an independent predictor of death.The changes of hemodynamic parameters and prognosis of the two groups before and after dobutamine stress test were analyzed by ROC curve,the result showed the area under the curve of ΔCI,ΔDO2I,ΔCPI and AGGI for predicting the survival of patients with septic shock were 0.86,0.61,0.64,0.66 respectively.Among them,ΔCI was the best indicator to predict the survival.When the Yoden index was at its maximum,ΔCI boundary value was 1.05 L/(min·m^2),the ROC curve predicted the survival

关 键 词：感染性休克 无创全身阻抗法心输出量监测系统(NICaS) 多巴酚丁胺负荷试验 血流动力学 预后 

分 类 号：R459.7[医药卫生—急诊医学]