重症超声引导下液体复苏与早期目标导向治疗对复苏效果血流动力学和氧代谢指标的影响  

Effect of ultrasound-guided fluid resuscitation vs.early goal-directed therapy on hemodynamics and oxygen metabolism in the patients with septic shock

作　　者：柯慧娟 吴爽 马琴琴[1] 杨晓静[1] 李天民[1] 王磊[1] Ke Hui-juan;Wu Shuang;Ma Qin-qin;Yang Xiao-jing;Li Tian-min;Wang Lei(Department of Critical Care Medicine,the First Affiliated Hospital of Hebei North University,Zhangjiakou 075000,China)

机构地区：[1]河北北方学院附属第一医院重症医学科,河北张家口075000

出　　处：《中国急救医学》2021年第8期676-682,共7页Chinese Journal of Critical Care Medicine

基　　金：河北省重点研发计划项目(203777102D);2019张家口市科技计划项目(1921130H)。

摘　　要：目的重症超声(CCUS)引导下滴定式液体复苏与早期目标导向治疗(EGDT)对复苏效果、血流动力学和氧代谢指标的影响。方法以2019年1月至2020年10月在河北北方学院附属第一医院重症医学科(ICU)住院的感染性休克患者56例作为研究对象,随机数字表法按照1∶1的比例将患者分为CCUS组(n=28)和EGDT组(n=28)。记录两组一般血流动力学[心率、收缩压、舒张压、平均动脉压(MAP)]及氧代谢[动脉血氧分压(Pa O_(2))、动脉血二氧化碳分压(Pa CO_(2))、血乳酸清除率]指标。主要研究终点包括6 h复苏达标率和血乳酸清除率。次要研究终点包括24 h复苏达标率和血乳酸清除率、24 h液体输注量、液体平衡量和去甲肾上腺素使用量,7 d不良事件发生率[组织水肿和急性肾损伤(AKI)发生率、连续性肾脏替代疗法(CRRT)使用率]及28 d病死率。结果(1)CCUS组患者24 h心率(次/min)低于EGDT组(89.18±13.73 vs.100.29±19.44,P<0.05),且6 h、12 h、24 h收缩压(mm Hg)高于EGDT组[117.5(104.50,125.50)vs.96.50(78.75,113.75),121.0(109.50,128.75)vs.103.50(90.75,119.50),123.50(109.50,128.75)vs.111.00(94.50,120.0),P<0.05],6 h每搏量指数(SVI,m L/m2)高于EGDT组(53.82±7.95 vs.49.14±7.33,P<0.05)。(2)CCUS组患者6 h、12 h Scv O_(2)(%)低于EDGT组(77.10±7.65 vs.84.69±8.22,79.33±8.04 vs.85.50±7.89,P<0.05),且6 h Pcv-a CO_(2)(mmol/L)高于EDGT组(1.83±0.74 vs.1.45±0.63,P<0.05)。(3)CCUS组患者24 h液体输注量(m L)和液体平衡量(m L)均少于EGDT组(4158.54±1413.01 vs.5238.46±2092.01,1281.07±607.28 vs.1890.82±988.24,P<0.05)。(4)与EGDT组比较,CCUS组24 h复苏达标率(%)更高[14/28(50.0%)vs.6/28(21.43%),P<0.05],而且组织水肿发生率(%)降低[5/28(17.86%)vs.14/28(50.0%),P<0.05]。结论CCUS可提高24 h复苏达标率,降低AKI发生率,减少24 h液体输注量和液体平衡量,有助于早期改善患者血流动力学指标,优化个体化治疗方案,降低复苏不足或早期补液过量的风险。Objective To compare the effects of ultrasound-guided fluid resuscitation vs.early goal-directed therapy(EGDT)on hemodynamics and oxygen metabolism in the patients with septic shock.Methods Fifty-six patients with septic shock who were hospitalized in the Department of Intensive Care Medicine of our hospital from January 2019 to October 2020 were used as the research objects,who were divided into critical care ultrasound(CCUS)group and EGDT group according to the random number table method with the ratio of 1:1,28 patients in each group.The hemodynamics[the heart rate,systolic pressure,diastolic pressure,mean arterial pressure(MAP)]and the indexes of oxygen metabolism[arterial partial pressure of oxygen(Pa O_(2)),arterial partial pressure of carbon dioxide(Pa CO_(2)),lactate clearance rate]were recorded in both groups.The main end points included the successful rate of 6 h resuscitation and lactate clearance rate.Secondary end points included 24 h resuscitation compliance and lactate clearance,24 h fluid infusion,fluid balance,and noradrenaline usage,7 d incidence of adverse events[the incidence of tissue edema and acute kidney injury(AKI),CRRT use]and 28-day mortality.Results(1)The 24 h heart rate(times/min)of CCUS group was lower than that of EGDT group(89.18±13.73 vs.100.29±19.44,P<0.05),and 6,12,24 h systolic blood pressure(mm Hg)was higher in CCUS group than in EGDT group[117.5(104.50,125.50)vs.96.50(78.75,113.75),121.00(109.50,128.75)vs.103.50(90.75,119.50),123.50(109.50,128.75)vs.111.00(94.50,120.00),P<0.05],6 h SVI(m L/m2)was higher in CCUS group than in EGDT group(53.82±7.95 vs.49.14±7.33,P<0.05).(2)The 6 h and 12 h Scv O_(2)(%)of the CCUS group were lower than those of the EDGT group(77.10±7.65 vs.84.69±8.22,79.33±8.04 vs.85.50±7.89,P<0.05),and the 6 h Pcv-a CO_(2)(mmol/L)of the CCUS group was higher than that of the EDGT group(1.83±0.74 vs.1.45±0.63,P<0.05).(3)The liquid infusion volume and liquid balance volume(m L)at 24 h were less in CCUS group than those in EGDT group(4158.54±1413.01 vs.

关 键 词：重症超声(CCUS) 液体复苏 早期目标导向治疗(EGDT) 血流动力学 氧代谢 

分 类 号：R459.7[医药卫生—急诊医学]