重症超声指导婴幼儿脓毒性休克血流动力学治疗的临床研究  

Using ultrasound for hemodynamic therapy among infants with septic shock

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

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

出　　处：《中国小儿急救医学》2021年第12期1071-1076,共6页Chinese Pediatric Emergency Medicine

摘　　要：目的探讨重症超声监测指导血流动力学治疗在PICU婴幼儿脓毒性休克不同阶段液体管理中的应用价值。方法2017年1月至2018年12月,我院PICU收治的脓毒性休克婴幼儿为研究对象(n=22)。按照脓毒性休克指南给予抗休克、抗感染、机械通气治疗。同时在入院后给予重症急会诊超声流程(CCUE流程)动态监测,评估血流动力学状态,滴定式调整液体及血管活性药物治疗方案。比较不同阶段CCUE监测结果对液体管理方案的影响。结果CCUE评估对原有治疗方案改变率各阶段不一致(P<0.001)。第1阶段(入院后0~6 h)CCUE评估32次,24次改变液体管理方案,方案改变率75.0%,大于其他3个阶段(P<0.001)。第4阶段(撤机~撤机后2 d),CCUE评估44次,改变液体管理方案1次,方案改变率2.3%,小于其他3个阶段(P<0.01)。第2阶段(入院后6~42 h)CCUE评估118次,改变液体管理方案36次,方案改变率30.5%。第3阶段(入院后48 h~撤呼吸机),CCUE评估136次,改变液体管理方案32次,方案改变率23.5%。在第1阶段,与控制输液组比较,快速输液组肺脏超声评分(LUS)更低,左室射血分数(LVEF)及右室射血分数(RVEF)>50%者占比更多(P<0.05)。在第2阶段和第3阶段,与控制输液组比较,快速输液组LVEF>50%者占比更多(P<0.05),但LUS及RVEF>50%、下腔静脉内径随呼吸变异度(△Divc)>20%者占比多,但差异均无统计学意义(P>0.05)。结论应用重症超声CCUE流程对PICU中的脓毒性休克婴幼儿进行动态血流动力学监测,液体复苏早期尤其是抢救阶段对液体管理策略帮助更大。而CCUE监测下的快速输液,常受限于心脏射血分数、LUS,主要是LVEF,特别是在抢救阶段,需综合多项超声指标并结合临床资料共同评估。Objective To investigate the effects of critical care chest ultrasonic examination(CCUE)on different fluid management phases among septic shock infants in pediatric intensive care unit(PICU).Methods Twenty-two infants who were hospitalized in PICU during January 2017 to December 2018 and diagnosed as septic shock were included in this study.These infants received shock and infection management as well as mechanical ventilation according to the septic shock management guidelines.CCUE was applied as needed to monitor the hemodynamic status for titrated adjustment in fluid and vasoactive drug management and its impacts were evaluated.Results The change frequencies of treatment regimen according to CCUE evaluation were different among different phases(P<0.001).Compared with the other 3 phases,the number of adjustment made to fluid management scheme caused by CCUE during the first phase was the largest(75.0%,P<0.001),and that during the fourth phase was the smallest(2.3%,P<0.01).The frequency of change during the second phase(30.5%)and the third phase(23.5%)showed no difference(P=0.210).During the first phase,compared with the group with intravenous infusion speed<10 mL/(kg·h),the group with faster intravenous infusion speed had lower LUS score and more proportion of LVEF and RVEF above 50%(P<0.05).During the second phase and the third phase,compared with group receiving slower intravenous infusion,group with faster intravenous infusion had more LVEF>50%(P<0.05).Conclusion Application of CCUE to monitor dynamic hemodynamic of infants with septic shock in PICU has different effects on fluid management scheme adjustment at different phase.CCUE evaluation during the early 3 phases,especially during the first phase has greater influence on fluid management strategy.Rapid infusion under CCUE monitoring is often limited by cardiac ejection fraction,LUS,and mainly LVEF,especially during the first phase.Multiple ultrasonic indicators should be combined with clinical data for full evaluation.

关 键 词：重症超声急会诊流程 血流动力学监测 脓毒性休克 液体管理 婴幼儿 

分 类 号：R720.597[医药卫生—急诊医学]