下腔静脉变异度联合中心静脉-动脉血二氧化碳分压差指导脓毒性休克患者液体复苏的疗效分析  

Efficacy analysis of inferior vena cava variability combined with difference of central venous-to-arterial partial pressure of carbon dioxide on guiding fluid resuscitation in patients with septic shock

作　　者：何招辉[1] 杨小刚[1] 杨春丽[1] 王荣胜[1] 贺慧为[1] He Zhaohui;Yang Xiaogang;Yang Chunli;Wang Rongsheng;He Huiwei(Department of Critical Care Medicine,Jiangxi Provincial People's Hospital,Nanchang 330006,Jiangxi,China)

机构地区：[1]江西省人民医院重症医学科,南昌330006

出　　处：《中华危重病急救医学》2022年第1期18-22,共5页Chinese Critical Care Medicine

基　　金：江西省卫生计生委科技计划项目(20185011)。

摘　　要：目的探讨采用下腔静脉变异度(IVCV)联合中心静脉-动脉血二氧化碳分压差(Pcv-aCO_(2))指导脓毒性休克液体复苏的效果。方法选择2018年1月1日至2020年12月31日江西省人民医院重症医学科收治的脓毒性休克患者,按照随机数字表法分为对照组及观察组。两组均按照脓毒性休克液体复苏指南给予液体复苏。对照组按早期目标导向治疗(EGDT)策略进行液体复苏;复苏目标:中心静脉压(CVP)12~15 cmH_(2)O(1 cmH_(2)O≈0.098 kPa),平均动脉压(MAP)>65 mmHg(1 mmHg≈0.133 kPa),平均尿量(UO)>0.5 mL·kg^(-1)·h^(-1),中心静脉血氧饱和度(ScvO_(2))>0.70。观察组采用床旁B超动态监测IVCV并结合Pcv-aCO_(2)评估患者复苏终点;复苏目标:下腔静脉充盈固定且直径>2 cm,IVCV<18%,Pcv-aCO_(2)<6 mmHg。观察两组患者复苏前及复苏6 h、24 h复苏指标的变化,并记录6 h复苏达标率、6 h乳酸清除率(LCR)、6 h和24 h液体总入量,同时比较两组患者机械通气时间、重症监护病房(ICU)住院时间、28 d病死率及急性肾衰竭和急性肺水肿的发生率。结果共80例患者纳入分析,对照组和观察组各40例。两组患者液体复苏6 h及24 h MAP、CVP、ScvO_(2)均较复苏前明显增加,而Pcv-aCO_(2)和血乳酸(Lac)均较复苏前明显下降,且UO随复苏时间延长逐渐增加,说明两种复苏终点评估方案均能缓解患者的休克状态。与复苏前比较,观察组复苏6 h及24 h IVCV明显下降〔(17.54±4.52)%、(18.32±3.64)%比(27.49±10.56)%,均P<0.05〕。与对照组比较,观察组患者复苏6 h MAP、ScvO_(2)明显升高〔MAP(mmHg):69.09±4.64比66.37±4.32,ScvO_(2):0.666±0.033比0.645±0.035,均P<0.05〕,24 h MAP明显升高(mmHg:75.16±3.28比70.12±2.18,P<0.05),但CVP偏低(cmH_(2)O:9.25±1.49比10.25±1.05,P<0.05),说明观察组复苏效率更高。与对照组比较,观察组复苏6 h LCR明显升高〔(55.64±6.23)%比(52.45±4.52)%,P<0.05〕,6 h和24 h液体总入量均明显下降(mL:2860.73±658.32比356Objective To investigate the effect of inferior vena cava variability(IVCV)combined with difference of central venous-to-arterial partial pressure of carbon dioxide(Pcv-aCO_(2))on guiding fluid resuscitation in septic shock.Methods Patients with septic shock admitted to the department of critical care medicine of Jiangxi Provincial People's Hospital from January 1,2018 to December 31,2020 were enrolled,and they were divided into control group and observation group according to random number table method.Patients in both groups were given fluid resuscitation according to septic shock fluid resuscitation guidelines.The patients in the control group received fluid resuscitation strictly according to the early goal-directed therapy(EGDT)strategy.Resuscitation target:central venous pressure(CVP)12-15 cmH_(2)O(1 cmH_(2)O≈0.098 kPa),mean arterial pressure(MAP)>65 mmHg(1 mmHg≈0.133 kPa),mean urine volume(UO)>0.5 mL·kg^(-1)·h^(-1),central venous oxygen saturation(ScvO_(2))>0.70.In the observation group,the endpoint of resuscitation was evaluated by IVCV dynamically monitored by bedside ultrasound and Pcv-aCO_(2).Resuscitation target:fixed filling of inferior vena cava with diameter>2 cm,IVCV<18%,and Pcv-aCO_(2)<6 mmHg.The changes in recovery indexes before and 6 hours and 24 hours of resuscitation of the two groups were recorded,and the 6-hour efficiency of fluid resuscitation,6-hour lactate clearance rate(LCR)and 6-hour and 24-hour total volume of resuscitation were also recorded;at the same time,the duration of mechanical ventilation,length of intensive care unit(ICU)stay,28-day mortality and the incidence of acute renal failure and acute pulmonary edema between the two groups were compared.Results A total of 80 patients were enrolled in the analysis,with 40 in the control group and 40 in the observation group.The MAP,CVP and ScvO_(2) at 6 hours and 24 hours of resuscitation in the two groups were significantly higher than those before resuscitation,while Pcv-aCO_(2) and blood lactic acid(Lac)were significantly de

关 键 词：下腔静脉变异度 中心静脉-动脉血二氧化碳分压差 脓毒性休克 液体复苏 

分 类 号：R459.7[医药卫生—急诊医学]