左室内压最大上升速率评价脓毒性心肌病患者心功能变化的价值  

The value of maximal rate of left ventricular pressure in evaluating cardiac function in patients with sepsis-induced cardiomyopathy

作　　者：王俊义 何正中 高心晶[1,2] 王志勇[1,2] 尹承芬 李彤[2,4] Wang Junyi;He Zhengzhong;Gao Xinjing;Wang Zhiyong;Yin Chengfen;Li Tong(Department of Intensive Care Unit,Tianjin Third Central Hospital,Tianjin 300170,China;Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases,Tianjin Artificial Cell Engineering Technology Research Center,Tianjin Institute of Hepatobiliary Disease,Tianjin 300170,China;Department of Ultrasonography,Tianjin Third Central Hospital,Tianjin 300170,China;Department of Heart Center,Tianjin Third Central Hospital,Tianjin 300170,China)

机构地区：[1]天津市第三中心医院重症医学科,天津300170 [2]天津市重症疾病体外生命支持重点实验室,天津市人工细胞工程技术研究中心,天津市肝胆疾病研究所,天津300170 [3]天津市第三中心医院超声科,天津300170 [4]天津市第三中心医院心脏中心,天津300170

出　　处：《中华危重病急救医学》2023年第6期620-626,共7页Chinese Critical Care Medicine

基　　金：天津市医学重点学科(专科)建设项目(2022-414);天津市科技计划项目(21JCYBJC01200,18ZXDBSY00100);天津市"项目+团队"重点培养专项(XC202040)。

摘　　要：目的探讨左室内压最大上升速率(dp/dtmax)评价脓毒性心肌病(SIC)患者心率下降前后心功能变化的价值。方法采用单中心、前瞻性、随机对照研究。纳入2020年4月1日至2022年2月28日天津市第三中心医院重症医学科收治的脓毒症/脓毒性休克成人患者,入组患者完成1 h-Bundle集束化治疗后即刻进行斑点追踪超声心动图(STE)和脉搏指示连续心排血量(PiCCO)监测,筛选出心率>100次/min的SIC患者作为研究对象,并按随机数字表法分为艾司洛尔组和常规治疗组,每组55例。所有患者均于入重症监护病房(ICU)6、24和48 h完成STE及PiCCO监测,并计算急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)及序贯器官衰竭评分(SOFA)。主要结局指标:艾司洛尔控制心率后dp/dtmax的变化值。次要结局指标:dp/dtmax与左心室整体纵向应变(GLS)的相关性;艾司洛尔治疗后血管活性药物用量、氧输送(DO_(2))、氧消耗(VO_(2))及每搏量(SV)的变化;艾司洛尔治疗后心室率控制达目标值的比例;两组患者28 d及90 d病死率。结果艾司洛尔组与常规治疗组年龄、性别、体质量指数、SOFA评分、APACHEⅡ评分、心率、平均动脉压、乳酸、24 h液体平衡量、脓毒症病因及既往合并症等基线数据相似,差异均无统计学意义。SIC患者应用艾司洛尔治疗24 h后均达到目标心率,且与常规治疗组相比,艾司洛尔组GLS、全心射血分数(GEF)及dp/dtmax等反映心肌收缩的参数均明显升高〔GLS:(-12.55±4.61)%比(-10.73±4.82)%,GEF:(27.33±4.62)%比(24.18±5.35)%,dp/dtmax(mmHg/s):1312.1±312.4比1140.9±301.0,均P<0.05〕,N末端脑钠肽前体(NT-proBNP)明显降低〔μg/L:1364.52(754.18,2389.17)比3508.85(1433.21,6988.12),P<0.05〕,DO_(2)、SV明显升高〔DO_(2)(mL·min^(-1)·m^(-2)):647.69±100.89比610.31±78.56,SV(mL):49.97±14.71比42.79±15.77,均P<0.05〕;且即使两组患者在去甲肾上腺素用量相似的情况下,艾司洛尔组外周血管阻力指Objective To investigate the value of maximal rate of left ventricular pressure(dp/dtmax)in evaluating the changes of cardiac function before and after heart rate reduction in patients with sepsis-induced cardiomyopathy(SIC).Methods A single-center,prospective randomized controlled study was conducted.Adult patients with sepsis/septic shock admitted to the department of intensive care unit(ICU)of Tianjin Third Central Hospital from April 1,2020 to February 28,2022 were enrolled.Speckle tracking echocardiography(STE)and pulse indication continuous cardiac output(PiCCO)monitoring were performed immediately after the completion of the 1 h-Bundle therapy.The patients with heart rate over 100 beats/minutes were selected and randomly divided into esmolol group and regular treatment group,55 cases in each group.All patients underwent STE and PiCCO monitoring at 6,24 and 48 hours after admission in ICU and calculated acute physiology and chronic health evaluationⅡ(APACHEⅡ)and sequential organ failure assessment(SOFA).Primary outcome measure:change in dp/dtmax after reducing heart rate by esmolol.Secondary outcome measures:correlation between dp/dtmax and global longitudinal strain(GLS);changes of vasoactive drug dosage,oxygen delivery(DO_(2)),oxygen consumption(VO_(2))and stroke volume(SV)after the administration of esmolol;proportion of heart rate reaching the target after the administration of esmolol;28-day and 90-day mortality in two groups.Results Baseline data on age,gender,body mass index,SOFA score,APACHEⅡscore,heart rate,mean arterial pressure,lactic acid,24-hour fluid balance,sepsis etiology and prior comorbidities were similar between esmolol group and regular treatment group,there were no significant differences between the two groups.All SIC patients achieved the target heart rate after 24 hours of esmolol treatment.Compared with regular treatment group,parameters reflecting myocardial contraction such as GLS,global ejection fraction(GEF)and dp/dtmax were significantly increased in esmolol group[GLS:(-

关 键 词：脓毒性心肌病 左心室整体纵向应变 左室内压最大上升速率 心功能 

分 类 号：R542.2[医药卫生—心血管疾病] R459.7[医药卫生—内科学]