1例脓毒性休克患者抢救过程思考  

Thoughts on the rescue process of a patient with septic shock

作　　者：董静 郑一 Dong Jing;Zheng Yi(Department of Intensive Care Medicine,Civil Aviation General Hospital,Beijing 100123,China)

机构地区：[1]民航总医院重症医学科,北京100123

出　　处：《中华危重病急救医学》2025年第1期73-76,共4页Chinese Critical Care Medicine

摘　　要：脓毒性休克是重症医学科常见急危重症,可导致多器官功能衰竭,心脏为靶器官之一。液体复苏对于脓毒性休克治疗至关重要,但当患者出现脓毒性心肌病时,其循环通常无法通过液体复苏被改善,甚至会造成循环恶化。2023年10月2日民航总医院重症医学科收治了1例在补液过程中循环突然恶化的52岁女性脓毒性休克患者。患者主因"左侧面部麻木20余天,加重伴意识不清5 d"入院。入院时,患者昏迷、经口气管插管状态,血压128/82 mmHg(1 mmHg≈0.133 kPa;静脉泵入去甲肾上腺素0.2μg·kg^(-1)·min^(-1));胸部CT提示肺部感染;感染指标升高。主要诊断:脓毒性休克、肺炎、左侧桥臂急性脑梗死等。入院12 h,根据患者动脉及中心静脉血气分析,氧摄取率为31%(>30%),静脉-动脉血二氧化碳分压(Pv-aCO 2)为7 mmHg(>6 mmHg),血乳酸(Lac)升高,结合下腔静脉宽度为1.0~1.6 cm,提示有效循环血容量相对不足,予适当补液。补液后,患者尿量由40 mL/h升至100 mL/h,但血压较前未见明显升高,提示不具备容量反应性,故加用多巴酚丁胺3μg·kg^(-1)·min^(-1)强心治疗,心率无明显上升,血压相对稳定。入院21 h,患者收缩压(SBP)由110~120 mmHg骤降至60~70 mmHg,同时心率由100~110次/min降至80~90次/min,故上调去甲肾上腺素剂量至2μg·kg^(-1)·min^(-1)、多巴酚丁胺剂量至10μg·kg^(-1)·min^(-1),循环仍无法维持,结合胸片未见张力性气胸等,血常规未提示急性失血可能,肌钙蛋白I(TnI)由3778.8 ng/L降至2025.9 ng/L,B型脑钠肽(BNP)由15 ng/L升至1638 ng/L,心肌酶学变化不符合急性心肌梗死,心脏彩超未见肺动脉高压,故考虑血压下降由心功能下降引起,提示患者合并了脓毒性心肌病。经上调多巴酚丁胺泵入剂量至20μg·kg^(-1)·min^(-1),并下调输液速度,减轻心脏前负荷,继续使用血管活性药物升压约1 h后,患者血压上升,循环趋于稳定,抢救成功。经过60 d的治疗,最终�Septic shock is a common acute and critical illness in intensive care medicine.It can lead to multiple organ failure,of which the heart is one of the target organs.Fluid resuscitation plays an important role in the treatment of septic shock,but when a patient develops septic-induced cardiomyopathy,the circulation is often not improved by fluid resuscitation,and may even lead to deterioration of circulation.On October 2,2023,a 52-year-old female patient with septic shock was admitted to the department of intensive care medicine of Civil Aviation General Hospital,whose circulation deteriorated during fluid resuscitation.The main complaint of the patient was left face numbness for more than 20 days,aggravated with unconsciousness for 5 days.Upon admission,the patient was in a coma and intubated by oral tube.The blood pressure was 128/82 mmHg(1 mmHg≈0.133 kPa;intravenous pump of norepinephrine 0.2μg·kg^(-1)·min^(-1)).Chest CT indicated lung infection,and infection markers were elevated.The main diagnoses were septic shock,pneumonia,acute cerebral infarction of left pontine arm and etc.At 12 hours after admission,according to arterial and central vein blood gas analyses,the oxygen uptake rate was 31%(>30%),and the veno-arterial blood partial pressure of carbon dioxide(Pv-aCO 2)was 7 mmHg(>6 mmHg),blood lactic acid(Lac)increased,combined with the width of the inferior vena cava of 1.0-1.6 cm,also indicated a relative insufficiency of effective circulating blood volume,so appropriate fluid resuscitation was given.After fluid resuscitation,the urine volume of the patient increased from 40 mL/h to 100 mL/h,but the blood pressure did not increase significantly,indicating that there was no volume responsiveness,so dobutamine 3μg·kg^(-1)·min^(-1) was added to enhance myocardial contractility.The heart rate did not increase significantly,and the blood pressure was relatively stable.At 21 hours after admission,the patient's systolic blood pressure(SBP)suddenly dropped from 110-120 mmHg to 60-70 mmHg,while heart rate dr

关 键 词：脓毒症 脓毒性休克 脓毒性心肌病 限制性液体复苏 

分 类 号：R54[医药卫生—心血管疾病]