摘要
目的观察重症超声(CCUS)在成人脓毒性休克患者液体复苏中的临床应用价值.方法选择2019年8月1日至2021年5月31日合肥医科大学附属医院重症医学科收治的102例成人脓毒性休克患者作为研究对象.将患者按随机数字表法分为目标导向治疗(GDT)组和CCUS组,每组51例.GDT组根据监测指标[中心静脉压(CVP)、平均动脉压(MAP)、中心静脉血氧饱和度(ScvO_(2))、血乳酸(Lac)、尿量]指导液体复苏;CCUS组根据心脏收缩和舒张功能、下腔静脉直径(IVCD)、下腔静脉扩张指数(dIVC)及肺部超声检查结果指导液体管理.观察两组临床资料、主要实验室指标、复苏液体量及结局指标,包括6h复苏达标率[MAP≥65 mmHg(1 mmHg≈0.133 kPa)、Lac<2 mmol/L、尿量≥0.5 mL·kg^(-1)·h^(-1)]、6 h乳酸清除率(LCR)、24 h复苏达标率、机械通气时间、重症监护病房(ICU)住院时间、总住院时间、ICU病死率、28d病死率的变化;绘制Kaplan-Meier生存曲线比较不同复苏管理模式下两组患者28d累积生存率的差异.结果两组患者性别、年龄、急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、序贯器官衰竭评分(SOFA)、入住ICU时降钙素原(PCT)、Lac和行机械通气及接受连续性肾脏替代治疗(CRRT)患者比例比较差异均无统计学意义.治疗6h开始,两组患者心率(HR)均明显变慢(次/min:GDT组为108.0±18.2比120.1±23.0,CCUS组为103.0±19.1比112.8±19.3,均P<0.05),MAP及氧合指数(PaO_(2)/FiO_(2))均明显升高[MAP(mmHg):GDT组为84.5±10.6比63.9±9.6,CCUS组为84.3±11.7比61.8±9.3,PaO_(2)/FiO_(2)(mmHg):GDT组为183.4±58.0比148.5±48.1,CCUS组为202.3±83.1比142.7±59.7,均P<0.05],于治疗24h达最低和最高水平.两组各时间点HR、MAP、PaO_(2)/FiO_(2)比较差异均无统计学意义.随治疗时间延长,两组复苏液体量、24h内尿量、LCR均逐渐增加,治疗24h达峰值;GDT组复苏平衡量逐渐增加,CCUS组逐渐减少.两组患者治疗6h内复苏液体量、复苏平衡量、24h内尿量比较差异无统计学意义,CCUS组治疗12 h、24 h后复苏液体量和复苏平衡量均较GDT组明显减少[复苏液体量(mL):12 h为2300.0(1963.0,3099.0)比3035.0(2159.0,3940.0),24 h为4054.0(3087.0,5141.0)比4512.0(3584.0,6884.0);复苏平衡量(mL):12 h为683.0(-75.0,1248.0)比1180.0(405.0,2122.0),24 h为749.0(-250.0,1899.0)比1399.0(434.0,3015.0),均P<0.05].GDT组和CCUS组治疗后6h复苏达标率、机械通气时间、ICU住院时间、住院时间、ICU病死率、28d病死率比较差异均无统计学意义[复苏达标率:15.7%(8/51)比25.5%(13/51),机械通气时间(h):143(37,263)比99.0(32,240),ICU住院时间(h):279(117,426)比168(103,359),住院时间(d):18(8,26)比14(5,26),ICU病死率:5.9%(3/51)比2.0%(1/51),28 d病死率:35.3%(18/51)比31.4%(16/51),均P>0.05],CCUS组治疗6h后LCR明显高于GDT组[24.0%(9.0%,35.0%)比11.0%(-11.0%,25.0%),P<0.05],CCUS组治疗24h后复苏达标率明显高于GDT组[43.1%(22/51)比21.6%(11/51),P<0.05].Kaplan-Meier生存曲线显示,GDT组和CCUS组28d累积生存率比较差异无统计学意义(Log-Rank检验:χ^(2)=0.055,P=0.815).结论CCUS能有效指导成人脓毒性休克患者的液体复苏,减少总体液体输注量,加快Lac清除,有利于临床诊治.
Objective To observe the clinical application value of critical care ultrasound(CCUS)in fluid resuscitation of adult patients with septic shock.Methods A total of 102 adult patients with septic shock admitted to the department of critical care medicine of Affiliated Hospital of Zunyi Medical University from August 1,2019 to May 31,2021 were recruited as the subjects of the study,and they were equally divided into goal-directed therapy(GDT)group and CCUS group according to random number table,with 51 patients in each group.Fluid resuscitation was guided according to monitoring indicators[central venous pressure(CVP),mean arterial pressure(MAP),central venous oxygen saturation(ScvO_(2)),blood lactic acid(Lac),urine output)in GDT group,and the CCUS group guided fluid management according to cardiac systolic and diastolic function,inferior vena cava(IVC)diameter(IVCD)and distensibility index of the IVC(dIVC),and lung status.The clinical data,main laboratory indicators,resuscitation fluid volume and end-point indicators of the two group were compared,including 6-hour resuscitation targeting rate[MAP≥65 mmHg(1 mmHg~0.133 kPa),Lac<2 mmol/L,urine output≥0.5 mL kg^(-1).h^(-1)],6-hour lactate clearance rate(LCR),24-hour resuscitation targeting rate,mechanical ventilation time,length of intensive care unit(ICU)and hospital stay,mortality within ICU and 28 days were compared between the two groups.Kaplan-Meier survival curve was drawn to compare the difference of 28-day cumulative survival rate between the two groups under different resuscitation management modes.Results There was no significant difference in gender,age,acute physiology and chronic health evaluation I(APACHE II),sequential organ failure assessment(SOFA),procalcitonin(PCT)and Lac at admission ICU,and the proportion of patients of mechanical ventilation and continuous renal replacement therapy(CRRT)between the two groups.At the beginning of 6 hours of treatment,the heart rate(HR)was significantly slower(bpm:108.0±18.2 vs.120.1±23.0 in the GDP group,103.0±19.1 vs.112.8±19.3 in the CCUS group,both P<0.05),the MAP and oxygenation index(PaO_(2)/FiO_(2))were significantly increased[MAP(mmHg):84.5±10.6 vs.63.9±9.6 in the GDP group,84.3±11.7 vs.61.8±9.3 in the CCUS group,PaO_(2)/FiO_(2)(mmHg):183.4±58.0 vs.148.5±48.1 in the GDT group and 202.3±83.1 vs.142.7±59.7 in the CCUS group,both P<0.05],the lowest and highest levels were reached at 24 hours after treatment.There was no significant difference in HR,MAP,PaO_(2)/FiO_(2)between the two groups at each time point.With the prolongation of treatment,the resuscitation fluid volume,urine volume within 24 hours and LCR in both groups increased gradually and reached the peak at 24 hours,while the fluid volume balance increased gradually in GDT group and decreased gradually in CCUS group.There was no significant difference in resuscitation fluid volume and fluid balance within 6 hours,fluid balance,and urine volume within 24 hours between the two groups;the resuscitation fluid volume and fluid balance in CCUS group were significantly lower than those in GDT group at 12 hours and 24 hours after treatment[the resuscitation fluid volume(mL):2300.0(1963.0,3099.0)vs.3035.0(2159.0,3940.0)at 12 hours,4054.0(3087.0,5141.0)vs.4512.0(3584.0,6884.0)at 24 hours;fluid balance(mL):683.0(-75.0,1248.0)vs.1180.0(405.0,2122.0)at 12 hours,749.0(-250.0,1899.0)vs.1399.0(434.0,3015.0)at 24 hours,all P<0.05].There were no significant differences in the 6-hour resuscitation targeting rate,the time of mechanical ventilation,length of stay in ICU and hospital,mortality in ICU and 28 days between GDT group and CCUS group[resuscitation targeting rate:15.7%(8/51)vs.25.5%(13/51),the time of mechanical ventilation(hour):143(37,263)vs.99(32,240),ICU length of stay(hour):279(117,426)vs.168(103,359),hospital length of stay(days):18(8,26)vs.14(5,26),the mortality in ICU was 5.9%(3/51)vs.2.0%(1/51)and the mortality in 28 days was 35.3%(18/51)vs.31.4%(16/51),all P>0.05],the LCR in CCUS group was significantly higher than that in GDT group after 6 hours of treatment[24.0%(9.0%,35.0%)vs.11.0%(-11.0%,25.0%),P<0.05]and the resuscitation targeting rate of CCUS group after 24 hours of treatment was significantly higher than that of GDT group[43.1%(22/51)vs.21.6%(11/51),P<0.05].The Kaplan-Meier survival curve showed that there was no statistical difference between the GDT group and CCUS group(Log-Rank test:χ^(2)=0.055,P=0.815.Conclusion Critical care ultrasound can effectively guide the fluid resuscitation of adult patients with septic shock,reduce cumulative fluid administration,accelerate the clearance of lactic acid,and facilitate clinical diagnosis and treatment.
作者
余琨
陈淼
陈涛
李康
梅鸿
陈妮
Yu Kun;Chen Miao;Chen Tao;Li Kang;Mei Hong;Chen Ni(Department of Critical Care Medicine,Affiliated Hospital of Zunyi Medical University,Zunyi 563000,Guizhou,China)
出处
《中国中西医结合急救杂志》
CAS
CSCD
北大核心
2023年第2期185-190,共6页
Chinese Journal of Integrated Traditional and Western Medicine in Intensive and Critical Care
关键词
液体复苏
重症超声
脓毒性休克
Fluid resuscitation
Critical care ultrasound
Septic shock
