PiCCO指导下的液体复苏对合并心肌损伤感染性休克患者预后的影响

摘要

目的 探讨脉搏指示剂连续心排血量(pulse indicator continuous cadiac output,PiCCO)监测指导下的液体复苏对合并心肌损伤的感染性休克患者预后的影响.方法 收住本院重症医学科的60例合并心肌损伤的感染性休克患者,按随机数字表法分为PiCCO组(30例)和对照组(30例).PiCCO组以PiCCO监测的参数指导液体复苏.对照组按照2012严重脓毒症与感染性休克治疗国际指南(SSC 2012)中推荐的早期目标导向治疗(earlygoal_directed therapy, EDGT)集束化治疗方案指导复苏.记录患者诊断为感染性休克及复苏后第6h、24h、48h、72h的血流动力学、心功能、氧代谢及组织灌注等参数;记录患者第3d序贯器官衰竭(sequential organ failure assessment,SOFA)评分、机械通气时间、住ICU时间及28天病死率.结果 (1)PiCCO组在复苏后第24h、48h、72h的血清B型脑钠肽(brain natriuretic peptide,BNP)明显低于对照组(均 P<0.05).(2)PiCCO组在复苏第24h、48h及72h的复苏液体量和液体正平衡量均少于对照组.(3)PiCCO组第3d SOFA评分[(5.6 ± 2.2)分比(7.7 ± 2.6)分,t= -3.32,P<0.01]、机械通气时间[(8.5 ± 9.2)天比(13.4 ± 13.1)天,t= -2.58,P<0.01]、住ICU时间[(10.2 ± 9.2)天比(15.1 ± 13.0)天,t= -3.25,P<0.01]均明显低于对照组.两组28d病死率比较差异无统计学意义(P>0.05).结论 与传统EGDT方案比较,PiCCO指导下的血流动力学管理能优化合并心肌损伤感染性休克患者的液体复苏,减少液体过负荷的风险,并减轻器官功能障碍的程度,缩短机械通气时间和住ICU时间.%Objective To investigate the effects of fluid resuscitation based on PiCCO(pulse indicator continuous cadiac output)_de-rived physiological values on clinical outcome of patients with sepsis_induced cardiac dysfunction.Methods Sixty patients with sepsis_induced cardiac dysfunction in Shengzhou People's Hospital of Zhejiang Province were enrolled and randomly divided into two groups using a random number table as PiCCO group(n=30)and control group(n=30).The patients in PiCCO group were received fluid resuscitation guided by PiCCO_derived physiological values.The patients in control group were received the standard EGDT(early goal_directed therapy)bundles according to the Surviving Sepsis Campaign(2012).The hemodynamic,cardiac function,tissue per-fusion and oxygen metabolism parameters were recorded before,and at 6h,24h,48h and 72h after the start of fluid resuscitation. The 28d mortality,Sequential Organ Failure Assessment(SOFA)score at day 3,ICU length of stay,days on mechanical ventilation were recorded.Results(1)The BNP levels in the PiCCO group at 24 h,48 h and 72 h after resuscitation were significantly lower than those in the control group(all P<0.05).(2)In the PiCCO group,the fluid volume and the positive balance of the resuscita-tion were less than those of the control group at the 24h,48h and 72h after resuscitation.(3)The 3d SOFA score(SOFA score:5. 6 ± 2.2 vs.7.7 ± 2.6,t= -3.32,P=0.002),mechanical ventilation time(d:8.5 ± 9.2 vs.13.4 ± 13.1,t= -2.58,P<0.01)and ICU length of stay(d:10.2 ± 9.2 vs.15.1 ± 13.0,t= -3.25,P<0.01)were significantly lower in the PiCCO group than those in the control group.There was no statistically significant difference in 28_day mortality between the two groups (P> 0.05).Conclusions Compared with conventional EGDT regimens,hemodynamic management based on PiCCO_derived parameters can optimize fluid resuscitation,reduce the risk of fluid overload and the degree of organ dysfunction as well as shorten the duration of mechanical ventilation and ICU length of stay in patients with sepsis_induced cardiac dysfunction.