腹腔压监测在脓毒症休克患者液体复苏中的临床意义

摘要

Objective To evaluate the application of intra- abdominal pressure monitoring for fluid resuscitation in pa-tients with septic shock. Methods Total 142 septic shock patients with abdominal pressure (IAP)<10mmHg were admitted in ICU from January 2011 to 2014 June, among whom 64 cases with IAP>17mmHg within 24h achieving the standards after early fluid resuscitation were enrol ed in the study. According to different liquid management scenarios, patients were randomly divided into limited fluid resuscitation group (n=32) and non- limited fluid resuscitation group (n=32). The liquid management was imple-mented under PiCCO (pulse induced contour cardiac output) monitoring. The abdominal pressure, PiCCO parameters, total vol-ume of liquid and ScVO2 were compared between two groups. The incidence of acute kidney injury (AKI) and abdominal com-partment syndrome (ACS), duration of mechanical ventilation and 28- day fatality rate were compared between two groups after 28d. Results Comparing with non- limited fluid resuscitation group, the total amount of liquid, incidence of AKI and ACS within 72h in resuscitation group were significantly lower(P<0.05). The IAP, EVLWL and mechanical ventilation in limited fluid resuscita-tion group were lower than those of non- limiting fluid resuscitation group(P<0.05). There was no significant difference in 28d- fa-tality between two groups (P>0.05). Conclusion Continuous monitoring of bladder pressure during fluid resuscitation in septic shock patients can timely detect abdominal hypertension. The limited fluid resuscitation to control abdominal pressure (≤17mmHg) can reduce the incidence of ACS and AKI, shorten the mechanical ventilation for septic shock patients with IAP≥17mmHg after early standardized resuscitation.%目的：探讨腹腔压（IAP）监测指导脓毒症休克患者液体复苏的临床意义。方法对142例确诊为脓毒症休克且IAP＜10mmHg患者进行持续性IAP监测，在早期液体复苏达标后24h内，IAP≥17mmHg共64例。按随机数字表法分为限制性液体复苏组32例和非限制性液体复苏组32例，在PiCCO监测下执行液体管理，并采集病例相关数据，比较两组间IAP、PiCCO参数、液体总量和中心静脉血氧饱和度（ScVO2），并比较两组间急性肾功能损伤（AKI）和腹腔间隔室综合征（ACS）发生率、机械通气时间和28d病死率。结果限制性液体复苏组72h内液体正平衡总量、AKI和ACS的发生率均低于非限制性液体复苏组，限制性液体复苏组治疗72h内IAP、血管外肺水指数（EVLWI）和机械通气时间均低于非限制性液体复苏组，差异均有统计学意义（P＜0.05）。限制性液体复苏组28d病死率有下降趋势，但两组间比较差异无统计学意义（P＞0.05）。结论脓毒症休克患者液体复苏期间持续监测膀胱压可及时发现腹腔高压，对早期液体复苏达标后IAP≥17mmHg的脓毒症休克者，尽早进行限制性液体复苏治疗和控制IAP≤17mmHg，可降低ACS和AKI的发生率，缩短机械通气时间。