脓毒性休克患者Cv-aCO_2/Ca-vO_2、乳酸清除率与IVCrvi的关系
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摘要
目的探讨脓毒性休克患者静脉-动脉血二氧化碳含量差与动脉-静脉血氧含量差的比值(Cva CO_2/Ca-v O_2)、乳酸与下腔静脉内径呼吸变异指数(IVCrvi)的关系。方法选取2016年6月—2018年2月遵义市第一人民医院收治的66例脓毒性休克患者,随机分为A组(23例)、B组(21例)及C组(22例)。采用连续多普勒无创血液动力学监测仪记录患者血流动力学数据,在抗感染、早期复苏等基础上,A组加用Cv-aCO_2/Ca-vO_2<1.1作为24 h复苏终点指导治疗;B组加用乳酸清除率>50%作为24 h复苏终点指导治疗;C组加用IVCrvi<30%作为24 h复苏终点指导治疗。观察3组治疗前后急性生理学与慢性健康状况评估Ⅱ(APACHEⅡ)评分、序贯器官衰竭评估(SOFA)评分、平均动脉压(MAP)、中心静脉压(CVP)、氧气指数(PaO_2/FiO_2)、中心静脉血氧饱和度(ScvO2)、每搏量变异度(SVV)、心脏指数(CI)、外周血管阻力指数(SVRI)、降钙素原(PCT)及28 d病死率等变化。结果 3组治疗前APACHEⅡ评分、SOFA评分、MAP、血乳酸水平及PCT水平比较,差异无统计学意义(P>0.05);3组治疗6 h后CVP水平比较,差异有统计学意义(P <0.05);3组MAP值、达到目标MAP所需液体量、PaO_2/FiO_2、心率(HR)及乳酸值比较,差异无统计学意义(P>0.05);3组治疗24 h后,中心静脉动脉二氧化碳分压差(Pcv-a CO_2)、SVRI及脑肽钠比较,差异无统计学意义(P>0.05),而ScvO_2、WBC比较,差异有统计学意义(P <0.05);3组治疗7 d后,CI、SVRI、氧输送(DO_2)及PCT比较,差异无统计学意义(P>0.05),而SVV值比较,差异有统计学意义(P <0.05);3组28 d总CBP时间、机械通气时间、住ICU时间及28 d病死率比较,差异无统计学意义(P>0.05)。结论 Cv-aCO_2/Ca-vO_2、乳酸清除率与IVCrvi有关。
Objective To explore the correlation between the ratio of the difference of carbon dioxide content in venous and arterial blood to the difference of oxygen content in arterial and venous(Cv-aCO_2/Ca-vO_2), the lactate clearance rate(LAC) and the respiratory variations index of inferior vena cava(IVCrvi) in patients with septic shock. Methods Totally 66 patients with septic shock treated from June 2016 to February 2018 in our hospital were randomly divided into group A(23 cases), group B(21 cases) and group C(22 cases). Using USCOM to record the patient's hemodynamic data, based on anti-infection and early resuscitation, group A was treated with Cv-aCO_2/Ca-v O_2 < 1.1 as the guide for the end point of 24-hour resuscitation; group B was treated with LCR > 50% to guide the end point of the 24-hour resuscitation; group C was treated with IVCrvi < 30% to guide the end point of the 24-hour resuscitation. The changes of APACHE II score, SOFA score, MAP, CVP, PaO_2/FiO_2, ScvO_2, SVV, CI, SVRI, PCT,28-day mortality and so on in patients before and after treatment were observed. Results There was no significant difference in SOFA score, MAP, levels of blood Lac level and PCT among three groups before treatment(P > 0.05);there was a significant difference in CVP after 6-hour treatment(P < 0.05). There was no significant difference in the values of MAP, the amount of fluid needed to reach the target MAP, PaO_2/FiO_2, HR and Lac among three groups(P > 0.05); after 24 hours of treatment, there was no significant difference in P(Cv-a) CO2, SVRI and brain peptide sodium(BNP)(P > 0.05), but there were significant differences in the values of ScvO_2 and WBC(P < 0.05). After 7 days of treatment, there was no significant difference in CI, SVRI, DO_2 and PCT among three groups(P > 0.05), but there was a significant difference in SVV(P < 0.05); there was no significant difference in total CBP time, mechanical ventilation time, ICU stay time and 28-day mortality among three groups(P > 0.05). Conclusions Cv-aCO_2/Ca-vO_2 and LCR have a positive correlation with IVCrvi.
Objective To explore the correlation between the ratio of the difference of carbon dioxide content in venous and arterial blood to the difference of oxygen content in arterial and venous(Cv-aCO_2/Ca-vO_2), the lactate clearance rate(LAC) and the respiratory variations index of inferior vena cava(IVCrvi) in patients with septic shock. Methods Totally 66 patients with septic shock treated from June 2016 to February 2018 in our hospital were randomly divided into group A(23 cases), group B(21 cases) and group C(22 cases). Using USCOM to record the patient's hemodynamic data, based on anti-infection and early resuscitation, group A was treated with Cv-aCO_2/Ca-v O_2 < 1.1 as the guide for the end point of 24-hour resuscitation; group B was treated with LCR > 50% to guide the end point of the 24-hour resuscitation; group C was treated with IVCrvi < 30% to guide the end point of the 24-hour resuscitation. The changes of APACHE II score, SOFA score, MAP, CVP, PaO_2/FiO_2, ScvO_2, SVV, CI, SVRI, PCT,28-day mortality and so on in patients before and after treatment were observed. Results There was no significant difference in SOFA score, MAP, levels of blood Lac level and PCT among three groups before treatment(P > 0.05);there was a significant difference in CVP after 6-hour treatment(P < 0.05). There was no significant difference in the values of MAP, the amount of fluid needed to reach the target MAP, PaO_2/FiO_2, HR and Lac among three groups(P > 0.05); after 24 hours of treatment, there was no significant difference in P(Cv-a) CO2, SVRI and brain peptide sodium(BNP)(P > 0.05), but there were significant differences in the values of ScvO_2 and WBC(P < 0.05). After 7 days of treatment, there was no significant difference in CI, SVRI, DO_2 and PCT among three groups(P > 0.05), but there was a significant difference in SVV(P < 0.05); there was no significant difference in total CBP time, mechanical ventilation time, ICU stay time and 28-day mortality among three groups(P > 0.05). Conclusions Cv-aCO_2/Ca-vO_2 and LCR have a positive correlation with IVCrvi.
引文
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[12]PEAKE S L,DELANEY A,BAILEY M,et al.Goal-directed resuscitation for patients with early septic shock[J].N Engl JMed,2014,371(16):1496-1506.
[13]MOUNCEY P R,OSBORN T M,POWER G S,et al.Trial of early,goal-directed resuscitation for septic shock[J].N Engl JMed,2015,372(14):1301-1311.
[14]GU W J,WANG F,BAKKER J,et al.The effect of goal-directed therapy on mortality in patients with sepsis-earlier is better:a meta-analysis of randomized controlled trials[J].Crit Care,2014,18(5):570.
[2]VINCENT J L,MARSHALL J C,NAMENDYS-SILVA S A,et al.Assessment of the worldwide burden of critical illness:the intensive care over nations(ICON)audit[J].Lancet Respir Med,2014,2(5):380-386.
[3]姜智敏,吕丹,张柯基,等.重症脓毒症及脓毒性休克患者复苏中P(cv-a)CO2/C(a-v)02变化与P(cv-a)C02变化的临床价值比较[J].现代生物医学进展,2016,16(34):6762-6765.
[4]龚仕金,宋佳,周娟娣,等.静-动脉二氧化碳分压差与动-静脉氧含量差比值联合乳酸对感染性休克患者预后的预测价值[J].中华内科杂志,2016,5(9):673-678.
[5]OSPINA-TASCóN G A,BERMúDEZ W,et al.Combination of arterial lactate levels and venous-arterial CO2 to arterial-venous O2content difference ratio as markers of resuscitation in patients with septic shock[J].Intensive Care Med,2015,41(5):796-805.
[6]祖国亮,朱宏泉,许庆林,等.脓毒性休克患者中心静脉-动脉二氧化碳分压差持续增高与预后关系研究[J].赣南医学院学报,2015,35(6):891-894.
[7]JAKOB S M,GROENEVELD A B,TEBOUL J L.Venous-arterial CO2 to arterial-venous O2 difference ratio as a resuscitation target in shock states[J].Intensive Care Med,2015,41(5):936-938.
[8]OSPINA-TASCóN G A,BERMúDEZ W F,et al.Can venousto-arterial carbon dioxide differences reflect microcirculatory alterations in patients with septic shock[J].Intensive Care Med,2016,42(2):211-221.
[9]BOULAIN T,GAROT D,VIGNON P.Prevalence of low central venous oxygen saturation in the first hours of intensive care unit admission and associated mortality in septic shock patients:a prospective multicentre study[J].Crit Care,2014,18(6):609.
[10]MALLAT J,LEMYZE M,TRONCHON L.Use of venous-toarterial carbon dioxide tension difference to guide resuscitation therapy in septic shock[J].Crit Care Med,20165(1):47-56.
[11]MESQUIDA J,SALUDES P,GRUARTMONER G.Lactate or Scv O2 as an endpoint in resuscitation of shock states[J].Minerva Anestesiol,201379(9):1049-1058.
[12]PEAKE S L,DELANEY A,BAILEY M,et al.Goal-directed resuscitation for patients with early septic shock[J].N Engl JMed,2014,371(16):1496-1506.
[13]MOUNCEY P R,OSBORN T M,POWER G S,et al.Trial of early,goal-directed resuscitation for septic shock[J].N Engl JMed,2015,372(14):1301-1311.
[14]GU W J,WANG F,BAKKER J,et al.The effect of goal-directed therapy on mortality in patients with sepsis-earlier is better:a meta-analysis of randomized controlled trials[J].Crit Care,2014,18(5):570.