超声心排血量监测指导低排高阻危重病人治疗的价值
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摘要
目的探讨超声心排血量监测(USCOM)指导低排高阻危重病人治疗的临床应用价值。方法选取2016年1月—2018年6月入住青岛市海慈医疗集团重症医学科的低排高阻病人82例,将其随机分为2组。对照组40例仅根据临床常规监测进行经验性治疗,观察组42例则根据常规监测及动态监测USCOM指标对病人进行精准化治疗。常规监测指标包括心率(HR)、平均动脉压(MAP)、血乳酸(Lac)、氧合指数(OI)、中心静脉压(CVP)、脑钠肽(BNP);USCOM指标包括心排血指数(CI)、外周血管阻力指数(SVRI)、心脏收缩期射血所用时间(FTc)。比较两组病人治疗6、12、24、48、72 h血流动力学和血气分析指标的变化,血管活性药物使用剂量,28 d内ICU转出率及病死率。结果观察组血流动力学和血气分析指标改善优于对照组,治疗6 h时,两组仅OI比较差异有统计学意义(F=5.14,P<0.05);治疗12 h时,两组HR、MAP、Lac、OI、CI、SVRI、FTc、BNP比较差异有统计学意义(F=2.84～9.87,P<0.05);治疗24、48、72 h时,两组所有指标差异均有统计学意义(F=3.03～86.57,P<0.05)。治疗24、48、72 h时观察组多巴酚丁胺、硝酸甘油的泵入速度显著低于对照组(F=3.21～3.98,P<0.05)。观察组28 d内ICU转出率显著高于对照组(χ~2=4.383,P<0.05),病死率显著低于对照组(χ~2=4.082,P<0.05)。结论通过USCOM对低排高阻危重症病人血流动力学进行动态监测,能个体化精准指导临床治疗,减少药物的使用及住ICU的时间,降低病死率。
Objective To investigate the clinical value of ultrasound cardiac output monitor(USCOM) in guiding the treatment of critically ill patients with low cardiac output and high systemic vascular resistance. Methods A total of 82 patients with low cardiac output and high systemic vascular resistance who were admitted to Department of Critical Care Medicine in Qing-dao Hiser Medical Group from January 2016 to June 2018 were enrolled and randomly divided into control group with 40 patients and observation group with 42 patients. The patients in the control group were given empiric therapy based on conventional clinical monitoring, and those in the observation group were given precision therapy based on conventional clinical monitoring and dynamic USCOM indices. Conventional clinical monitoring indices included heart rate(HR), mean arterial pressure(MAP), blood lactic acid(Lac), oxygenation index(OI), central venous pressure(CVP), and brain natriuretic peptide(BNP), and USCOM indices included cardiac output index(CI), peripheral systemic vascular resistance index(SVRI), and corrected flow time(FTc). The two groups were compared in terms of the changes in hemodynamics and blood gas parameters at 6, 12, 24, 48, and 72 h of treatment, dose of vasoactive agent, intensive care unit(ICU) discharge rate within 28 d, and mortality rate. Results The observation group had significantly greater improvements in hemodynamics and blood gas parameters than the control group, and at 6 h of treatment, there was a significant difference in OI between the two groups(F=5.14,P<0.05); at 12 h of treatment, there were significant differences between the two groups in HR, MAP, Lac, OI, CI, SVRI, FTc, and BNP(F=2.84-9.87,P<0.05); at 24, 48, and 72 h of treatment, there were significant differences in all indices between the two groups(F=3.03-86.57,P<0.05). Compared with the control group at 24, 48, and 72 h of treatment, the observation group had a significantly lower pumping speed of dobutamine and nitroglycerin(F=3.21-3.98,P<0.05). Compared with the control group, the observation group had a significantly higher ICU discharge rat within 28 d(χ~2=4.383,P<0.05) and a significantly lower mortality rate(χ~2=4.082,P<0.05). Conclusion Dynamic monitoring of hemodynamics in patients with low cardiac output and high systemic vascular resistance by USCOM can guide individualized clinical treatment and reduce the use of drugs, the length of ICU stay, and mortality rate.
Objective To investigate the clinical value of ultrasound cardiac output monitor(USCOM) in guiding the treatment of critically ill patients with low cardiac output and high systemic vascular resistance. Methods A total of 82 patients with low cardiac output and high systemic vascular resistance who were admitted to Department of Critical Care Medicine in Qing-dao Hiser Medical Group from January 2016 to June 2018 were enrolled and randomly divided into control group with 40 patients and observation group with 42 patients. The patients in the control group were given empiric therapy based on conventional clinical monitoring, and those in the observation group were given precision therapy based on conventional clinical monitoring and dynamic USCOM indices. Conventional clinical monitoring indices included heart rate(HR), mean arterial pressure(MAP), blood lactic acid(Lac), oxygenation index(OI), central venous pressure(CVP), and brain natriuretic peptide(BNP), and USCOM indices included cardiac output index(CI), peripheral systemic vascular resistance index(SVRI), and corrected flow time(FTc). The two groups were compared in terms of the changes in hemodynamics and blood gas parameters at 6, 12, 24, 48, and 72 h of treatment, dose of vasoactive agent, intensive care unit(ICU) discharge rate within 28 d, and mortality rate. Results The observation group had significantly greater improvements in hemodynamics and blood gas parameters than the control group, and at 6 h of treatment, there was a significant difference in OI between the two groups(F=5.14,P<0.05); at 12 h of treatment, there were significant differences between the two groups in HR, MAP, Lac, OI, CI, SVRI, FTc, and BNP(F=2.84-9.87,P<0.05); at 24, 48, and 72 h of treatment, there were significant differences in all indices between the two groups(F=3.03-86.57,P<0.05). Compared with the control group at 24, 48, and 72 h of treatment, the observation group had a significantly lower pumping speed of dobutamine and nitroglycerin(F=3.21-3.98,P<0.05). Compared with the control group, the observation group had a significantly higher ICU discharge rat within 28 d(χ~2=4.383,P<0.05) and a significantly lower mortality rate(χ~2=4.082,P<0.05). Conclusion Dynamic monitoring of hemodynamics in patients with low cardiac output and high systemic vascular resistance by USCOM can guide individualized clinical treatment and reduce the use of drugs, the length of ICU stay, and mortality rate.
引文
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[20] 王洪亮,刘海涛,于凯江.被动抬腿试验联合无创心排血量监测系统预测容量反应性的临床研究[J].中国危重病急救医学,2011,23(3):146-149.
[21] 黄磊,张卫星,蔡文训,等.每搏量变异度预测严重感染和感染性休克患者容量反应性的价值[J].中华急诊医学杂志,2010,19(9):916-920.
[22] TAN H L,PINDER M,PARSOND R,et al.Clinical evaluation of USCOM ultrasonic cardiac output monitor in cardiac surgical patients in intensive care unit[J].British Journal of Anaesthesia,2005,94(3):287-291.
[23] 卞爱琳,郭莹.卡维地洛对心力衰竭病人血流动力学相关指标影响[J].青岛大学医学院学报,2004,40(3):261-262.
[24] 范江花,罗海燕,杨龙贵,等.无创血流动力学监测指标心脏指数对重症手足口病预测价值[J].中国循证儿科杂志,2016,5(5):341-345.
[25] 赵洪芹,张晓芳,丁磊,等.重度EICAS血流动力学改变与不同类型脑梗死的关系[J].青岛大学医学院学报,2015,59(4):427-429.
[26] 孟庆涛,王辉山,韩宏光,等.连续多普勒无创血流动力学监测仪在冠状动脉旁路移植术后的应用[J].中国胸心血管外科临床杂志,2014,12(2):203-206.
[27] 梁金鑫,张琪,任晓旭,等.无创血流动力学监测在感染性休克患儿早期液体复苏中的应用[J].北京医学,2016,38(7):698-702.
[28] 石根萍.无创血流动力学监测在危重患者液体复苏中的应用[J].中国实用医药,2015,10(24):38-39.
[29] 左坤,朱莎,赵有红,等.无创血流动力学监测系统评价硫酸镁治疗重度子痫前期患者的效果[J].中国妇幼保健,2017,32(19):4841-4843.
[30] 罗曼,孙青松,徐亮,等.无创血流动力学监测指导严重脓毒症患者血管活性药物的应用[J].现代生物医学进展,2017,17(7):1297-1300.
[2] 高娜,袁清霞.无创血流动力学监测系统在ICU的应用进展[J].医疗装备,2018,5(6):25-27.
[3] 刘大为.血流动力学从监测走向治疗[J].中国危重病急救医学,2012,24(1):1-3.
[4] 于文刚,孙晓燕.氨力农对老年直肠癌并高血压病人术中血流动力学相关指标的影响[J].青岛大学医学院学报,2004,40(3):269-270.
[5] DOHERTY A,EL-KHUFFASH A,MONTEITH C,et al.Comparison of bioreactance and echocardiographic non-invasive cardiac output monitoring and myocardial function assessment in primagravida women[J].British Journal of Anaesthesia,2017,118(4):527-532.
[6] BELTRAMO F,MENTEER J,RAZAVI A,et al.Validation of an ultrasound cardiac output monitor as a bedside tool for pediatric patients[J].Pediatric Cardiology,2016,37(1):177-183.
[7] 孟美娟,叶红,蔡婷,等.无创血流动力学监测临床应用的临床进展[J].现代生物医学进展,2016,16(14):2789-2792.
[8] SMITH B E,MADIGAN V M.Non-invasive method for rapid bedside estimation of inotropy:theory and preliminary clinical validation[J].British Journal of Anaesthesia,2013,111(4):580-588.
[9] 郭春文,闫红,黄阿勤.无创超声心输出量监测在休克早期复苏中的指导作用[J].东南国防医药,2015,12(3):263-265.
[10] 洪文超,裘刚,龚小慧,等.床旁无创血流动力学监系统在新生儿感染性休克诊治中的应用价值[J].中华实用儿科临床杂志,2018,33(18):14-16.
[11] HE Shaoru,SUN Xin,ZHANG Cheng,et al.Measurement of systemic oxygen delivery and inotropy in healthy term neonates with the Ultrasonic Cardiac Output Monitor (USCOM)[J].Early Human Development,2013,89(5):289-294.
[12] 李美慧,端木鲁健,赵瑞涛,等.无创血流动力学联合脑钠肽、左室射血分数对心力衰竭患者血流动力学的评估[J].重庆医学,2016,45(29):4117-4121.
[13] 董能斌,胡凯,罗雅月,等.无创血流动力学监测在心力衰竭患者中的应用[J].湘南学院学报(医学版),2017,12(4):34-36.
[14] CHONG S W,PEYTON P J.A meta-analysis of the accuracy and precision of the ultrasonic cardiac output monitor (USCOM)[J].Anaesthesia,2012,67(11):1266-1271.
[15] 莫国欢,曾秋月,袁碧丹,等.无创血流动力学监测在86例新生儿感染性休克早期液体复苏中的应用观察[J].中外医学研究,2018,12(9):65-68.
[16] 陈柏梁,戴建伟.无创血流动力学监测在感染性休克早期复苏中的应用[J].中国实用医刊,2018,45(2):56-58.
[17] 汪亚芸,陈曼华.新活素对老年顽固性心力衰竭患者无创血流动力学参数的影响[J].实用药物与临床,2015,11(4):406-408.
[18] THIEL S W,KOLLEF M H,ISAKOW W.Non-invasive stroke volume measurement and passive leg raising predict vo-lume responsiveness in medical ICU patients:an observational cohort study[J].Critical Care,2009,13(4):111-116.
[19] 沈君,杨好妹.超声心输出量监测仪在脓毒性休克患儿中的应用[J].实用临床医学,2018,11(1):68-71.
[20] 王洪亮,刘海涛,于凯江.被动抬腿试验联合无创心排血量监测系统预测容量反应性的临床研究[J].中国危重病急救医学,2011,23(3):146-149.
[21] 黄磊,张卫星,蔡文训,等.每搏量变异度预测严重感染和感染性休克患者容量反应性的价值[J].中华急诊医学杂志,2010,19(9):916-920.
[22] TAN H L,PINDER M,PARSOND R,et al.Clinical evaluation of USCOM ultrasonic cardiac output monitor in cardiac surgical patients in intensive care unit[J].British Journal of Anaesthesia,2005,94(3):287-291.
[23] 卞爱琳,郭莹.卡维地洛对心力衰竭病人血流动力学相关指标影响[J].青岛大学医学院学报,2004,40(3):261-262.
[24] 范江花,罗海燕,杨龙贵,等.无创血流动力学监测指标心脏指数对重症手足口病预测价值[J].中国循证儿科杂志,2016,5(5):341-345.
[25] 赵洪芹,张晓芳,丁磊,等.重度EICAS血流动力学改变与不同类型脑梗死的关系[J].青岛大学医学院学报,2015,59(4):427-429.
[26] 孟庆涛,王辉山,韩宏光,等.连续多普勒无创血流动力学监测仪在冠状动脉旁路移植术后的应用[J].中国胸心血管外科临床杂志,2014,12(2):203-206.
[27] 梁金鑫,张琪,任晓旭,等.无创血流动力学监测在感染性休克患儿早期液体复苏中的应用[J].北京医学,2016,38(7):698-702.
[28] 石根萍.无创血流动力学监测在危重患者液体复苏中的应用[J].中国实用医药,2015,10(24):38-39.
[29] 左坤,朱莎,赵有红,等.无创血流动力学监测系统评价硫酸镁治疗重度子痫前期患者的效果[J].中国妇幼保健,2017,32(19):4841-4843.
[30] 罗曼,孙青松,徐亮,等.无创血流动力学监测指导严重脓毒症患者血管活性药物的应用[J].现代生物医学进展,2017,17(7):1297-1300.