脉搏指数连续心输出量监测下液体复苏对重症感染所致急性肾损伤患者内稳态指标及预后的影响
|
摘要
目的探究脉搏指数连续心输出量监测(PiCCO)液体复苏对重症感染所致急性肾损伤(AKI)患者内稳态指标及预后的影响。方法选取2017年10月至2018年2月河北医科大学第三医院收治的重症感染所致AKI患者64例,采用随机数字表法分为对照组和观察组,每组32例。对照组患者在漂浮导管(Swan-Ganz导管)监测下进行液体复苏,观察组患者在PiCCO指导下进行液体复苏。比较2组监测前后的血流动力学指标、内稳态指标、血清肌酐和尿素氮、临床预后以及监测复苏后AKI再发生率。结果 2组基线指标差异均无统计学意义(P>0. 05)。监测后第1、3天,观察组心率、中心静脉压明显低于对照组,平均动脉压、中心静脉血氧饱和度明显高于对照组;观察组血pH值、吸入氧浓度、血细胞比容、阴离子间隙、血乳酸水平明显低于对照组,血Na~+、Cl~-、HCO_3~-浓度明显高于对照组;观察组血清肌酐和尿素氮水平明显低于对照组,差异均有统计学意义(均P<0. 05)。观察组重症监护病房住院时间、总住院时间、机械通气时间、院内死亡率均明显短于/低于对照组(均P <0. 05)。观察组监测复苏后AKI再发生率明显低于对照组[21.9%(7/32)比65. 6%(21/32)](P<0. 01)。结论 PiCCO液体复苏可有效改善重症感染所致AKI患者的血流动力学和内稳态,有利于降低复苏后AKI再发生率及院内死亡率,缩短住院时间。
Objective To investigate the effect of fluid resuscitation with pulse-induced contour cardiac output(PiCCO) monitoring on homeostasis and prognosis in patients with acute renal injury(AKI) caused by severe infection. Methods A total of 64 AKI patients caused by severe infection in the Third Hospital of Hebei Medical University from October 2017 to February 2018 were randomly divided into control group and observation group, with 32 cases in each group. The control group was treated with fluid resuscitation monitored by floating catheter( Swan-Ganz catheter). Fluid resuscitation was performed in the observation group with the guidance of PiCCO. Hemodynamic indexes, homeostasis indexes, serum creatinine and urea nitrogen, clinical prognosis and the reoccurrence of AKI after fluid resuscitation were analyzed. Results Baseline indexes were similar between the two groups(P >0. 05). On the 1 st and 3 rd day after resuscitation, heart rate and central venous pressure were significantly lower, mean arterial pressure and central venous oxygen saturation were significantly higher in the observation group than those in the control group; blood pH value, inspired oxygen fraction, hematocrit, anion gap and blood lactic acid level in the observation group were lower than those in the control group; blood contents of Na~+, Cl~-and HC0_3~-in the observation group were higher than those in the control group; serum levels of creatinine and urea nitrogen in the observation group were lower than those in the control group(all P<0. 05).Intensive care unit stay time, total hospitalization time, mechanical ventilation time and the in-hospital mortality rate in the observation group were shorter/lower than those in the control group(all P <0. 05). Incidence of AKI after fluid resuscitation in the observation group was significantly lower than that in the control group [21.9%(7/32) vs65.6%(21/32)](P<0.01). Conclusion Fluid resuscitation with PiCCO monitoring can effectively improve hemodynamics and homeostasis, reduce mortality and hospital stay time in patients with AKI caused by severe infection.
Objective To investigate the effect of fluid resuscitation with pulse-induced contour cardiac output(PiCCO) monitoring on homeostasis and prognosis in patients with acute renal injury(AKI) caused by severe infection. Methods A total of 64 AKI patients caused by severe infection in the Third Hospital of Hebei Medical University from October 2017 to February 2018 were randomly divided into control group and observation group, with 32 cases in each group. The control group was treated with fluid resuscitation monitored by floating catheter( Swan-Ganz catheter). Fluid resuscitation was performed in the observation group with the guidance of PiCCO. Hemodynamic indexes, homeostasis indexes, serum creatinine and urea nitrogen, clinical prognosis and the reoccurrence of AKI after fluid resuscitation were analyzed. Results Baseline indexes were similar between the two groups(P >0. 05). On the 1 st and 3 rd day after resuscitation, heart rate and central venous pressure were significantly lower, mean arterial pressure and central venous oxygen saturation were significantly higher in the observation group than those in the control group; blood pH value, inspired oxygen fraction, hematocrit, anion gap and blood lactic acid level in the observation group were lower than those in the control group; blood contents of Na~+, Cl~-and HC0_3~-in the observation group were higher than those in the control group; serum levels of creatinine and urea nitrogen in the observation group were lower than those in the control group(all P<0. 05).Intensive care unit stay time, total hospitalization time, mechanical ventilation time and the in-hospital mortality rate in the observation group were shorter/lower than those in the control group(all P <0. 05). Incidence of AKI after fluid resuscitation in the observation group was significantly lower than that in the control group [21.9%(7/32) vs65.6%(21/32)](P<0.01). Conclusion Fluid resuscitation with PiCCO monitoring can effectively improve hemodynamics and homeostasis, reduce mortality and hospital stay time in patients with AKI caused by severe infection.
引文
[1]丁峰,张琪,马绍骏,等.急性肾损伤的诊断新进展认识[J].诊断学理论与实践,2017,16(4):347-352.DOI:10.16150/j.1671-2870.2017.04.001.Ding F, Zhang Q, Ma SJ, et al. New progress in diagnosis of acute renal injury[J]. Journal of Diagnostics Concepts&Practice,2017,16(4):347-352. DOI:10.16150/j. 1671-2870.2017.04.001.
[2]王丽锋,张逸尘,何双军,等.急诊科脓毒症相关性肺损伤和肾损伤的发病情况及预后分析[J].临床内科杂志,2017,34(9):600-602. DOI:10. 3969/j.issn. 1001-9057.2017.09.006.Wang LF, Zhang YC, He SJ, et al. Incidence and prognosis of sepsis-associated acute lung injury and acute kidney injury in emergency department[J]. Journal of Clinical Internal Medicine, 2017,34(9):600-602. DOI:10.3969/j. issn. 1001-9057.2017.09.006.
[3]李志,林健球.Swan-Ganz飘浮导管监测血流动力学指标在心肺复苏中指导价值[J].临床肺科杂志,2016,21(3):396-399.DOI:10.3969/j. issn. 1009-6663.2016.03.003.Li Z, Lin JQ. Guidance of Swan-Ganz float catheter monitoringhemodynamic indexes in cardiopulmonary resuscitation[J]. Journal of Clinical Pulmonary Medicine, 2016,21(3):396-399. DOI:10.3969/j. issn. 1009-6663.2016.03.003.
[4]卢露,潘国权,汤鲁明,等.PICCO指导下液体复苏对脓毒症休克患者免疫功能及炎症介质的影响[J].中华全科医学,2017,15(4):562-564. DOI:10.16766/j. cnki. issn. 1674-1152.2017. 04. 005.Lu L, Pan GQ, Tang LM, et al. Effects of fluid resuscitation under the guidance of PICCO on the immune function and inflammatory mediator in patients with septic shock[J]. Chinese Journal of General Practice, 2017,15(4):562-564. DOI:10. 16766/j.cnki. issn. 1674-4152.2017.04.005.
[5]郭锦洲.改善全球肾脏病预后组织(KDIGO)临床实践指南:急性肾损伤[J].肾脏病与透析肾移植杂志,2013,22(1):57-60.DOI:10.3969/j. issn. 1006-298X.2013.01.014.Guo JZ. Kidney Disease:Improving Global Outcomes(KDIGO)clinical guidelines:acute Renal injury[J]. Chinese Journal of Nephrology, Dialysis&Transplantation, 2013,22(1):57-60.DOI:10.3969/j. issn. 1006-298X.2013.01.014.
[6]赵文婷,刘刚,杨莉.急性肾损伤中补体系统作用机制的研究进展[J].临床肾脏病杂志,2017,17(1):58-60. DOI:10.3969/j. issn. 1671-2390.2017.01.013.Zhao WT, Liu G, Yang L. Progress in the mechanism of complement system in acute renal injury[J]. Journal of Clinical Nephrology, 2017,17(1):58-60. DOI:10.3969/j.issn. 1671-2390.2017.01.013.
[7] Kellum JA, Chawla LS, Keener C, et al. The effects of alternative resuscitation strategies on acute kidney injury in patients with septic shock[J]. Am J Respir Crit Care Med, 2016,193(3):281-297.DOI:10. 1164/rccm.201505-0995OC.
[8] Haasefielitz A, Haase M, Bellomo R, et al. Perioperative hemodynamic instability and fluid overload are associated with increasing acute kidney injury severity and worse outcome after cardiac surgery[J].Blood Purif, 2017,43(4):298-308. DOI:10.1159/000455061.
[9]王松岚,毛永辉.连续性肾脏替代治疗治疗模式的选择和液体平衡目标的设定[J].临床内科杂志,2017,34(4):224-226.DOI:10.3969/j. issn. 1001-9057.2017.04.002.Wang SL, Mao YH. Choice of continuous renal replacement therapy mode and the setting of fluid balance goal[J]. Journal of Clinical Internal Medicine, 2017,34(4):224-226. DOI:10. 3969/j. issn.1001-9057.2017.04.002.
[10]王刚,孙志军,高磊,等.PiCCO与Swan-Ganz在急性下壁心肌梗死患者中血流动力学监测比较[J].中国循证心血管医学杂志,2016,8(7):812-813.816. DOI:10.3969/j. issn. 1674-4055.2016.07.11.Wang G, Sun ZJ, Gao L, et al. Comparison in hemodynamics between PiCCO and Swan-Ganz in monitoring patients with acute inferior wall myocardial infarction[J]. Chinese Journal of Evidence-Bases Cardiovascular Medicine, 2016,8(7):812-813,816. DOI:10.3969/j. issn. 1674-4055.2016.07. 11.
[11]史春芝,王助衡,孙立平,等.PiCCO为导向的液体复苏策略在创伤性休克急性期中的应用[J].中国医刊,2017,52(7):65-68. DOI:10.3969/j. issn. 1008-1070.2017.07.017.Shi CZ, Wang ZH, Sun LP, et al. Transpulmonary thermodilution technique in application of traumatic shock[J]. Chinese Journal of Medicine, 2017,52(7):65-68. DOI:10. 3969/j. issn. 1008-1070.2017.017.
[12]白国欣,王伟,曹振敏,等.脉搏指示连续心排血量联合中心静脉压监测对机械通气老年危重患者的临床价值[J].中国煤炭工业医学杂志,2017,20(6):673-677.DOI:10.11723/mtgyyx1007-9564201706012.Bai GX, Wang W, Cao ZM, et al. Clinical value of PICCO combined with CVP monitoring in critically ill patients with mechanical ventilation[J]. Chinese Journal of Coal Industry Medicine, 2017,20(6):673-677. DOI:10. 11723/mtgyyx1007-9564201706012.
[13]王彦军,高蕊,贾文元,等.中心静脉压在感染性休克致急性肾损伤中的作用[J].创伤外科杂志,2017,19(8):566-569. DOI:10.3969/j. issn. 1009-4237.2017.08.002.Wang YJ, Gao R, Jia WY, et al. Effect of central venous pressure on septic shock induced acute kidney injury[J]. Journal of Traumatic Surgery, 2017, 19(8):566-569. DOI:10. 3969/j.issn. 1009 4237.2017.08.002.
[14]尚新志,尚若愚,胡东升,等.重度烧伤合并急性肾衰引发肺部真菌感染1例报告[J].中国烧伤创疡杂志,2017,29(1):24-26. DOI:10. 3969/j.issn. 1001-0726.2017.01.004.Shang XZ, Shang RY, Hu DS, et al. A case report of pulmonary fungal infection caused by severe burns complicated with acute renal failure[J]. The Chinese Journal of Burns Wounds And Surface Ulcers, 2017,29(1):24-26. DOI:10.3969/j. issn. 1001-0726.2017.01.004.
[15]严莹,刘颖,孙加奎,等.血管外肺水监测对脓毒症急性肾损伤的应用研究[J]护士进修杂志,2016,31(10):873-876.DOI:10.16821/j. cnki. hsjx. 2016.10.005.Yan Y, Liu Y, Sun JK, et al. Nursing for patients with acute kidney injury induced by sepsis by extravascular lung water monitoring[J].Journal of Nurses Training, 2016,31(10):873-876. DOI:10.16821/j.cnki. hsjx. 2016.10.005.
[2]王丽锋,张逸尘,何双军,等.急诊科脓毒症相关性肺损伤和肾损伤的发病情况及预后分析[J].临床内科杂志,2017,34(9):600-602. DOI:10. 3969/j.issn. 1001-9057.2017.09.006.Wang LF, Zhang YC, He SJ, et al. Incidence and prognosis of sepsis-associated acute lung injury and acute kidney injury in emergency department[J]. Journal of Clinical Internal Medicine, 2017,34(9):600-602. DOI:10.3969/j. issn. 1001-9057.2017.09.006.
[3]李志,林健球.Swan-Ganz飘浮导管监测血流动力学指标在心肺复苏中指导价值[J].临床肺科杂志,2016,21(3):396-399.DOI:10.3969/j. issn. 1009-6663.2016.03.003.Li Z, Lin JQ. Guidance of Swan-Ganz float catheter monitoringhemodynamic indexes in cardiopulmonary resuscitation[J]. Journal of Clinical Pulmonary Medicine, 2016,21(3):396-399. DOI:10.3969/j. issn. 1009-6663.2016.03.003.
[4]卢露,潘国权,汤鲁明,等.PICCO指导下液体复苏对脓毒症休克患者免疫功能及炎症介质的影响[J].中华全科医学,2017,15(4):562-564. DOI:10.16766/j. cnki. issn. 1674-1152.2017. 04. 005.Lu L, Pan GQ, Tang LM, et al. Effects of fluid resuscitation under the guidance of PICCO on the immune function and inflammatory mediator in patients with septic shock[J]. Chinese Journal of General Practice, 2017,15(4):562-564. DOI:10. 16766/j.cnki. issn. 1674-4152.2017.04.005.
[5]郭锦洲.改善全球肾脏病预后组织(KDIGO)临床实践指南:急性肾损伤[J].肾脏病与透析肾移植杂志,2013,22(1):57-60.DOI:10.3969/j. issn. 1006-298X.2013.01.014.Guo JZ. Kidney Disease:Improving Global Outcomes(KDIGO)clinical guidelines:acute Renal injury[J]. Chinese Journal of Nephrology, Dialysis&Transplantation, 2013,22(1):57-60.DOI:10.3969/j. issn. 1006-298X.2013.01.014.
[6]赵文婷,刘刚,杨莉.急性肾损伤中补体系统作用机制的研究进展[J].临床肾脏病杂志,2017,17(1):58-60. DOI:10.3969/j. issn. 1671-2390.2017.01.013.Zhao WT, Liu G, Yang L. Progress in the mechanism of complement system in acute renal injury[J]. Journal of Clinical Nephrology, 2017,17(1):58-60. DOI:10.3969/j.issn. 1671-2390.2017.01.013.
[7] Kellum JA, Chawla LS, Keener C, et al. The effects of alternative resuscitation strategies on acute kidney injury in patients with septic shock[J]. Am J Respir Crit Care Med, 2016,193(3):281-297.DOI:10. 1164/rccm.201505-0995OC.
[8] Haasefielitz A, Haase M, Bellomo R, et al. Perioperative hemodynamic instability and fluid overload are associated with increasing acute kidney injury severity and worse outcome after cardiac surgery[J].Blood Purif, 2017,43(4):298-308. DOI:10.1159/000455061.
[9]王松岚,毛永辉.连续性肾脏替代治疗治疗模式的选择和液体平衡目标的设定[J].临床内科杂志,2017,34(4):224-226.DOI:10.3969/j. issn. 1001-9057.2017.04.002.Wang SL, Mao YH. Choice of continuous renal replacement therapy mode and the setting of fluid balance goal[J]. Journal of Clinical Internal Medicine, 2017,34(4):224-226. DOI:10. 3969/j. issn.1001-9057.2017.04.002.
[10]王刚,孙志军,高磊,等.PiCCO与Swan-Ganz在急性下壁心肌梗死患者中血流动力学监测比较[J].中国循证心血管医学杂志,2016,8(7):812-813.816. DOI:10.3969/j. issn. 1674-4055.2016.07.11.Wang G, Sun ZJ, Gao L, et al. Comparison in hemodynamics between PiCCO and Swan-Ganz in monitoring patients with acute inferior wall myocardial infarction[J]. Chinese Journal of Evidence-Bases Cardiovascular Medicine, 2016,8(7):812-813,816. DOI:10.3969/j. issn. 1674-4055.2016.07. 11.
[11]史春芝,王助衡,孙立平,等.PiCCO为导向的液体复苏策略在创伤性休克急性期中的应用[J].中国医刊,2017,52(7):65-68. DOI:10.3969/j. issn. 1008-1070.2017.07.017.Shi CZ, Wang ZH, Sun LP, et al. Transpulmonary thermodilution technique in application of traumatic shock[J]. Chinese Journal of Medicine, 2017,52(7):65-68. DOI:10. 3969/j. issn. 1008-1070.2017.017.
[12]白国欣,王伟,曹振敏,等.脉搏指示连续心排血量联合中心静脉压监测对机械通气老年危重患者的临床价值[J].中国煤炭工业医学杂志,2017,20(6):673-677.DOI:10.11723/mtgyyx1007-9564201706012.Bai GX, Wang W, Cao ZM, et al. Clinical value of PICCO combined with CVP monitoring in critically ill patients with mechanical ventilation[J]. Chinese Journal of Coal Industry Medicine, 2017,20(6):673-677. DOI:10. 11723/mtgyyx1007-9564201706012.
[13]王彦军,高蕊,贾文元,等.中心静脉压在感染性休克致急性肾损伤中的作用[J].创伤外科杂志,2017,19(8):566-569. DOI:10.3969/j. issn. 1009-4237.2017.08.002.Wang YJ, Gao R, Jia WY, et al. Effect of central venous pressure on septic shock induced acute kidney injury[J]. Journal of Traumatic Surgery, 2017, 19(8):566-569. DOI:10. 3969/j.issn. 1009 4237.2017.08.002.
[14]尚新志,尚若愚,胡东升,等.重度烧伤合并急性肾衰引发肺部真菌感染1例报告[J].中国烧伤创疡杂志,2017,29(1):24-26. DOI:10. 3969/j.issn. 1001-0726.2017.01.004.Shang XZ, Shang RY, Hu DS, et al. A case report of pulmonary fungal infection caused by severe burns complicated with acute renal failure[J]. The Chinese Journal of Burns Wounds And Surface Ulcers, 2017,29(1):24-26. DOI:10.3969/j. issn. 1001-0726.2017.01.004.
[15]严莹,刘颖,孙加奎,等.血管外肺水监测对脓毒症急性肾损伤的应用研究[J]护士进修杂志,2016,31(10):873-876.DOI:10.16821/j. cnki. hsjx. 2016.10.005.Yan Y, Liu Y, Sun JK, et al. Nursing for patients with acute kidney injury induced by sepsis by extravascular lung water monitoring[J].Journal of Nurses Training, 2016,31(10):873-876. DOI:10.16821/j.cnki. hsjx. 2016.10.005.