PiCCO监测指导脓毒性休克患者早期目标导向液体治疗的临床研究

Clinical Study on PiCCO Monitoring in Guidance of Early Goal-Directed Fluid Therapy in Patients with Septic Shock

摘要: 目的：探讨脉搏指示连续心排血量(PiCCO)监测在脓毒性休克患者早期目标导向液体治疗(EGDT)中的应用价值。方法：选择2015年9月~2017年7月宁夏医科大学第二附属医院ICU收治的脓毒性休克患者60例，按随机数字表法分为两组：PiCCO组(30例)患者在PiCCO监测指导下进行EGDT，传统组(30例)患者在中心静脉压(CVP)监测下进行EGDT。记录所有患者治疗前序贯器官衰竭估计评分(SOFA)和急性生理学与慢性健康状况评分系统II(APACHE II)，以及治疗前的CVP、平均动脉压(MAP)、血乳酸(LAC)。观察治疗后6 h、24 h、72 h两组患者的CVP、MAP、LAC、每小时尿量、血管活性药物使用剂量、复苏液体量，比较两组患者机械通气时间、住ICU时间、液体复苏6 h达标率、28天病死率等预后指标。记录PiCCO组患者治疗前后四个时间点的PiCCO监测参数。结果：1) 两组患者的年龄、性别比例、治疗前的SOFA评分、APACHE II评分、CVP、MAP、LAC相比无明显差异(P > 0.05)。2) 治疗后6 h、24 h的CVP、MAP、每小时尿量、复苏液体量，PiCCO组患者显著高于传统组(P < 0.05)；PiCCO组患者治疗后6 h、24 h LAC较传统组明显降低(P < 0.05)；治疗后6 h、24 h、72 h血管活性药物使用剂量(去甲肾上腺素)，PiCCO组患者显著低于传统组(P < 0.05)。3) 与传统组相比，治疗后PiCCO组患者机械通气时间和住ICU时间显著缩短(P < 0.05)；治疗后PiCCO组患者液体复苏6 h达标率显著高于传统组(P < 0.05)；两组患者28天病死率相比无明显差异(P > 0.05)。4) 与治疗前相比，PiCCO组患者治疗后6 h、24 h、72 h的心排指数(CI)、胸腔内血容积指数(ITBVI)、全心舒张末期容积指数(GEDVI)明显增大(P < 0.05)，但治疗后6 h、24 h、72 h的每搏量变异(SVV)显著减小(P < 0.05)；与治疗后6 h相比，治疗后72 h的SVV明显减小(P < 0.05)。与治疗前相比，治疗后72 h的外周血管阻力指数(SVRI)明显增大(P < 0.05)。治疗前后血管外肺水指数(EVLWI)无明显变化(P > 0.05)。结论：PiCCO指导脓毒性休克患者的EGDT，能提高患者液体复苏6 h达标率的同时不增加肺水，减少患者机械通气时间及住ICU时间，但对患者远期病死率改善无明显影响。

Abstract: Objective: To observe the application value of pulse indicator continuous cardiac output (PiCCO) monitoring in guidance of early goal-directed fluid therapy (EGDT) in patients with septic shock. Methods: 60 cases patients with septic shock in intensive care unit (ICU) of the second affiliated hospital of Ningxia Medical University from September 2015 to July 2017 were selected. All pa-tients were randomly divided into two groups: PiCCO group (30 cases) received PiCCO monitoring to guide EGDT, traditional group (30 cases) received central venous pressure (CVP) monitoring to guide EGDT. Sequential organ failure assessment (SOFA) scores and acute physiology and chronic health evaluation II (APACHE II) scores, CVP, mean arterial pressure (MAP), blood lactic acid (LAC) before treatment of all patients were recorded. CVP, MAP, LAC, urine volume per hour, vascular active drug dosage, amount of fluid resuscitation at 6 h, 24 h, 72 h after the treatment of patients in the two groups were observed. Prognostic indicators (duration of mechanical ventilation, ICU stay time, 6 h fluid resuscitation standard rate, 28-day case fatality rate) of patients in the two groups were compared. PiCCO monitoring parameters at the four time points before and after treatment of patients in PiCCO group were recorded. Results: 1) There were no significant differences in age, sex ratio, SOFA scores, APACHE II scores, CVP, MAP, LAC before treatment of patients in the two groups (P > 0.05). 2) CVP, MAP, urine volume per hour, amount of fluid resuscitation at 6 h, 24 h after the treatment of patients in PiCCO group were obviously higher than traditional group (P < 0.05); LAC at 6 h, 24 h after the treatment of patients in PiCCO group was obviously lower than traditional group (P < 0.05); vascular active drug dosage (norepinephrine) at 6 h, 24 h, 72 h after the treatment of patients in PiCCO group was obviously lower than traditional group (P < 0.05). 3) In comparison to traditional group, PiCCO group showed obviously shorter in duration of mechanical ventilation and ICU stay time (P < 0.05); 6 h fluid resuscitation standard rate of patients in PiCCO group was obviously higher than traditional group (P < 0.05); there was no significant difference in 28-day case fatality rate of patients in the two groups (P > 0.05). 4) Compared with that before treatment, cardiac output index (CI), intrathoracic blood volume index (ITBVI), global end diastolic volume index (GEDVI) at 6 h, 24 h, 72 h after the treatment of patients in PiCCO group were significantly increasing (P < 0.05) while stroke volume variation (SVV) at 6 h, 24 h, 72 h after the treatment was significantly decreasing (P < 0.05); SVV at 72 h after the treatment was obviously smaller than that at 6 h after the treatment (P < 0.05). Compared with that before the treatment, systemic vascular resistance index (SVRI) at 72 h after the treatment was signifi-cantly increasing (P < 0.05). Extravascular lung water index (EVLWI) had no significant change before and after treatment (P > 0.05). Conclusion: PiCCO monitoring guiding EGDT in patients with septic shock can increase 6 h fluid resuscitation standard rate while does not increase lung water, reduces duration of mechanical ventilation and ICU stay time, but it has no obvious effect on long-term case fatality rate of patients.