不同监测手段指导液体复苏对脓毒症休克患者的影响

Effects of Different Monitoring Methods on Fluid Resuscitation in Patients with Septic Shock

摘要: 脓毒症是发生感染后所引起的一系列全身炎症反应综合征，可同时累及多个脏器，导致宿主反应失调，是危及生命的器官功能损害的疾病。如果不能及时识别治疗，可发展为脓毒症休克，脓毒症在充分液体复苏和血管升压药使用的基础上，患者的平均动脉压(MAP) < 65 mmHg，并且血乳酸水平 > 2 mmol/L时，则诊断为脓毒症休克。2021国际指南建议，对脓毒症所致的低灌注和休克患者，推荐在复苏前3 h内至少静注30 ml/kg晶体液。我们通过多种方法来评估患者容量状态，并预测容量反应性，来指导液体复苏治疗。评估的方法主要有静态指标和动态参数，静态指标相当于心脏前负荷，而动态指标更能体现心肺的交互作用。一般使用动态检测手段如每搏量(SV)、每搏量变异(SVV)、脉压变异(PPV)及心脏超声。传统的静态评估方法如：观察患者的生命体征、体格检查、循环压的静态测量如CVP等。使用动态变量(如被动抬腿试验)可以比静态变量(如中心静脉压)更好地预测患者对输液的血流动力学反应。然而，使用“液体反应性”来指导输液是否能改善患者的预后仍是未知的。

Abstract: Sepsis is a series of systemic inflammatory response syndromes caused by infection, which can in-volve multiple organs at the same time, leading to host response disorders, and is a life-threatening disease of organ function damage. Failure to recognize treatment in time may lead to septic shock. Septic shock is diagnosed when the patient’s mean arterial pressure (MAP) is < 65 mmHg and blood lactic acid level is > 2 mmol/L on the basis of adequate fluid resuscitation and vasopressors. The 2021 International Guidelines recommend that patients with hypoperfusion and shock due to sep-sis be given at least 30 ml/kg crystalloid infusion within 3 hours prior to resuscitation. We use a va-riety of methods to assess volume status and predict volume reactivity to guide fluid resuscitation therapy. The evaluation methods mainly include static indicators and dynamic parameters. The static indicators are equivalent to cardiac preload, while the dynamic indicators can better reflect the interaction of the heart and lung. Dynamic measures such as stroke volume (SV), stroke volume variation (SVV), pulse pressure variation (PPV), and echocardiography are commonly used. Tradi-tional static assessment methods include: observation of patients’ vital signs, physical examination, static measurement of circulating pressure such as CVP, etc. The use of dynamic variables (e.g., pas-sive leg lift tests) can better predict hemodynamic responses to infusion than static variables (e.g., central venous pressure). However, whether using “fluid reactivity” to guide infusion improves pa-tient outcomes remains unknown.