每搏输出量变异指数在老年脓毒症患者液体复苏中的价值

Value of stroke volume variation in guiding fluid resuscitation therapy in the elderly septic patients

目的在老年脓毒症患者进行液体复苏过程中，观察每搏输出量变异指数（SVV）为复苏指标时相应的功能性血流动力学参数的变化、组织灌注的改善及预后。方法选取30例老年脓毒症患者进行早期目标指导治疗（EGDT），在液体复苏同时予脉搏指数连续心输出量监测（PiCCO）监测，随机将患者分为研究组和标准液体复苏组（对照组）。观察复苏前和6h后达标患者的中心静脉压（CVP）、全心舒张末容积指数（GEDVI）、胸腔内血容量指数（ITBVI）、血管外肺水指数（EVLWI）、心排指数（CI）、中心静脉血氧饱和度（ScvO2）和乳酸清除率、急性生理和慢性健康评分（APACHEⅡ）评分。其后观察第3天APAcHEⅡ变化、需要进行连续性肾脏替代治疗（CRRT）的例数、机械通气时间、ICU住院时间及28d病死率。结果两组28d病死率差异无统计学意义（x^2=0．240，P=0．624）。但是在存活患者中，与对照相比较，研究组患者ICU住院时间、机械通气时间缩短（t=2．166，P=0．041；t=2．104，P=0．046），第3天APACHEⅡ评分降低（t：2．20，P=0．038），需要进行CRRT的例数无统计学差异。在存活患者中，研究组的CVP、ITBVI、GEDVI、CI、乳酸清除率均明显高于对照组（t=2．759，P=0．011；t=2．146，P=0．043；t=2．199，P=0．038；t=2．654，P=0．014;t=3．362，P=0．003），EVLWI和ApacheⅡ评分差异无统计学意义。结论在机械通气状态下老年脓毒症患者液体复苏治疗中，以SVV作为复苏目标的液体复苏方案，较以CVP为指导的EGDT方案达到更好的复苏效果，并在一定程度上改善预后。

Objective To investigate the clinical values of central venous pressure （CVP） versus stroke volume variation （SVV） in patients with severe sepsis after early goal-directed therapy （EGDT）. Methods Totally 30 mechanically ventilated patients with severe sepsis who underwent goal-achieved EGDT were enrolled and randomly divided into CVP group （study group） and SVV group （control group） according to the data detected by pulse contour continuous cardiac output （PiCCO） analysis device. The differences in 28-day survival, 3-day APACHE Ⅱ score, time of ICU stay, duration of mechanical ventilation, number that need CRRT, entral venous pressure （CVP）, heart end-diastolic volume index （GEDVI）, intrathoracic blood volume index （ITBVI）, extravascular lung water index （EVLWI）, cardiac index （CI）, central venous oxygen saturation （ScvO2）, lactate clearance rate and APACHEⅡ score were compared between the 2 groups. Results The death rate had no difference between the 2 groups（x2：0. 240,P=0. 624）. Among survival patients in the CVP group, the time of ICU stay and duration of mechanical ventilation were shorter in study group than in control group（t= 2. 166,P=0.041;t= 2. 104, P= 0.046）, APACHE Ⅱ score at 3th day was decreased（t= 2.20,P= 0. 038）. The values of ITBVI, GEDVI, CI, lactate clearance rate were higher in study group than in control group （t=2.759, 2.146, 2.199, 2.654, 3.362, P=0.011, 0.043, 0. 038, 0. 014, 0. 003）. EVLWI and APACHEⅡ score were not different （P〉0.05） between the two groups. Conclusions SVV as a recovery target for fluid resuscitation can reach a better recovery results and improvement of prognosis than CVP goal-achieved EGDT.