PiCCO指导心功能不全合并脓毒症休克患者精准救治的效果

PiCCO guided precise treatment in septic shock patients with cardiac insufficiency

目的探讨脉搏指示连续心排血量监测(PiCCO)技术在指导心功能不全合并脓毒症休克患者进行液体复苏的临床效果。方法采用前瞻性随机对照研究方法,以2019年6月至2022年12月东台市人民医院ICU收治入院的154例心功能不全合并脓毒症休克患者作为研究对象,随机将其分为研究组(79例)与对照组(75例)。研究组选用PiCCO技术开展液体复苏,对照组按照Rivers提出的经典早期目标导向治疗(EGDT)方案进行复苏。记录并比较2组患者液体复苏达标所需液体总量、各个时间节点的乳酸(Lac)水平、Lac清除率、机械通气时间、ICU 14 d病死率及28 d病死率。结果复苏后指标:(1)研究组液体复苏达标所需液体总量为(2602±1086)ml,对照组为(3296±919)ml,2组比较差异有统计学意义(P<0.05)。(2)复苏后6 h 2组中心静脉压(CVP)均较初始CVP提升(P<0.05),但2组间比较差异无统计学意义(P>0.05),24 h研究组CVP水平较对照组降低,差异有统计学意义(P<0.05)。(3)研究组6 h Lac水平为(4.44±1.67)mmol/L,对照组为(5.03±1.74)mmol/L,2组Lac水平均较初始水平下降,且研究组6 h及24 h Lac水平均明显低于对照组,差异有统计学意义(P<0.05);各个时间点研究组Lac清除率明显高于对照组,差异有统计学意义(P<0.05)。(4)不同时间点平均动脉压(MAP)均较初始MAP提升,但差异无统计学意义(P>0.05)。心功能指标:研究组6 h的N末端脑利尿钠肽前体(NT-pro BNP)及心肌肌钙蛋白Ⅰ(cTnI)水平均低于对照组,差异有统计学意义(P<0.05),24 h 2组均较初始数值下降,但差异无统计学意义(P>0.05)。血管活性药物用量:研究组较对照组可以明显减少去甲肾上腺素(NE)的使用量,差异有统计学意义(P<0.05)。预后指标:研究组较对照组可以显著缩短机械通气时间,差异有统计学意义(P<0.05),但在远期预后指标中,2组14 d及28 d病死率差异无统计学意义(P>0.05)。结论PiCCO技术在指导心功能不全合并脓毒症休克患者液体复苏中具有重要临床价值,可以尽可能地减少达标所需的液体总量,减轻肺水肿和心脏负荷,改善组织灌注。

Objective To investigate the application of pulse-indicated continuous cardiac output(PiCCO)guided fluid resuscitation in septic shock patients with cardiac insufficiency.Methods One hundred and fifty four septic shock patients with cardiac insufficiency in Department of Intensive Care Unit of Dongtai People's Hospital from June 2019 to December 2022 were randomly divided into research group(79 cases)and control group(75 cases).PiCCO guided fluid resuscitation in research group was compared the River's early goal-directed therapy(EGDT)guided fluid resuscitation in the control group.The total resuscitated fluid,lactic acid and lactate clearance at each time point,duration of mechanical ventilation,morality in ICU and mortality at 28 day were recorded and compared between two groups.Results After resuscitation:(1)In terms of the total amount of resuscitation fluid,(2602±1086)ml in research group and(3296±919)ml in control group,there was significant difference between 2 groups(P<0.05);(2)In terms of central venous pressure(CVP),there was no significant difference(P>0.05)at initial time point,but much lower after 24 h in research group with significant difference(P<0.05);(3)In terms of lactated and lactate clearance,lactate level at 6 hour was(4.44±1.67)mmol/L in research group and(5.03±1.74)mmol/L in control group,all 2 groups had decreased lactate levels compared with the initial levels,and lactate level at 6 and 24 hour were lower in research group,with significant differences(P<0.05);Lactate clearance rate was significantly higher in research group than that in the control group at each time point,with significant differences(P<0.05);(4)The mean arterial pressure(MAP)at different time points was increased compared with the initial MAP,but there was no statistically significant difference(P>0.05).N terminal pro-brain natriuretic peptide(NT-proBNP)and cardiac troponin I(cTnI)at 6 hour were lower in research group than those in the control group with significant differences(P<0.05).In terms of dose of vasoactive drugs,dose of norepinephrine was significantly reduced in research group,with significant differences(P<0.05).In terms of prognosis,duration of mechanical ventilation was significantly lower in research group,with significant differences(P<0.05),but there was no significant difference in motalities(P>0.05).Conclusion PiCCO has important clinical value in guiding fluid resuscitation in septic shock patients with cardiac insufficiency,by reducing total amount of resuscitation fluid,decreasing lung water and cardiac preload,but still improving tissue perfusion.