连续右心容量监测指导感染性休克的液体复苏

Fluid resuscitation in elderly patients with septic shock guided by right ventricuinr end-diastofic volume index

目的比较以右房压（right atria pressure，RAP）和右室舒张末期容积指数（right ventricular end-diastolic volume index，RVEDVI）指导老年感染性休克患者液体复苏的效果。方法前瞻性、随机、对照临床研究。入选2007年1月至2008年10月入住浙江医院重症加强治疗病房，低血压发生时间〈6h的老年感染性休克患者30例，应用改良的容量性肺动脉导管连续同步监测容量和压力的变化，指导液体复苏。随机分为对照组和实验组，对照组的治疗目标为RAP8～12mmHg，实验组的治疗目标为右室射血分数（right ventricular ejection fraction，RVEF）校正的RVEDVI达到100～200mL／m^2。记录液体复苏治疗前后两组患者RAP、肺动脉嵌顿压（pulmonary artery occlusion pressure，PA（）P）、RVEF、RVEDVI等参数；记录治疗前后两组患者急性生理和慢性健康评分（acutephysiologyandchronichealthe—valuationⅡ，APACHEII）和混合静脉血氧饱和度（mixed venous oxygen saturation，SvO2）的变化；记录治疗前两组患者动脉血乳酸浓度及治疗后6h乳酸清除率；并将液体复苏治疗后6hRVEDVI差值与乳酸清除率作相关分析。结果对照组液体复苏15例达标12例，达标率为80％，实验组液体复苏15例达标13例，达标率为86．7％，两组差异无统计学意义（P〉0．05）。液体复苏达标患者中，实验组与对照组相比，RVEDVI、RVEDVI差值、RVEF（％）、RAP和6h乳酸清除率（％）明显增高[（119．92±15．65）111L／n12，（38．54±6．63）ⅡlL／m2，（36．08±3．40），（14．46±1．13）mmHg，（58．31±13．36）vs．（99．92±11．71）mL/m^2，（21．00±11．01）mL／m^2，（32．42±2．47），（13．08±1．08）mmHg，（43．99±16．26）；P〈0．05]，但PAOP、APACHEⅡ和SvO2差异无统计学意义（P〉0．05）。液体复苏治疗6h后两组患者RVEDVI差值与乳酸清除率显著相关（P〈0．01）。结论以RVEDVI指导老年感染性休克患者液体复苏与传统的以PAP心为指导的液体复苏相比，复苏过程更安全，对乳酸清除率的改善更为满意，可能更好地改善全身组织灌注与氧合。

Objective To assess the effects of fluid resuscitation in elderly patients with septic shock by right ventricular enddiastolic volume index （RVEDVI）. Method Thirty elderly patients with septic shock within 6 hours after onset, admitted to intensive care unit of Zhejiang Hospital from January 2007 to October 2008, were randomly divided into control group （ n = 15） and experimental group （ n = 15）. Homodynamic profile of the right ventricular was monitored by using modified Swan-Ganz catheter. Fluid resuscitation was given to the patients of control group monitored by right atria pressure （RAP）. The expected efficacy of treatment was the RAP elevated to 8 - 12 mmHg. The goal of fluid resuscitation in patients of experimental group was 100 - 200 mL/m^2 RVEDVI corrected by right ventricular ejection fraction （RVEF）. RAP, pulmonary artery occlusion pressure （PAOP）, RVEF, RVEDVI, acute physiology and chronic health evaluation Ⅱ（APACHE Ⅱ ） and mixed venous oxygen saturation （SvO2） were recorded before and after the treatment for 6 hours in both groups. The concentration of lactate and the lactate clearance rate of patiennts in beth groups after fluid resuscitation were detected. The relationship between lactate clearance rate and △RVEDVI was evaluated by using correlation analysis. Results The percentage of patients reaching goal of resuscitation in experimental group （ 86.7 % ） was higher than that in control group （80%）, however, there was no significant difference statistically. In goals-achieving group, RVEDVI, △RVEDVI, RVEF（ % ）, RAP and lactate clearance rate（ % ） of the patients in experimental group were significantly higher than those in control group [ （ 119.92 ± 15.65） mL/m^2, （38.54 ± 6.63） mL/m^2, （36.08 ± 3.40）, （14.46± 1.13）mm/Hg,（58.31± 13.36） vs. （99.92± 11.71） mL/m^2,（21.00± 11.01） mL/m^2,（32.42±2.47）, （ 13.08± 1.08） mmHg, （43.99 ± 16.26） ; P 〈 0.05 ]. However, there was no significant difference in PAOP, APACHE Ⅱ and SvO2 between two groups （P 〉 0.05）. The lactate clearance rate in goals-achieving patients with septic shock has a significant correlation with RVEDVI and △RVEDVI （P 〈 0.01 ）. Conclusions Huid resuscitation guided by RVEDVI in elderly patients with septic shock is safe and more effective than that guided by RAP.