胸腔内血容量指数在感染性休克患者液体管理中的应用

lntrathoracic blood volume index as an indicator of fluid management in septic shock

目的探讨胸腔内血容量指数（ITBVI）在感染性休克患者液体管理中的应用价值。方法采用前瞻性临床观察研究方法，将入住重症监护病房（ICU）的33例感染性休克患者分为两组。ITBVI组17例患者接受脉搏指示连续心排血量（PiCCO）监测，以ITBVI作为液体管理的指导指标；对照组16例患者以中心静脉压（CVP）作为液体管理的指导指标。对比两组患者治疗1d和3d时的急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分、感染相关器官功能衰竭评分系统（SOFA）评分、血管活性药物评分，以及补液72h内两组患者的液体管理数据。结果①ITBVⅠ组3d时APACHEⅡ、SOFA和血管活性药物评分（分）均较1d时显著下降（21．3±6．2比25．4±7．2，6．1±3．4比9．0±3．5，5．0（0，8．0）比20．0（8．0，35．0），均P〈0．01]；而对照组则均无显著变化。②虽然ITBVⅠ组48～72h液体出量（ml）大于对照组（2421±868比1721±934，P=0．039），但ITBVI组与对照组0～72h的液体出入量和平衡量（ml）比较差异均无统计学意义（入量：9918±137比10529±1331，出量：6035±1739比5827±2897，平衡量：3882±1889比4703±2813，均P〉0．05）。③在快速补液试验中，ITBVⅠ组与对照组患者除0～6h胶体液入量[ml：250（125，500）比250（69，250）3差异无统计学意义（P〉0．05）外，其余时段液体入量（ml）ITBVⅠ组均比对照组高[0～6h晶体液：250（150，250）比125（105，125），6～72h晶体液：125（125，250）比100（56，125），0～72h晶体液：250（125，250）比125（75，125），6～72h胶体液：125（106，250）比75（50，125），0～72h胶体液：200（125，250）比100（50，125），均P〈0．013。结论与以CVP指导相比，用ITBVⅠ指导感染性休克患者的液体管理显示，3d时患者病情较1d改善，这种改善可能得益于对血容量状态的准确判断和适当的快速补液速度。

Objective To investigate the value of intrathoracic blood volume index （ITBVI） monitoring in fluid management strategy in septic shock patients. Methods In a prospective study, 33 patients who were diagnosed to be suffering from septic shock in the intensive care unit （ICU） were enrolled. Seventeen patients who received pulse-indicator continuous cardiac output （PiCCO） monitoring, and ITBVⅠ was used as indicator of fluid management, were enrolled into ITBVI group; 16 patients who received traditional fluid management strategy [directed by central venous pressure （CVP）] were enrolled into control group. Acute physiology and chronic health evaluation Ⅱ（APACHE Ⅱ ） score, sepsis related organ failure assessment （SOFA） score and vasopressor score were compared between 1 day and 3 days of treatment. The characteristics of fluid management were recorded and compared within 72 hours. Results ① In 3 days of treatment, APACHE 1I , SOFA and vasopressor score were significantly lower in ITBVI group compared with that of in 1 day of treatment [21.3±6.2 vs. 25.4±7.2, 6.1±3.4 vs. 9.0±3.5, 5 （0, 8.0） vs. 20.0 （8.0, 35.0）, respectively, all P〈0.01], whereas there were no changes in control group. ② Although fluid output （ml） was higher in ITBVI group during 48 - 72 hours period （2 421± 868 vs. 1 721±934, P=0. 039）, there was no difference in fluid intake, fluid output or fluid balance （ml） within 0-72 hours between two groups （fluid intake：9 918±137 vs. 10 529±1 331, fluid output： 6 035±1 739 vs. 5 827±2 897, fluid balance： 3 882±1 889 vs. 4 703±2 813, all P〉0.05）. ③Comparing the fluid volume （ml） used for fluid replacement period, except that there was no significance in fluid challenge with colloid during 0 -6 hours between two groups [ml： 250 （125, 500） vs. 250 （69,250）, P〉0. 05], more fluid intake （ml） was found in ITBVI group [0 6 hours crystalloid： 250（150,250） vs. 125 （105,125）, 6 -72 hours crystalloid： 125 （125, 250） vs. 100 （56, 125）, 0- 72 hours crystalloid.. 250 （125, 250） vs. 125 （75, 125）, 6-72 hours colloid： 125 （106, 250） vs. 75 （50, 125）, 0-72 hours colloid, 200 （125, 250） vs. 100 （50, 125）, all P〈0. 01]. Conclusion Clinical picture in patients with septic shock is improved after 3 days of treatment than 1 day of treatment under fluid management directed by ITBVI, compared with by CVP. This improvement may be attributable to accurate assessment of preload and appropriate infusion rate in fluid challenge.