早期目标乳酸清除率对肺部感染致脓毒性休克治疗的作用

The effect of early goal lactate clearance rate on the outcome of septic shock patients with severe pneumonia

目的观察以10％、30％乳酸清除率与早期目标导向治疗（EGDT）为6h复苏标准，指导肺部感染致脓毒性休克治疗的临床意义。方法采用随机、前瞻性研究，选择严重肺部感染致脓毒性休克患者，按随机数字表法分为对照组及10％和30％乳酸清除率2个试验组。对照组采用脓毒性休克国际指南的6hEGDT方案治疗；试验组除遵照EGDT治疗标准外，分别加用10％或30％乳酸清除率两种目标为6h治疗目标。结果对照组共人选19例，试验组共入选43例，其中10％乳酸清除率组22例，30％乳酸清除率组21例，3组患者基本情况比较无明显差异。治疗后48h患者的急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分（分）无论是10%乳酸清除率组（13．76±6．00）或30％乳酸清除率组（13．60±6．18）均显著低于对照组（18．15±6．62，均P〈O．05）。3组机械通气时间（h）比较差异无统计学意义（10％组136．90±100．02，30％组97．00±75．20，对照组152．32±96．51，P〉O．05）。10％和30％乳酸清除率组重症监护病房（ICU）住院时间（d）均较对照组明显缩短（10％组7．94±6．00，30％组7．51±3．99，对照组11．31±5．97，均P〈0．05）。与对照组相比，10％和30％乳酸清除率组7d病死率（10％组18．18％，30％组14．29％，对照组21．05％）差异无统计学意义（均P〉O．05）；但10％和30％乳酸清除率组均可降低患者28d病死率（10％组36．36％，30％组28．57％，对照组63．16％），尤其是以30％乳酸清除率组降低更为明显（P〈0．05）。结论对于肺部感染所致脓毒性休克的液体复苏治疗，在完成EGDT的前提下进一步以早期乳酸清除率目标指导液体复苏更具有临床意义，并且应尽可能将6h乳酸清除率达到30％以上。

Objective To observe the clinical effects of 10%, 30% lactate clearance rate and early goal-directed therapy （EGDT） as 6-hour resuscitation goals directing treatment in septic shock patients with severe pneumonia. Methods In this randomized, perspective study, septic shock patients with severe pneumonia were divided into control group and experimental group, which included 10% lactate clearance rate group and 30% lactate clearance rate group, adopting random number method. The control group was treated with 6-hour EGDT strategy, and the experimental groups were treated with 10% lactate clearance rate protocol and 30% lactate clearance rate protocol respectively, beside the EGDT. Results There were 19 patients in control group, and 43 patients in experimental group,, which included 22 patients in 10% lactate clearance rate group and 21 patients in 30% lactate clearance rate group. Patients were well matched by basic features. After 48 hours, the acute physiology and chronic health evaluation Ⅱ （APACHE Ⅱ ） score of both 10% lactate clearance rate group （ 13.76 ± 6.00, P〈0.05 ） and 30% lactate clearance rate group （ 13.60 ±6.18, P〈0.05 ） were lower than that of control group （ 18.15 ± 6.62）. There were no differences in time of mechanical ventilation （hours） between control group and experimental group （ 10% group 136.90± 100.02, 30% group 97.00 ± 75.20, control group 152.32± 96.51, P〉0.05 ）. The length in intensive care unit （ICU, days） of 10% and 30% lactate clearance rate groups were significantly shorter than control group （ 10% group 7.94 ± 6.00, 30% group 7.51 ±3.99, control group 11.31±5.97, both P〈0.05）. The three groups had no differences in 7-day mortality rate （ 10% group 18.18%, 30% group 14.29%, control group 21.05%, all P〉0.05 ）, but the 28-day mortality of 10% and 30% lactate clearance rate groups were significantly lower than control group （ 10% group 36.36%, 30% group 28.57%, control group 63.16% ）, especially in 30% lactate clearance rate group （P〈0.05）. Conclusion For the septic shock patients with severe pneumonia, prompt arehiving EGDT strategy and 6-hour lactate clearance more than 30% were associated with an optimal outcome.