主动脉内球囊反搏术在感染性休克患者抢救治疗中的应用价值

The clinical application and value of intra-aortic balloon pump in patients with septic shock

目的探讨血管活性药物联合应用主动脉内球囊反搏术（IABP）治疗感染性休克患者的临床疗效及应用价值。方法采用单中心注册研究方法。选择北京世纪坛医院2006年7月至2010年10月人住重症监护病房（ICU）确诊为感染性休克的晚期患者78例，根据患者家属自愿的原则分为单用血管活性药物组（多巴胺＋去甲肾上腺素治疗）和联合IABP组（多巴胺＋去甲。肾上腺素＋IABP治疗）两组，每组39例。两组在治疗前后均行血流动力学及组织灌注监测，同时观察休克恢复时间、血管活性药物用量、住ICU时间、28d死亡情况。结果两组治疗前各监测指标比较差异无统计学意义；两组治疗后心率、血压及心脏功能等指标均较治疗前明显改善。联合IABP组平均动脉压（MAP，mmHg，1mmHg=0．133kPa）在IABP后24h和72h，心排血指数（CI，L·min-1·m-2）在IABP后48h、停用IABP后2h，多巴胺用量（μg·kg-1·min-1）在IABP后24、48、72h和停用IABP后2h的改善程度均明显优于单用血管活性药物组（MAP：53．0±6．3比52．1±6．2，65．6±4．3比65．0±2．1；CI：3．40±0．20比3．30±0．50，3．60±0．30比3．60±0．30；多巴胺用量：17．5±1．2比17．6±1．3，10．2±1．3比12．8±1．6，5．8±1．5比6．8±1．7，3．0±0．7比4．1±1.3，P〈0．05或P〈O．01）；且与单用血管活性药物组比较，联合IABP组患者休克恢复时间（d）明显缩短（10．4±2．2比14．1±3．4），28d病死率明显降低（34．1％比45．6％，均P〈O．01）；两组住ICU时间无明显差异。结论IABP对感染性休克患者能显著改善血流动力学指标，增加冠状动脉及全身组织灌注，减轻心脏后负荷，提高CI，减少血管活性药物用量，对缩短住ICU时间、改善预后、减少患者病死率都有着重要的临床价值，可推荐作为感染性休克患者药物治疗不佳的备选治疗方法。

Objective To investigate the clinical efficacy and value of intra-aortic balloon pump （ IABP ） with vasoactive drugs for septic shock patients. Methods A method of single-centre registry was conducted. Data were collected from 78 consecutive septic shock patients in late stage in intensive care unit （ ICU ） of Beijing Shijitan Hospital diagnosed between July 2006 and October 2010. With the consent of family members of the patients, they were divided into two groups ： group A, in whom only vasoactive drugs were used （dopamine ＋ norepinephrine treatment, n = 39 ）, and group B, in whom vasoactive drugs were used combined with IABP （dopamine ＋ norepinephrine ＋ IABP therapy, n = 39 ）. Before and after treatment of two groups, hemodynamic and tissue perfusion monitoring were executed. At the same time, the shock recovery time, the doses of vasoactive drugs, length of ICU stay, and mortality within 28 days were observed. Results There was no significant difference in all above parameters between two groups. After treatment, heart rate, blood pressure and heart function parameters were significantly improved compared with those before treatment. In group B, mean arterial pressure （MAP, mm Hg, 1 mm Hg =0.133 kPa） 24 hours and 72 hours after IABP, cardiac index （CI, L min-1 m-2） after 48 hours of IABP, and in 2 hours after termination of IABP, dopamine dosage （μg·kg-1·min-1） in 24, 48, 72 hours after IABP and 2 hours after termination were significantly improved than those in group A （MAP： 53.0 ± 6.3 vs. 52.1 ± 6.2, 65.6 ± 4.3 vs. 65.0 ±2.1 ; CI： 3.40 ± 0.20 vs. 3.30 ±0.50, 3.60 ±0.30 vs. 3.60 ±0.30; dopamine dosage： 17.5 ± 1.2 vs. 17.6±1.3, 10.2± 1.3 vs. 12.8± 1.6, 5.8 ± 1.5 vs. 6.8 ± 1.7, 3.0 ± 0.7 vs. 4.1 ± 1.3, P〈O.05 or P〈O.01）. Compared with group A, shock recovery time （days） of group B was significantly shorter （ 10.4 ± 2.2 vs. 14.1 ± 3.4, P〈0.01 ） than that of group A; mortality within 28 days was significantly lower （34.1% vs. 45.6%, P〈0.O1 ） in group B; length of ICU stay of two groups showed no significant difference between two groups. Conclusions IABP in patients with septic shock significantly improved hemodynamics, increased coronary and systemic tissue perfusion, reduced cardiac afterload, elevated CI, reduced doses of vasoactive drugs, shortened length of ICU stay, improved prognosis, and lowered the mortality rate. IABP had important clinical value, and could be recommended as an additional treatment option in patients with septic shock in whom the effect of drug was poor.