容量与压力指标对照监测指导老年感染性休克液体复苏对氧代谢的影响

Assessment of fluid resuscitation in elderly patients with septic shock by volume combined with pressure parameters

目的 比较以压力指标右房压（RAP）和容量指标右室舒张末期容积指数（RVEDVI）指导老年感染性休克患者液体复苏的效果,并观察达标过程中其对氧代谢的影响.方法 将收治的45例老年感染性休克患者随机分为对照组（22例）和实验组（23例）,对照组的治疗目标为使RAP值达到12mmHg,实验组的治疗目标为经右室射血分数（RVEF）校正后的RVEDVI值达到100~200ml/m2;并记录两组患者经液体治疗前、后的RAP、肺动脉嵌顿压（PAOP）、RVEF、RVEDVI等参数和急性生理、慢性健康评分（APACHE II） 及混合静脉血氧饱和度（SvO2）的变化,同时记录治疗前后两组患者的动脉血乳酸浓度,并计算治疗后6h时的乳酸清除率,后将液体复苏治疗后6h的RVEDVI差值与乳酸清除率作相关分析.结果 实验组和对照组液体复苏达标率（分别为86.9%和81.8%）的差异无统计学意义（P ＞0.05）.在液体复苏达标的患者中,实验组的RVEDVI、RVEDVI差值、RVEF、RAP和治疗后6h的乳酸清除率均较对照组增高（均P＜0.01）,而两组患者的PAOP、APACHE II和SvO2的差异则均无统计学意义（均P ＞0.05）.液体复苏治疗6h后两组患者RVEDVI差值与乳酸清除率呈相关性（P＜0.01）;达标患者乳酸清除率与复苏后SvO2呈相关性（P＜0.05）.结论 以RVEDVI指导老年感染性休克患者液体复苏,较传统的压力指标RAP更安全、有效,可更好改善氧代谢.

Objective To assess the effects of fluid resuscitation therapy in elderly patients with septic shock by right ventricular end-diastolic volume index （RVEDVI） and right atria pressure, （RAP）. Methods Fourty-five elderly patients with septic shock, enrolled in intensive care unit, were randomly divided into control group （n=22） and experimental group （n =23）. Fluid resuscitation treatment was given to the patients in control group monitored by right atria pressure （RAP）. The treatment destination was RAP 12 mmHg. The resuscitative destination of patients in experimental group is RVEDVI corrected by right ventricular ejection fraction （RVEF）, 100-200 ml/m〈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 in both groups. The concentration of lactate and the lactate clearance rate 6 h after fluid resuscitation of two groups of patients were detected. Finally, the relationship between ARVEDVI and lactate clearance rate was evaluated using correlation analysis. Results The percent of patients reaching resuscitation destination in experimental group （86.9%） was higher than those in control group （81.8%）, however, there was no significant difference statistically. In goals-achieving group, RVEDVI, ARVEDVI ,RVEF, RAP and lactate clearance rate of the patients in experimental group were significantly higher than those in control group. However, there was no significant difference in PAOP,APACHE II and SvO2 between two groups（P〉0.05）. Correlation analysis showed that the level of lactate clearance rate of goals-achieving patients has a significant correlation with RVEDVI and △RVEDVI （P〈0.01）. Conclusion Fluid resuscitation therapy guided by RVEDVI in elderly patients with septic shock is safe and more effective than that guided by RAP.It may improve better oxygen metabolism.