左心室-主动脉偶联在难治性感染性休克复苏中的意义

Left ventricular-arterial coupling in the resuscitation of refractory septic shock

目的探讨左心室-主动脉偶联在难治性感染性休克复苏中的意义。方法回顾分析2010年1月至2011年7月北京协和医院重症医学科收治的难治性感染性休克患者58例。根据28d生存状况分存活组和死亡组，记录初始及治疗24h后血流动力学参数、动脉血乳酸、APACHEⅡ评分及28d生存状况。结果死亡组初始及24h点APACHEⅡ评分，24h有效主动脉弹性／左心室收缩末弹性变化值（AEa／Ees）高于存活组，乳酸清除率（rLac）低于存活组，差异有统计学意义。二分类Logistic回归分析，AEa／Ees是难治性感染性休克患者死亡的独立危险因素，且OR值高于APARCHEⅡ评分（2．0比1．6），ROC曲线下面积为0．705（95％C10．569—0．841，P=0．007）。ΔEa／Ees〉0组24h点心输出量、每搏量、EGDT达标率及rLac低于ΔEa／Ees≤0组，28d病死率高于后者，差异均有统计学意义。AEa／Ees与△心指数、△心搏指数和rLac呈负相关。结论AEa／Ees具有良好的评估难治性感染性休克预后的作用，降低Ea／Ees对EGDT达标、乳酸清除及生存状况改善有积极意义。

Objective To explore the role of left ventricular-arterial coupling in the resuscitation of refractory septic shock. Methods A total of 58 patients with refractory septic shock admitted from January 2010 to July 2011 were retrospectively studied. Hemodynamic data, arterial lactate concentration and APACHE I1 （ acute physiology ＆ chronic health evaluation ]] ） score at the beginning of and 24 hours after cardiac output monitoring, as well as the outcome of Day 28 post-diagnosis were recorded. Stroke volume index （SVI）, cardiac index （CI） and global end diastolic volume index （GEDVI） were obtained through transpulmonary thermodilution technique by a pulse induced continuous cardiac output （PiCCO） system. Left ventricular end systolic volume index （LVESVI） was approximated to （GEDVI/4-SVI） while effective arterial elastance index/ventricular end systolic elastance index （Ea I/Ees I ） was approximated to LVESVI/SVI. Results （ 1 ） APACHE Ⅱ score at the 24th hour, 24 hs lactate clearance rate and 24 hs Ea/ Ees variation （AEa/Ees） were higher in non-survivors than those in survivors; （2） binary Logistic regression analysis showed that AEa/Ees and APACHE ]I score at the 24th hour were the independent risk factors of mortality for refractory septic shock. And the OR value of AEa/Ees was higher than that of APACHE Ⅱ score （2. 04 vs 1.63 ）. Their areas of ROC curve were 0. 705 （ 95% CI 0. 569 - 0. 841, P = 0. 007 ） and 0. 939 （95 % CI 0. 878 - 1. 000, P = 0. 000） respectively ; （ 3 ） all hemodynamic parameters at the beginning had no difference between ΔEa/Ees 〉 0 and AEa/Ees ≤0 groups. CI, SVI, EGDT （early goal- directed therapy） compliance rate at the 24th hour in the ΔEa/Ees 〉 0 group were lower than those in the ΔEa/Ees ≤0 group. The effective arterial elastance index （Ea I ） at the 24th hour and the mortality rate of Day 28 in the ΔEa/Ees 〉0 group were higher than those in the ΔEa/Ees≤0 group; （4） during the 24 hs treatment, AEa/Ees was correlated negatively with the variations of CI, SVI, Ees I and lactate clearance rate and positively with the variations of heart rate, GEDVI, systolic vascular resistance index and Ea Ⅰ. Conclusion ΔEa/Ees may be used as an excellent marker of predicting the outcome of refractory septic shock. Lowing Ea/Ees in resuscitation has beneficial effects on EGDT compliance, lactate clearance and outcome.