液体管理对感染性休克合并急性肺损伤患者预后的影响

Fluid management improves the prognosis of septic shock complicated by acute lung injury

目的感染性休克早期根据早期目标性治疗(early goal-directed therapy,EGDT)进行液体管理能有效改善患者预后已得到大家共识,最近研究表明感染性休克后期限制性液体管理同样可以改善患者预后。文中探讨感染性休克合并急性肺损伤(acute lung injury,ALI)患者早期及后期液体管理与预后的关系。方法采用回顾性研究的方法,将2009年9月至2011年8月收住南京大学医学院附属鼓楼医院ICU的感染性休克合并ALI患者67例患者纳入研究,以入ICU后6 h内液体复苏后实现中心静脉压(central venous pressure,CVP)>8 mmHg(1 mmHg=0.133 kPa)且中心静脉血氧饱和度(ScvO2)>70%者为早期液体复苏达标(early fluid loading,EFL),入ICU后3 d内至少1 d液体负平衡的则为后期限制性液体管理达标(conservative fluid management,CFM)。结果死亡组与存活组入组前6h液体平衡量无明显差异(P>0.05),死亡组患者3d内每日液体平衡量均为正平衡,并高于存活组(P<0.01),且3 d内累计液体量高于存活组(P<0.01),存活组第2天即出现液体负平衡。EFL达标组生存时间明显高于EFL未达标组(P<0.05),CFM达标组生存时间明显高于CFM未达标组(P<0.05),符合EFL和CFM的患者死亡率最低,只符合EFL或只符合CFM的患者死亡率次之,EFL和CFM均不符合的患者死亡率最高,APACHEⅡ评分、EFL未达标以及CFM未达标均为独立死亡危险因素。结论感染性休克合并ALI患者早期充足液体复苏联合后期限制液体复苏能更好改善患者预后。

Objective It is commonly accepted that fluid management according to early goal-directed therapy （EGDT） in early septic shock can improve the prognosis, and recent research suggests that restricted fluid management in late septic shock can achieve the same result. This study was to determine the value of early and late fluid management in the prognosis of septic shock com- plicated by acute lung injury （ALI）. Methods We retrospectively analyzed 67 cases of septic shock complicated by ALI, which were enrolled on the requirement of meeting the definition of ALI within 72 h after septic shock onset. Early fluid loading （EFL） was defined as the administration of an initial fluid bolus for a central venous pressure of 〉 8 mmHg and ScvO2 〉 70% within 6 h, and conservative fluid management （CFM） defined as negative fluid balance measured in at least 24 h during the first 72 h. Results The fluid balance of the first 6 h in the non-survivors showed no significant difference from that in the survivors （ P 〉 0.05 ）. The daily fluid balance and cumulative daily fluid balance of the first 72 h were markedly higher in the non-survivors than in the survivors （P 〈 0.01 ）, and the latter exhibited negative fluid balance on the 2nd day. The survival time was significantly longer in the up-to-EFL and -CFM groups than in the not-up-to-EFL and -CFM groups （P 〈 0.05 ）. Hospital mortality was the lowest in the former two groups, the highest in the latter two, and next came the up-to-EFL only or up-to-CFM only group. Multivariate analysis identified APACHE ITscores, not-up-to-EFL and not-up-to-CFM as independent risk iactors for hospital mortality. Conclusion Early combined with late fluid management can even better improve the prognosis of septic shock with ALI.