利用呼吸末正压观察脉压变异率指导液体治疗的疗效

Effects of fluid therapy by guide of positive end-expiratory pressure combined pulse pressure variation

目的:评价联合应用呼吸末正压(PEEP)及脉压变异率(PPV)在心脏外科术后液体治疗中的作用,比较与液体负荷试验治疗的差异。方法:前瞻性、随机性、对照研究我院从2010年8月～12月间因行二尖瓣置换术后发生低灌注的患者共108例,随机分为液体负荷试验组和PEEP组,各54例。液体负荷试验组按照中心静脉压变化量来补充容量;PEEP组根据增加PEEP后PPV的变化分为两组,PPV≥11%组(30例)给予补液治疗,PPV<11%组(24例)给予维护心功能治疗。比较各组患者治疗前后各监测指标变化。结果:三组入选时的各项指标均无显著性差异(P>0.05);治疗后,与液体负荷试验组比较,PEEP组(PPV≥11%和PPV<11%组)平均动脉压[(55±13)mmHg比(64±9)mmHg、(67±6)mmHg]、脉压[(44±10)mmHg比(59±9)mmHg、(58±10)mmHg],中心静脉氧饱和度[(62±14)%比(72±11)%、(70±8)%]、尿量[(1.4±0.5)ml.kg-1.h-1比(2.1±0.4)ml.kg-1.h-1、(1.8±0.6)ml.kg-1.h-1]、氧合指数[(215±25)比(307±14)、(315±20)]明显增加(P均<0.05),乳酸水平[(2.3±1.0)mmol/L比(1.5±0.8)mmol/L、(1.4±0.9)mmol/L]明显降低,住ICU时间[(4.5±2.1)d比(2.8±1.1)d、(3.1±1.6)d]明显缩短(P均<0.05);PPV<11%组液体输入量明显低于液体负荷试验组和PPV≥11%[(1354±183)ml比(2563±214)ml、(2054±259)ml,P均<0.05]。结论:利用呼吸末正压及脉压变异率指导临床液体复苏治疗较传统的液体负荷试验有效地改善了循环,减少不利影响,缩短住ICU时间。

Objective： To evaluate effect of positive end-expiratory pressure （PEEP） combined pulse pressure variation rate （PPV） in fluid therapy after cardiac surgery and compare with liquid load test. Methods： A total of 108 pa- tients, who admitted in our hospital from Aug 2010 to Dec 2010, occurred hypoperfusion after mitral valve replace- ment, were studied prospectively and randomly. They were randomly and equally divided into liquid load test group and PEEP group. Patients in liquid load test group were supplemented with liquid according to central venous pres- sure; according to change of PPV after increasing PEEP, PEEP group was divided into PPV≥11% group （n = 30, received fluid replacement therapy） and PPV〈11% group （n = 24, received maintenance treatment of cardiac function）. Changes of monitoring indexes were compared among three groups before and after treatment. Results： There were no significant difference in these indexes among three groups before treatment （P〉0.05） ; compared with liq- uid load test group after treatment, there were significant increase in mean arterial pressure [ （55 ± 13） mmHg vs. （64 ± 9） mmHg, （67 ± 6） mmHg], pulse pressure E （44 ± 10） mmHg vs. （59 ± 9） mmHg, （58 ± 10） mmHg], oxygen saturation in central vein [-（62 ± 14） % vs. （72 ± 11） %, （70 ± 8） %], urine amount [ （1.4 ± 0.5） ml kg 1 h-1 vs. （2.1 ±0.4） mlkg-1 h-1, （1.8 ±0.6） mlkg-1 h-1] and oxygenation index[ （215 ±25） vs. （307±14）, （315 ±20）], and significant decrease in level of lactic acid [- （2.3 ± 1.0） mmol/L vs. （1.5 ±0.8） mmol/L, （1.4 ±_ 0.9） mmol/L] and stay time in ICU [（4.5 ± 2.1） d vs. （2.8 ± 1.1） d, （3.1 ± 1.6） d] in PEEP group （PPV∪11% group and PPV〈11% group）, P〈0.05 all; amount of fluid replacement in PPV〈11% group was significantly low- er than those of liquid load test group and PPV≥11% group [ （1354 ± 183） ml vs. （2563 ± 214） ml, （2054 ± 259） ml, P〈0.05 both]. Conclusion： The fluid therapy by guide of positive end-expiratory pressure combined pulse pressure variation rate may effectively improve circulation, decrease adverse influence, and shorten time in ICU.