更多〉〉相关学者刘大为樊寻梅李建国王仲杜朝晖席修明于学忠周青景亮严静静动脉血二氧化碳分压差指导感染性休克进一步液体复苏

Assessment of advance fluid resuscitation in septic shock patients guided by central venous to arterial carbon dioxide difference

目的探讨中心静脉-动脉二氧化碳分压差[P（cv-a）CO2]在感染性休克复苏治疗患者中心静脉血氧饱和度（ScvO2）目标值已达标情况下,对全身组织灌注指标评价的临床意义.方法选择2010年11月至2012年7月连续46例入住重症加强治疗病房经早期液体复苏,CVP〉8mmHg,ScvO2〉70%的感染性休克患者.根据入组患者 T0时 P（cv-a）CO2的值,以6mmHg 为界,分为低 P（cv-a）CO2组（低差组,24例）和高 P（cv-a）CO2组（高差组,22例）.继续复苏治疗,每6h 进行一次测量,持续12h 以上（T0、T6、T12、T24）.结果 T0时低差组患者的心脏指数（CI）与高差组患者[（4.5±1.5）L/min·m2比（2.8±0.9）L/min·m2]差异有统计学意义（P〈0.01）,但 ScvO2值[（77±6）%比（75±4）%]差异无统计学意义（P 〉0.05）.T0到 T12时段低差组的乳酸清除率均大于高差组（P〈0.05）,T24的序贯器官衰竭估计（SOFA）评分下降程度也大于高差组（P〈0.01）.T0、T6和 T12时段 CI 和 P（cv-a）CO2值呈负相关（r =0.67、0.65、0.65,均 P〈0.01）.结论感染性休克进行液体复苏的患者,ScvO270%目标值虽已达标,但仍不能充分指导治疗.P （cv-a）CO2〉6mmHg 可以作为识别患者复苏不足的有效补充指标,应作为感染性休克患者早期目标导向治疗（EGDT）液体复苏中的达标指标加以重视.

Objective To assess the value of central venous to arterial carbon dioxide difference [P（cv-a）CO2] as a global index of tissue perfusion in resuscitated septic shock patients with the central venous oxygen saturation （ScvO2） goal value has already been reached. Methods 46 consecutive septic shock patients with ScvO2 goal value 〉70% and central venous pres-sure （CVP）〉8 mmHg from November 2010 to July 2012 were divided into Low P（cv-a）CO2 group （Low gap; n = 24） and High P （cv-a）CO2 group （High gap; n = 22） according to a threshold of 6 mmHg. Measurements were performed every 6 h over 12h （T0, T6, T12）. Results There was significant difference between Low gap nd High gap in cardiac index （CI）（4.5±1.5 、2.8±0.9 L/min· m2, P〈0.001） at T0,but no significant difference in ScvO2 values （77±56、75±4%, P = 0.08）. From T0 to T12, the clearance of lac-tate was higher in the Low gap group than the High gap group （P=0.003） as wel as the decreasing degree of SOFA score at T24 （P〈0.01）. At T0, T6 and T12, CI and P（cv-a）CO2 values were negative correlated （P〈0.001）. Conclusion ScvO2 may not be suffi-cient to guide therapy in resuscitated septic shock patients. P（cv-a）CO2 might be another additional target for guidence of thera-py in septic shock when the ScvO2 goal-value come to the standard of 70%.