液体复苏对感染性休克患者内稳态及APACHE Ⅱ评分的影响及其意义

Effects of Fluid Resuscitation on Homeostasis and Acute Physiology and Chronic Health EvaluationsⅡof Patients with Septic Shock

目的观察液体复苏对感染性休克患者血气分析、酸碱平衡、电解质、急性生理和慢性健康状况评估Ⅱ(APACHEⅡ)评分的影响,进而分析它们与复苏液体总量的相关性,并探讨其临床意义。方法 24h达标(中心静脉压8～12mmHg、平均动脉血压≥65mmHg)复苏治疗21例符合本研究入选标准的感染性休克患者,前瞻性自身比较复苏治疗前及复苏治疗24h后血气分析、酸碱平衡、电解质及APACHEⅡ评分,直线回归分析电解质、酸碱、血气分析指标及APACHEⅡ评分与复苏液体总量的相关性。结果 21例感染性休克患者24h内复苏液体总量为(7775±1735)mL(5320～11028mL),复苏达标时间为(18.09±4.57)h。复苏治疗24h后血Na+(mmol/L)和Cl-(mmol/L)均较治疗前明显升高(Na+:138.71±5.67比135.62±7.23,P=0.024;Cl-:109.10±4.90比101.67±8.59,P=0.000);血pH值、红细胞比容(Hct,%)、阴离子隙(AG,mmol/L)、乳酸(mmol/L)及APACHEⅡ评分(分)均较治疗前明显下降(pH:7.31±0.05比7.37±0.06,P=0.000;Hct:28.48±2.56比32.76±9.19,P=0.049;AG:8.33±3.45比14.17±8.83,P=0.004;乳酸:1.66±0.89比2.96±1.23,P=0.001;APACHEⅡ评分:10.90±3.73比17.24±4.06,P=0.000)。血Cl-水平与复苏液体总量呈正相关(r=0.717,P<0.01)、其余电解质、酸碱、血气分析指标及APACHEⅡ评分与复苏液体总量无相关性(P>0.05)。结论感染性休克患者应制定适宜的液体复苏目标,并监测内环境的变化,尽可能控制晶体液输入量及不良内环境影响。复苏治疗减轻病情与输注液体总量无明显相关。

Objective To evaluate the effects and the clinical significances of liquid resuscitation on blood gas analysis,acid-base balance,electrolytes,acute physiology and chronic health evaluationsⅡ（APACHEⅡ） score of patients with septic shock,and then to analyze the relations between serum chlorine（Cl-） level and APACHEⅡscore and the volume of liquid resuscitation.Methods According to the target of resuscitation（centre venous pressure 8-12？mm Hg and mean arterial pressure≥65？mm Hg）,21 patients with septic shock received enough fluid for resuscitation during 24？h.The results of blood gas analysis,acid-base balance,electrolytes,and APACHE Ⅱ score were compared between pre-resuscitation and 24？h post-resuscitation by self-controlled prospective study.The relationships of the level of serum Cl-and APACHEⅡ score with the volume of liquid used in resuscitation were analyzed.Results The mean resuscitation duration was（18.09±4.57） h,and the volume of liquid during 24 h resuscitation was 5 320-11 028？mL with mean volume of（7 775±1 735） mL in 21 patients with septic shock.Serum sodium（Na＋,mmol/L） and Cl-？（mmol/L） levels of post-resuscitation were significant higher than those of pre-resuscitation（Na＋：138.71±5.67 versus 135.62±7.23,P=0.024;Cl-：109.10±4.90 versus 101.67±8.59,P=0.000）.Compared with the levels of pre-resuscitation,the blood pH value,hematocrit（Hct,%）,anion gap（AG,mmol/L）,lactic acid（mmol/L）,and APACHE Ⅱ score significantly decreased（pH：7.31±0.05 versus 7.37±0.06,P=0.000;Hct：28.48±2.56 versus 32.76± 9.19,P=0.049;AG：8.33±3.45 versus 14.17±8.83,P=0.004;lactic acid：1.66±0.89 versus 2.96±1.23,P= 0.001;APACHEⅡ：10.90±3.73 versus 17.24±4.06,P=0.000） after 24？h resuscitation.The correlation analysis showed that the level of serum Cl-was positively correlated with the volume of liquid used in resuscitation（r=0.717, P0.01）.However,there was no correlation between APACHEⅡscore and the volume of liquid used in resuscitation（P 0.05）.Conclusions The target of liquid resuscitation in patients with septic shock should be cautiously determined,including control of the volume of crystal liquid for resuscitation,in order to avoid acid-base imbalance or hyperchloraemia.At the same time,the change in internal environment should be monitored.An optimistic fluid resuscitation to decrease APACHE Ⅱ score in patients with septic shock is unrelated to the volume of liquid resuscitation.