老年严重脓毒症及脓毒性休克微循环变化的观察

Microcirculationai changes in elderly septic patients

目的 探讨老年严重脓毒症、脓毒性休克的舌下微循环特点.方法 2011年5月至2012年5月老年脓毒症患者23例及未发生脓毒症的老年重症患者10例,根据病情分成严重脓毒症组（12例）、脓毒性休克组（11例）及非脓毒症组（10例）进行前瞻性研究.另选取10名体检老年人作为对照组.应用旁流暗视野技术（SDF）于入组时及入组后第1、2、3天测定脓毒症患者的舌下微血管（≤25 μm）的灌注血管密度（PVD）、灌注血管比例（PPV）及微血管流动指数（MFI）.观察脓毒症患者的28 d病死率,根据28 d是否死亡,将脓毒症组分成死亡组与生存组,比较两组的PVD、PPV及MFI.结果 与严重脓毒症组相比,脓毒性休克组的28 d病死率较高（54.6％比33.3％）.所有老年患者无论是否发生脓毒症,与对照组相比,入选时舌下PDV、PPV及MFI值均较低并差异有统计学意义（P＜0.05）.非脓毒症组舌下微循环PVD、PPV、MFI较对照组明显降低[PVD：（13.7±4.0）比（19.1±4.0）,PPV：（64.9％±11.8％）比（79.1％±12.2％）,MFI：（2.4±0.5）比（2.9±0.7）,P＜0.05]；严重脓毒症组舌下微循环PVD、PPV、MFI较对照组明显降低[PVD：（12.0 ±4.3）比（19.1±4.0）,PPV：（59.7％±11.8％）比（79.1％±12.2％）,MFI：（2.2±0.6）比（2.9±0.7）,P＜0.05]；脓毒性休克组舌下微循环PVD、PPV、MFI较对照组明显降低[PVD：（7.9±4.2）比（19.1±4.0）,PPV：（48.5％±12.1％）比（79.1％±12.2％）,MFI：（1.7±0.6）比（2.9±0.7）,P＜0.05].脓毒性休克组舌下微循环PVD、PPV、MFI较非脓毒症组及严重脓毒症组均明显降低并有统计学意义.而非脓毒症组与严重脓毒症组舌下PDV、PPV及MFI值差异无统计学意义.脓毒性休克组较严重脓毒症组入组时及诊断后1、2、3d的PDV、PPV及MFI值均较低并有统计学意义,而乳酸值及MAP差异无统计学意义.死亡组较生存组入组时及诊断后第1、2、3天的舌下微循环PVD、PPV、MFI、乳酸水平均明显较低并有统计学意义,而MAP差异无统计学意义.结论 老年脓毒症患者会发生明显的微循环障碍,舌下微循环指标MFI、PVD及PPV是评价脓毒症严重程度的较好指标,微循环障碍的严重程度与老年脓毒症预后明显相关.

Objective To explore the changes of sublingual microcirculation in elderly patients with severe sepsis/septic shock.Methods Twenty-three patients with sepsis,10 patients without sepsis and 10 healthy elderly patients were enrolled.Sublingual microcirculation was evaluated by sidestream darkfield （SDF） imaging.And the 28-day mortality rates of all septic patients were recorded.Results Compared with the healthy group,all elderly patients had significant sublingual microcirculational dysfunctions.Compared with the severe septic and nonseptic patients,perfused vessel density （PDV）,proportion of perfused vessels （PPV）and microvascular flow index （MFI）of septic shocks were significantly lower.Compared with the severe septic patients,PDV,PPV and MFI instead of lactate and MAP of septic shocks were significantly lower from Day 1 to Day 3.The values of PDV,PPV,MFI and lactate but not MAP of the surviving septic patients were significantly higher than those of the deceased ones.Conclusion The elderly patients with septic shock have severe sublingual microcirculatory alterations.And these abnormalities are more marked in septic shock patients.Nonsurvivors showed more severe alterations than survivors.Microcirculatory alterations may be measured to guide the therapy.