内毒素休克幼猪高容量液体复苏后血流动力学和血管外肺水的变化

Changes of the hemodynamics and extravascular lung water after different-volume fluid resuscitation in a piglet model of endotoxic shock

目的探讨高容量液体复苏对内毒素休克幼猪血流动力学和血管外肺水的影响。方法建立内毒素休克动物模型，20只，随机分成三组，出模后1h内给予不同剂量生理盐水复苏，R．组（6只）：40m]／kg；R：组（6只）：80ml／kg；R，组（8只）：120ml／kg。观察全心舒张末期容量指数、胸内血容量指数、心指数、血管外肺水指数的变化。结果（1）全心舒张末期容量指数（ml／m2）：补液后15min时R1组261±64，R2组457±124，R3组413±148；4h时R1组251±68，R2组422±70，R，组470±160，三组间比较差异有统计学意义（F=26．373，P〈0．05）；R。与R：组、与R，组比较，差异均有统计学意义（P〈0．05）；R：与R1组间差异无统计学意义。（2）胸内血容量指数（ml／m2）：补液后15min时R1组335±69，R2组550±179，R3组520±183；4h时R1组314±84，R2组534±96，R，组594±200，三组间比较差异有统计学意义（F=26．466，P〈0．05）；R，与R2组、与凡组比较，差异均有统计学意义（P〈0．05）；R：与凡组间差异无统计学意义。（3）心指数[L／（min·m2）]：补液后15min时R1组4．5±0．7，R2组6．4±2．2，R3组5．5±0．7；4h时R1组4．1±1．0，R2组5．2±0．9，R，组5．1±0．8；三组间比较差异无统计学意义（P〉0．05）。（4）血管外肺水指数（ml／kg）：补液后15min组19．2±8．6，R2组29．2±5．5，R，组23．4±8．2；4h时R1组18．3±6．5，R2组23．8‘2．6，R，组21．4±3．9；三组间比较差异无统计学意义（P〉0．05）。结论内毒素休克早期，高容量补液组能更有效地增加前负荷、维持心输出量在基础水平，同时并未显著增加血管外肺水。

Objective Practice recommendations have evolved, and consensus now exists among leading organizations such as the American College of Critical Care Medicine （ACCM） and Surviving Sepsis Campaign that fluid infusion is best initiated with boluses of 20 ml/kg, commonly requires 40 - 60 ml/kg but can be as much as 200 m[/kg if the liver is not enlarged and/or rales are not heard. The present study aimed to investigate and compare the changes of the hemodynamies and extravascular lung water after higher volume fluid resuscitation in a piglet model of endotoxic shock. Method Twenty piglets were used for establishing animal models of endotoxic shock by intravenous infusing lipopolysaccharide （LPS）. The experimental animals were divided into three groups according to the volume infused during the resuscitation. The three groups received different volume of saline in less than an hour after endotoxic shock. By the PiCCO plus system, we investigated the changes of hemodynamics and extravascular lung water. Result After fluid resuscitation, global end diastolic volumeinder, （GEDI） and intrathoracic blood volumeindex, （ITBI） markedly increased in the group of 80 mL/kg and 120 ml/kg, but there was no change in the group of 40 ml/kg. GEDI：Fifteen min after fluid resuscitation Rt was （261 ±64） ml/m2 ,R2（457 ± 124） ml/m2 ,R3 （413 ± 148） ml/m2 ,4 h R1 （251 ±68） ml/m2 ,R2 （422 ± 70） ml/m2 ,R3 （470 ± 160） m[/m2 ;ITBI：Fifteen min after fluid resuscitation R1 was （335 ±69） ml/m2 ,R2（550 - 179） mL/m2 ,R3（520 ± 183） ml/m2 ,4 h R~ （ 314 ± 84） ml/m2, R2 （ 534 ± 96） nfl/mz, R3 （ 594 ± 200） rnl/m2 （ R1 vs. R2 vs. R3, F = 26. 373, P 〈 0. 05 ; 1：11 vs. R2, R1 vs. IR3, P〈O. 05; R2 vs. R3, P〉0.05）. CI of all three groups significantly decreased when the models were established. After fluid resuscitation,the base level was maintained in the group of 80 rnl/kg and 120 mL/kg, but it was under the basic level in the group of 40 ml/kg. Fifteen rain after fluid resuscitation R, was （4.5±0.7） L/（min. mZ）,R2（6.4 ±2.2） L/（min. mZ）,R3（5.5 ±0.7） L/（min-m2）, 4hR,（4.1 ±1.0） L/（min-m2）,Rz（5.2±0.9） L/（min. m2）,R3（5.1 ±0.8） L/（min ~ mZ）.There was no significant difference in CI between these two groups （ P 〉 0. 05 ）. ELWI of the group of 80 ml/kg and 120 mL/kg were still higher than that of the group of 40 ml/kg, 15 rain after fluid resuscitation R1 was （19.2±8.6） ml/kg,R2（29.2±5.5） ml/kg,R3（23.4 ±8.2） ml/kg,4 h R（18.3±6.5） ml/kg,R2 （23.8 ±2. 6） ml/kg,R3 （21.4 ±3.9） ml/kg,but there was no signifieant difference in ELWI among the groups （ P 〉 0. 05 ）. Conclusion Resuscitation with higher volume of fluid infusion in the early stage of endotoxie shock was more efficient to increase the preload and maintain the cardiac output at the baseline level, and might reduce the need for vasoaetive agents. Meanwhile ,resuscitation with higher volume of fluid in the early stage of endotoxie shock did not sharply increase the extravascular lung water.