β受体阻滞剂对脓毒性休克患者的心脏保护作用及对血流动力学影响的前瞻性研究

Effects of the β-blockers on cardiac protection and hemodynamics in patients with septic shock：a prospective study

目的：探讨β受体阻滞剂对脓毒性休克患者的心脏保护作用及对血流动力学的影响。方法采用前瞻性随机对照研究方法，以2012年1月至2014年1月山东济宁医学院附属湖西医院重症监护病房（ICU）收治的6 h早期目标导向治疗（EGDT）达标的41例脓毒性休克患者为研究对象，并按随机数字表法将患者分为治疗组（21例）和对照组（20例）。两组均按指南继续治疗脓毒性休克，治疗组同时经上腔静脉用微量泵持续泵入艾司洛尔，2 h内控制心率（HR）＜100次/min；对照组不予特殊干预。观察两组患者治疗前及治疗后12、24、48、72 h的血流动力学指标〔平均动脉压（MAP）、中心静脉压（CVP）、HR、心排血指数（CI）、每搏量指数（SVI）、外周血管阻力指数（SVRI）、全心舒张期末容积指数（GEDVI）〕、组织代谢指标〔中心静脉血氧饱和度（ScvO2）、乳酸（Lac）〕和心肌标志物〔心肌肌钙蛋白I（cTnI）〕的变化。结果①两组患者治疗前血流动力学指标、组织代谢指标及cTnI比较差异均无统计学意义（均P＞0.05）。②与治疗前比较，对照组治疗后血流动力学指标无明显改变；治疗组治疗后HR、CI逐渐下降，SVRI、GEDVI逐渐增加，且12 h起即与对照组比较差异有统计学意义〔HR（次/min）：93±4比118±13，CI（L·min^-1·m^-2）：3.3±0.8比4.5±0.6，SVRI（kPa·s·L^-1·m^-2）：159.2±27.4比130.5±24.2，GEDVI（mL/m^2）：668±148比588±103，P＜0.05或P＜0.01〕，而MAP、CVP、SVI均无明显改变。③两组治疗后Lac水平（mmol/L）均明显下降，12 h即与治疗前差异有统计学意义（对照组：8.8±3.2比9.8±3.4，治疗组：9.5±3.1比10.5±4.1，均P＜0.05），72 h时两组分别为2.5±1.2和2.7±1.1；但两组间各时间点比较差异无统计学意义（均P＞0.05）。两组治疗后ScvO2均无明显下降。④与治疗前比较，对照组治疗后cTnI逐渐升高，72 h达峰值；治疗组治疗后cTnI逐渐升高，24 h达峰值后逐渐下降。治疗组治疗后24、48、72 h时cTnI（μg/L）明显低于对照组（1.15±0.57比1.74±0.77、0.93±0.52比2.15±1.23、0.52±0.36比2.39±1.17，均P＜0.01）。结论β受体阻滞剂艾司洛尔能改善脓毒性休克患者心脏顺应性，减轻心肌损伤，虽然能引起心排血量下降，但对循环功能及组织灌注无影响。

Objective To investigate the effects of β-blockers on cardiac protection and hemodynamic in patients with septic shock. Methods A prospective randomized controlled trial was conducted. Forty-one patients with septic shock in accordance with early goal directed treatment and met the target within 6 hours,and admitted to intensive care unit （ICU）of Affiliated Huxi Hospital of Jining Medical College from January 2012 to January 2014 were enrolled. The patients were divided into treatment group （n=21）and control group （n=20）by random number table. The patients in both groups were given the standard treatment,esmolol was giving to patients in treatment group in order to control the heart rate （HR）below 100 bpm within 2 hours,and the patients in control group only received standard treatment. The changes in hemodynamic parameters〔mean arterial pressure（MAP）,central venous pressure（CVP）, HR,cardiac index（CI）,stroke volume index（SVI）,systemic vascular resistance（SVRI）,global end diastolic volume index（GEDVI）〕,biochemistry metabolic of tissue〔central venous oxygen saturation（ScvO2）,lactic acid（Lac）〕,and cardiac markers 〔troponin I （cTnI）〕before and 12,24,48,72 hours after the treatment were recorded. Results①Before treatment,the hemodynamic parameters,tissue metabolism index and cTnI had no significant differences in both groups （all P〉0.05）.②The hemodynamic parameters after treatment in the control group showed no significant difference compared with that before treatment. HR and CI in the treatment group were gradually declined after treatment,SVRI and GEDVI were gradually increased. There were significant differences in HR,CI,SVRI,and GEDVI between treatment group and control group from 12 hours on〔HR（bpm）：93±4 vs. 118±13,CI （L·min^-1·m^-2）：3.3 ±0.8 vs. 4.5 ±0.6,SVRI （kPa·s·L^-1·m^-2）：159.2 ±27.4 vs. 130.5 ±24.2,GEDVI（mL/m^2）：668 ±148 vs. 588 ±103,P〈0.05 or P〈0.01〕. MAP,CVP and SVI in the treatment group showed no significant changes. ③Lac after treatment in both groups was decreased slowly,Lac （mmol/L）at 12 hours after treatment was significantly decreased compared with that before treatment （control group：8.8 ±3.2 vs. 9.8 ±3.4,treatment group：9.5±3.1 vs. 10.5±4.1,both P〈0.05）. The Lac of control group and treatment group were 2.5±1.2 and 2.7±1.1 at 72 hours after treatment,and there was no significant difference between two groups （all P〉0.05）. The ScvO2 was not decreased in both groups.④Compared with before treatment,cTnI in the control group was gradually increased,peaked at 72 hours,and that in the treatment group was gradually increased,peaked at 24 hours and then gradually declined. Compared with control group,the cTnI （μg/L）in the treatment group was decreased significantly at 24,48,72 hours （1.15 ±0.57 vs. 1.74 ±0.77,0.93 ±0.52 vs. 2.15 ±1.23,0.52 ±0.36 vs. 2.39 ±1.17,all P〈0.01）. Conclusionsβ-blockers （esmolol） can improve cardiac function and myocardial compliance,reduce the myocardial injury in patients with sepsis shock. Although β-blockers can decrease cardiac output,it has no influence on the circulation function and tissue perfusion.