ScVO2联合乳酸清除率指导脓毒症休克患者的容量复苏

Efficacies of fluid resuscitation as guided by lactate clearance rate and central venous oxygen saturation in patients with septic shock

目的 评估中心静脉血氧饱和度（ScvO2）联合乳酸清除率（LC）指导脓毒症休克患者液体复苏的效果.方法 2012年6月至2014年6月浙江医院重症医学科纳入脓毒症休克患者100例,按照随机数字表法分为研究组及对照组,每组50例.患者诊断脓毒症休克后立即给予积极的对症处理,参照2008年严重脓毒症及脓毒症休克指南,并依据具体情况,尽早开始液体复苏.研究组使中心静脉压（CVP） ≥8 mmHg（1 mmHg =0.133 kPa）、平均动脉压（MAP） ≥65 mmHg、尿量≥0.5 ml·kg-1·h-1、ScvO2≥70％,LC≥10％或血乳酸≤2 mmol完成液体复苏,对照组使CVP≥8 mmHg、MAP≥65 mmHg、尿量≥0.5 ml·kg-1·h-1、ScvO2≥ 70％完成液体复苏.一直持续到所有相应指标达标,或达到6h.记录两组患者的一般情况及液体复苏使CVP,MAP,尿量,ScvO2以及LC或血乳酸水平的变化情况,以及相关预后指标.结果 两组脓毒症休克患者一般资料差异无统计学意义.研究组28 d死亡率40％,对照组56％,两组之间死亡率的差异无统计学意义（P≥0.05）,但研究组病死率低于对照组.研究组机械通气时间及ICU住院时间均低于对照组[机械通气时间（11.2±17.1）d比（15.8±14.2）d,P=0.150];ICU住院时间[（13.2±17.1）d比（24.0±18.3）d,P=0.003）].研究组28 d死亡率与乳酸清除率及ScvO2达标之间相关性差异有统计学意义（x2=10.930,P=0.001）,对照组28 d死亡率与ScvO2达标之间相关性差异有统计学意义（x2=6.395,P=0.011）.所有患者单独ScvO2达标与28 d死亡率之间相关性差异有统计学意义（x2=14.530,P=0.000）,单独乳酸清除率达标与28 d死亡率之间相关性差异无统计学意义（x2=1.175,P=0.278）.结论 联合乳酸清除率及ScvO2可用于指导脓毒症休克患者的早期液体复苏治疗.两者联合较单独的ScvO2用于指导脓毒症休克患者的液体复苏更加准确,安全和可靠.

Objective To estimate the efficacies of fluid resuscitations as guided by lactate clearance rate （LC） and central venous oxygen saturation （ScvO2） in patients with septic shock.Methods 100 patients diagnosed with septic shock from June 2012 to June 2014 in department of critical care medicine of sixteen hospitals were enrolled.They were randomly divided into two groups of study and control （each n =50）.After a diagnosis of sepsis shock,they were treated symptomatically timely and fluid resuscitation was started as early as possible according to the 2008 Guideline for Managing Sepsis ＆ Septic Shock.Central venous pressure （CVP） ≥8 mmHg （1 mmHg =0.133 kPa）,mean arterial pressure （MAP） ≥65 mmHg,urine output ≥ 0.5 ml · kg-1 · h-1,ScvO2 ≥70％ and LC ≥ 10％ （or lactate ≤ 2.0 mmol） served as target values for fluid resuscitation therapy in study group versus CVP ≥8 mmHg,MAP ≥65 mmHg,urine output ≥ 0.5 ml · kg-1 · h-1 and ScvO2 ≥70％ in control group.The general conditions and clinical characteristics,changes in CVP,MAP,urine output,ScvO2,lactate level and/or LC before （0 hour） and every hour （1-6 h） after the start of fluid resuscitation and other related outcome indicators were recorded.Results No significant difference existed in general data.The 28-day mortality was 40％ for study group versus 56％ for control group.There was no significant inter-group difference （P ＞ 0.05）.The time of mechanical ventilation and length of intensive care unit （ICU） stay were lower in study group than those in control group [mechanical ventilation time （11.200-± 17.069） vs （15.760 ± 14.215）,P =0.150 ; length ofICU stay （13.240 ± 17.127） vs （23.980 ± 18.298）,P =0.003].The 28-day mortality was independently associated with LC and ScvO2 reaching target values for fluid resuscitation in study group （x2 =10.930,P =0.001） while the 28-day mortality was independently associated with ScvO2 reaching target value for fluid resuscitation in control group （x2 =6.395,P =0.011）.Among all patients,the 28-day mortality was independently associated with ScvO2 reaching target value for fluid resuscitation （x2 =14.530,P =0.000）,but not LC （x2 =1.175,P =0.278）.Conclusion A combination of LC and ScvO2 may serve an index in confirming the endpoint of fluid resuscitation for patients with septic shock.Fluid resuscitation therapy under the guidance of LC and SevO2 is more accurate and reliable than the guidance of ScvO2 alone.