艾司洛尔联合米力农对严重脓毒症患者心功能炎性因子及预后的影响

Combination therapy of milrinone and esmolol on heart function, inflammatory factors and prognosis of sepsis patients

目的观察艾司洛尔联合米力农对严重脓毒症患者的治疗效果及探讨其可能作用机制。方法将90例符合严重脓毒症诊断标准且经早期目标导向治疗（EGDT）后心率〉195次／rain的患者，随机分为对照组（C组）、米力农组（M组）和艾司洛尔联合米力农组（ME组）。C组按照脓毒症指南常规治疗。M组在C组常规治疗基础上给予米力农持续静脉泵人，负荷剂量为30μg／kg，然后以0．375—0．5v．s／（kg·min）维持。ME组应用艾司洛尔持续静脉泵入，将患者心率控制在75～94次／min，余治疗方案同M组。采用脉搏指示连续心排血量监测（PiCCO）检测患者心脏指数（CI）及每搏指数（SVI）等心功能指标，同时连续观察治疗前及治疗后12、24、48、72、96h平均动脉压（MAP）、中心静脉压（CVP）、心率（HR）、氧合指数（PaO2／FiO2）和血乳酸（Lac），并检测TNF-α、IL-6、HMGB-1、CK-MB、cTnI及BNP水平。结果治疗前各组MAP、CVP、HR、PaO2／FiO2及Lac比较差异无统计学意义，治疗后各组MAP、CVP及PaO2／FiO2比较差异无统计学意义，治疗后12hME组HR显著低于C组和M组，治疗后48hM组、ME组Lac显著低于C组。治疗前各组cI及SVI比较差异无统计学意义，治疗后12hM组、ME组CI及SVI显著高于C组。治疗前各组血浆TNF—α、IL-6、HMG-1、CK—MB、cTnI及BNP水平比较差异无统计学意义，治疗后24hME组血浆TNF—α、IL-6、HMGB-1、CK—MB、cTnI及BNP水平显著低于C组和M组。ME组28天生存率和96小时心率达标率显著高于C组和M组。结论艾司洛尔联合米力农可显著改善严重脓毒症患者心功能及28天生存率，同时显著降低心率并抑制全身炎症反应。

Objective We aimed to investigate the safety of combination therapy with milrinone and esmolol on heart protection and prognosis improvement in patients with sepsis. Methods Ninety subjects with sepsis were consecutively recruited and randomly divided into control （ C）, milrinone （M） and milrinone - esmolol （ME） groups. Cardiac function indexes such as cardiac index （ CI）, stroke volume index （SVI）, mean arterial pressure （MAP）, central venous pressure （CVP）, heart rate （HR）, PaO2/FiO2 ratio and blood lactic acid （Lac） level were detected. In addition, the serum levels of proinflammatory factors （ including TNF - α, IL - 6 and HMGB - 1 ） and myocardial injury makers （including CK- MB, cTnI and BNP） were also tested by ELISA. Results There was no difference in all measured indexes before treatment. After combination therapy, no difference in MAP, CVP and PaO2/FiO2 was observed. However, 12 hours after treatment, the HR of patients in ME group was lower than that of patients in C and M groups, while the Lac level of M and ME groups was lower than that of C group 48 hours later. Similarly, the CI and SVI levels in M and ME groups were higher than those inC group at 12 hours after treatment, while the serum levels of proinflammatory factors and makers of myocardial injury in ME group were lower compared with C and M groups at 24 hours after treatment. Patients in ME group had higher 28 - day survival rate and better compliance rate of HR than the other two groups. Conclusion Combination therapy with milrinone and esmolol could improve cardiac function and 28 - day survival rate as well as inhibit the inflammatory response and myocardial injury in patients with severe sepsis.