不同全心舒张末期容积指数对感染性休克患者预后的影响

Outcomes Of Different Range Of Global End-Diastolic Volume In Septic Shock Patients

【目的】采用维持感染性休克患者早期目标导向治疗（EGDT）达标后全心舒张末期容积指数（GEDI）来指导后续液体治疗,探讨液体管理与预后的关系。【方法】采用前瞻性队列研究方法,选择64例感染性休克EGDT 达标患者,均给予使用 PICCO 监测,根据 GEDI 分为3组：A 组,22例（GEDI 600～680 mL/m2）、B 组,21例（GEDI 680～750 mL/m2）、C 组,21例（GEDI 750～850 mL/m2）,后续液体治疗均维持 GEDI 在本组范围内。分析各组28 d 病死率、多脏器功能衰竭（MODS）发生率、住 ICU 时间、机械通气时间（MVD）、5 d 每日液体入量、出量、液体平衡量、血管外肺水指数（EVLWI）、心指数（CI）、中心静脉压（CVP）和 GEDI,并评价 CVP 与 GEDI 的相关性。【结果】液体管理指标：EGDT 后5 d A 组患者每日液体入量、入量-出量明显低于 B、C 组（均 P ＜0.05）, d3 C 组与 B 组相比较差异无显著性（P＞0.05）,其余相比较差异均有显著性（均 P ＜0.05）。3组 CI 各时间点比较差异均无显著性（均 P ＞0.05）；3组 GEDI 维持在各组范围内；C 组 d4,d5 EVLWI 较 A、B 组明显增加（P ＜0.05）；GEDI 与 CVP 相关性较差（r =0.18,P =0.001）；3组 MODS 发生率相比较差异均无显著性（均 P ＞0.05）；A 组 MVD 短于 C 组（P ＜0.05）；生存曲线分析显示：3组患者28 d 生存率差异无统计学意义（F=0.7628,P =0.6953）。【结论】高 GEDI 组较低 GEDI 组后续液体需要量增加,液体负平衡天数减少,但不增加28 d 病死率,对 ICU 住院时间、MODS 发生率亦无明显影响,可能增加 EVLWI、MVD 风险。

[Objective]To observe the relationship between fluid management and outcomes by maintai-ning global end-diastolic volume （GEDI）after early goal-directed therapy （EGDT）in septic shock patients.[Methods]For this prospective controlled trial,a total of 64 septic shock patients after EGDT were enrolled into intensive care unit （ICU）and assigned into three groups according to different ranges of GEDI after EGDT.Under the guidance of Picco monitoring,GEDI was maintained in the assigned range [A,n =22,GE-DI （600～680 mL/m2 ）;B,n =21,GEDI （680～750 mL/m2 ）;C,n =21,GEDI （750～850 mL/m2 ）].The 28-day mortality,incidence of multiple organ dysfunction syndrome （MODS）,length of ICU stay,mechanical ventilation duration （MVD）,liquid intake,output volume and balances within 5 days,extravascular lung wa-ter index （EVLWI）,cardiac index （CI）,central venous pressure （CVP）and GEDI were recorded and ana-lyzed.[Results]Fluid management parameters：fluid intake and balance were significantly lower in group A than groups B and C groups daily during 5 days after EGDT （P 〈0.05 ）.No statistical difference existed at Day 3 between groups B and C （P 〉0.05）.The others had significant difference （all P 〈0.05）.Pulse-indica-ted continuous cardiac output index：CI showed no statistically difference among three groups （all P 〉0.05）, GEDI stayed within the above range,EVLWI was higher in group C than groups A and B in the last two days （P 〈0.05）.There was a poor relationship between GEDI and CVP （r =0.18,P =0.001）.The incidence of MODS was similar among three groups （all P 〉0.05）.MVD was shorter in group A than that in group C.The survival rate at 28 days by K-M survival curve was not different among three groups （F = 0.7628,P =0.6953）.[Conclusion]High GEDI group require a greater fluid intake and the days of negative fluid balance significant decrease.There is no higher mortality at 28 days.And length of ICU stay and incidence of MODS are not affected.But there are probably higher risks of EVLWI and MVD.