老年重症感染性休克患者PICCO监测仪应用的研究

Application of PICCO detector in elderly patients with severe septic shock

目的观察PICCO监测仪在老年重症感染性休克患者中的应用,分析中心静脉压(CVP)与全心舒张末期容积指数(GEDVI)对于监测循环血容量的临床价值,提高老年重症感染性休克患者早期液体复苏的临床效果。方法选取2013年1月-2015年6月在医院诊治的ICU感染性休克患者24例,且所有患者的APACHEⅡ>15分,均行PICCO监测,经锁骨下静脉置管,经股动脉置入股动脉型热稀释导管,PICCO监测置管时为T0,每小时进行一次热稀释测量,持续测量6h,并以心脏指数(CI)、全心舒张末期容积指数(GEDVI)、血管外肺水指数(EVLWI)为指导进行PICCO液体管理。结果将GEDVI作为循环血容量的判断标准,分析CVP对低血容量的敏感性、特异性、阳性预测值、阴性预测值分别为5.0%、100.0%、100.0%、67.0%;CVP对高血容量的敏感性、特异性、阳性预测值、阴性预测值分别为19.0%、58.0%、23.0%、51.0%;CVP与CI、GEDVI、EVLWI无相关性,但GEDVI与CI、EVLWI有相关性;CI与GEDVI的变化成一致性,而CI与CVP的变化成相反趋势。结论行PICCO监测老年重症感染性休克患者中,CVP对于低血容量特异性较高,但敏感性较低;而GEDVI能够有效反映心脏的前负荷,对于低血容量的敏感性较高,其在重症感染性休克早期液体复苏有更高的应用价值,PICCO监测能够有效降低CVP对低血容量敏感度较低造成的液体复苏不充分现象。

OBJECTIVE To observe the application of PICCO detector in elderly patients with severe septic shock and analyze the clinical value of central venous pressure（CVP）and general end-diastolic volume index（GEDVI）in monitoring of circulating blood volume so as to improve the clinical effect of early fluid resuscitation of the elderly patients with severe septic shock.METHODS A total of 24 ICU patients with septic shock who were treated in the hospital from Jan 2013 to Jun 2015 were enrolled in the study,the APACHEⅡ score of all the patients was more than 15 points,all the patients received the PICCO surveillance and were treated with subclavian vein catheterization and inserted the femoral artery thermal dilution catheter via the femoral artery;the time of monitoring of PICCO was T0,the thermal dilution was measured once an hour for 6hours of consecutive measurement.The PICCO fluid management was conducted based on the cardiac index（CI）,GEDVI,and extravascular lung water index（EVLWI）.RESULTS As the GEDVI was used as the criterion of the circulating blood volume,the sensitivity of CVP on the hypovolemia was 5.0%,the specificity 100.00%,the positive predictive value 100.0%,the negative predictive value 67.0%;the sensitivity of CVP on the high blood volume was 19.0%,the specificity 58.0%,the positive predictive value 23.0%,the negative predictive value 51.0%.The CVP was not associated with CT,GEDVI,or EVLWI,however,the GEDVI was associated with CI and EVLWI;the changes of CI and GEDVI were consistent,however,the CI changed inversely with the CVP.CONCLUSION Among the elderly patients with severe septic shock undergoing PICCO surveillance,the specificity of CVP on the hypovolemia is high,while the sensitivity is low.The GEDVI can effectively reflect the pre-load of the heart,the sensitivity on the hypovolemia is high,and it has even higher value in the early fluid resuscitation of the patients with severe septic shock.The monitoring of PICCO may effectively reduce the insufficient fluid resuscitation which is caused by the low sensitivity of the CVP on hypovolemia.