脓毒症休克患者早期舌下微循环改变对器官功能衰竭的预测价值

Predictive Value of Early Changes in Sublingual Microcirculation on Organ Failure of Patients with Septic Shock

目的探讨脓毒症休克患者早期舌下微循环的改变对器官功能衰竭的预测价值。方法使用旁流暗视野成像技术（SDF）观察诊断为脓毒症休克24h以内的成人患者0h、6h、24h舌下微循环图像,根据24h后器官功能衰竭评分（SOFA24h-0h评分）变化分为器官功能恶化组（ΔSOFA24h-0h评分≥1）和未恶化组（ΔSOFA24h-0h评分〈1）;分析比较两组间传统循环及舌下微循环指标的变化。结果两组患者的年龄、性别、急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ评分）等基本资料差异无统计学意义。恶化组和未恶化组相比,0h、6h、24h传统循环指标〔心率（HR）、平均动脉压（MAP）、中心静脉压（CVP）、尿量（urine output,UP）、动脉血乳酸（lactate,Lac）〕、血管活性药物的使用以及输注晶体液、胶体液的量和液体总量差异均无统计学意义。舌下微循环指标小血管灌注比例（PPVs）恶化组在0h〔（75.96±10.55）%vs.（84.03±10.16）%,P=0.032〕和24h时〔（79.43±9.23）%vs.（86.32±9.02）%,P=0.037〕低于未恶化组,差异有统计学意义。绘制0hPPVs和Lac的ROC曲线,曲线下面积PPVs〔0.750（95%CI,0.586~0.914）〕大于Lac〔0.588（95%CI,0.370~0.805）〕,但差异无统计学意义（P〉0.05）。根据0hPPVs最佳截断值81.5%将患者分为高、低两组,低PPVs组器官功能恶化发生率较高PPVs组更高（71.4%vs.20.0%,P〈0.05）。结论舌下微循环指标PPVs能够早于体循环指标反映器官功能的变化,对器官功能衰竭可能有一定预测价值。

Objective To determine the predictive value of early changes in sublingual microcirculation on organ failure of patients with septic shock.Methods Side-streamdark field imaging（SDF）videomicroscopy was performed to assess sublingual microcirculation of 34 adult patients at 0h,6hand 24 hafter they were diagnosed with septic shock.The patients were subject to sequential organ failure assessment（SOFA24h-0h）.The patients withΔSOFA24h-0h≥1（deteriorated conditions）were compared with those withΔSOFA24h-0h1in regard to sublingual microcirculation and the traditional hemodynamic indicators such as heart rate,mean arterial pressure,central venous pressure,urine output and lactate.Results No significant baseline differences were found between the two groups of patients in age,sex and acute physiology and chronic health evaluationⅡ（APACHE Ⅱ）,nor any differences in the traditional hemodynamic indicators,as well as dose of vasopressor,infusion of crystalloids,and colloids after septic shock was diagnosed.The patients with deteriorated conditions had lower proportion of perfused small vessels（PPVs）compared with the non-deteriorated patients at 0h〔（75.96±10.55）% vs.（84.03±10.16）%,P=0.032〕and 24h〔（79.43±9.23）% vs.（86.32±9.02）%,P=0.037〕.The ROC analysis showed a greater area under the curve（AUC）for PPVs at 0h〔0.750（95%CI,0.586-0.914）〕compared with the AUCfor Lac at 0h〔0.588（95%CI,0.370-0.805）〕,albeit a lack of statistical significance（P〉0.05）.The incidence of organ failure in the patients with a lower than optimal cut-off point（81.5%）of PPVs was significantly higher than that of those above the cutoff point（71.4% vs.20.0%）.Conclusion Changes in sublingual microcirculation（e.g.PPVs）can predict the development of organ failure earlier than systemic hemodynamic indicators in patients with septic shock.