感染性休克患者早期容量复苏达标后应用不同液体管理策略对左心室舒张功能的影响

Effects of different fluid management strategies on left ventricular diastolic function in patients with septic shock after early goal- directed therapy

目的 观察并探讨感染性休克患者早期容量复苏后应用不同液体管理策略对左心室舒张功能的影响。方法 采用前瞻性研究方法，选择2014-06～2016-06本院重症医学科（ICU）收治的感染性休克患者56例，对入选对象均实施早期液体复苏，复苏目标实现后随机分为治疗组和对照组各28例，治疗组实施限制性液体管理策略，对照组给予开放性液体管理。观察两组患者各时间段液体累积净平衡量。应用床旁超声监测患者入ICU 6 h、第3天及第7天二尖瓣舒张早期峰流速与二尖瓣环舒张早期运动速度比值（E/e＇）等左心室舒张功能指标，同时观察肌钙蛋白I（cTnI）及N末端脑钠肽前体（NT-proBNP）等心肌损伤标记物变化。结果 两组患者于转入ICU 0～6 h内均为液体正平衡。入ICU期间治疗组患者液体净平衡量明显低于对照组（P〈0.05）。单纯左室舒张功能障碍发生率为39.3%，高于收缩功能障碍（23.2%）等其他类型的心功能不全。入ICU 第3天及第7天治疗组E/e＇及cTnI较对照组明显下降，第7天治疗组NT-proBNP较对照组明显下降（P〈0.05）。与入ICU 6 h比较，两组患者于第3天E/e＇、cTnI及NT-proBNP均明显升高（P〈0.05）。与第3天比较，治疗组于第7天E/e＇、cTnI及NT-proBNP明显下降（P〈0.05）；而对照组E/e＇、cTnI下降不明显，NT-proBNP较第3天有所升高（P〉0.05）。结论 感染性休克患者广泛存在左心室舒张功能障碍，通过实施限制性液体管理策略可明显改善感染性休克患者左心室舒张功能，减轻心肌损伤和心肌抑制，对预后改善作用明显。

Objective To observe and explore the effects of different fluid management strategies on the left ventricular diastolic function in patients with septic shock after early goal - directed resuscitation. Methods As a prospective cohort study, 56 patients with septic shock admitted to the Department of Intensive Care Unit of Affiliated Hospital of Chengde Medical College during June 2014 to June 2016. The patients were randomly divided into two groups after early fluid resuscitation. Each group was of 28 cases. Treatment group was received restrictive fluid management strategies after early goal - directed therapy, but control group was continued to carry out open liquid management. Then liquid cumulative balance was observed with different periods in two groups. As the evaluation index of left ventricu- lar diastolic function, the ratio of early diastolic mitral inflow velocity to early diastolic mitral annulus velocity（E/e＇） was observed. Meanwhile, the myocardial injury markers like troponin -I（cTnI） and N-proBNP were observed at 6th hour, 3rd day and 7th day in ICU. Results The fluid balance of two groups was positive during 0 ~ 6 hours. However, the fluid balance in treatment group was significantly lower than that of control group in length of ICU stay（ P 〈 0.05 ）. The incidence of left ventricular diastolic dysfunction in patients was 39.3%, greater than other types of cardiac dysfunction, such as left ventrieular systolic dysfunction （23.2%）. Compared with control group, E/e＇ and cTnI in treatment group were decreased significantly in 3rd and 7th day, as well as NT - proBNP in 7th day（ P 〈 0.05 ）. Compared with that in 6 th hour, E/e＇, eTnI and NT - proBNP of two groups were significantly increased in 3rd day（P 〈0.05）. E/e＇, cTnl and NT- proBNP of treatment group were significantly decreased in 7th day compared to that in 3rd day（P 〈0.05） ; while E/e＇, cTnI of control group were decreased not significantly, even NT - proBNP was increased（P 〉 0.05 ）. Conclusion Left ventricular diastolic dysfunction existed widely in patients with septic shock, which could be improved significantly through the implementation of restrictive fluid management strategy. The effect of myocardial injury and myocardial depression was reduced, and the prognosis was improved.