舌下微循环监测在失血性休克液体复苏前后变化及临床意义研究

Prognositc value of sublingual microcirculation in hemorrhagic shock patients

目的探讨失血性休克患者液体复苏后舌下微循环的改变，以及通过早期监测舌下微循环的变化指导液体复苏可行性研究。方法2016—06—01～2017—06—30期间人海军军医大学附属长征医院ICU病房的失廊性休克患者59例，随机分成实验组30例和对照组29例，使用旁路暗视野成像技术（SDF）观察失血性休克患者液体复苏开始同时及复苏后2、6、12、24h等多时间段舌下微循环变化，实验组根据微循环结果进行复苏液体量的调整，对照组按经验性治疗，记录各时间点的微循环数据、24h的复苏液体量、APACHEⅡ评分、SOFA评分等数据。结果两组患者人组前年龄、性别、APACHEⅡ评分等基本资料差异无统计学意义，舌下微循环监测结果提示随着液体的复苏进行，两组微循环数据均朝好的方向发展，实验组通过了解微循环的变化，及时调整液体的复苏量，24h液体复苏总量少于对照组，而两组24h时平均动脉压、微循环情况、APACHEⅡ评分、SOFA评分、氧合指数等差异无统计学意义，而随着时间的延长，48h时的实验组SOFA评分、氧合指数优于对照组，7d时的APACHEⅡ评分、SOFA评分亦优于对照组，而且血管活性药物使用时间和呼吸机支持时间都明显短于对照组，差异有统计学意义（P〈0．05），但病死率差异无统计学意义。结论舌下微循环可以作为失血性休克微循环改变的指标进行监测，在一定程度上可以指导液体复苏，有利于失血性休克患者液体复苏量的控制，有利于器官功能的恢复和保护，尤其是呼吸功能。

Ofbjective To investigate the sublingual microcirculation changes after the resuscitation in hemorrhagic shock patients and the possibility to guide the fluid resuscitation of these patients. Methods A total of 59 patients, admitted to ICU from June 1, 2016 to June 30, 2017, diagnosed with hemorrhagic shock were studied. They were divided into experiment group and control group in random. Using bypass dark vision imaging technology （SDF） to observe the the sublingual microcirculation changes as the resuscitation began, 2 h later, 6 h later, 12 h later, and 24 h later. We also recorded these time points of microcirculation data, and the amount of fluid of 24 h resuscitation, APACHE II score, SOFA scores and other data. Results There was no differences in ages, gender, APACHE II scores and the sublingual microcirculation between the two groups at the beginning of the of the fluid resuscitation. The results of sublingual microcirculation monitoring showed that after the fluid resuscitation, two groups of microcirculation data showed positive trends. The amount of resuscitation fluid was adjusted according to the sublingual microcirculation status in experimental group. So the amount of recovered fluid of experimental group was less than that of control group during the first 24 h. The mean arterial pressure, sublingual microcirculation, APACHE II score, SOFA score and oxygenation index showed no significant difference in the first 24 h. With the prolonged experimental time（2 days - 7 days） ,in 48h, SOFA score and oxygenation index of the experimental groupwere better than those of the control group（P 〈 0.05）, and in 7th day, the APACHE II scores, SOFA scores were also better than those of the control group（P 〈 0. 05）. And there was significant difference between the time of vasoactive drug use and the duration of ventilator support. Although the mortality rate between the two groups was no statistically different（P 〉 0.05 ）. Conclusion The sublingual microcirculation can be used as an indicator to monitor the microcirculation of hemorrhagic shock, to a certain extent, it also can guide the fluid resuscitation in hemorrhagic shock patients, which is conducive to control the recovery fluid and protect the organ function, especially the respiratory function.