中心静脉-动脉血二氧化碳分压差联合乳酸清除率对感染性休克复苏指导意义的研究

Guiding significance of P（cv-a）CO2 and lactate clearance rate to the resuscitation in septic shock patients

目的研究中心静脉一动脉血二氧化碳分压差[P（cv—a）CO2]和乳酸清除率对感染性休克患者病情严重程度及疗效的评估价值。方法对2014年6月-2016年11月入住扬州大学第五临床医学院常熟市第二人民医院ICU治疗的60例感染性休克患者进行前瞻性观察性研究。根据液体复苏6h后P（cv—a）CO2是否大于6mmHg和乳酸清除率是否大于10％分为4组。组A：P（CV—a）CO2≥6mmHg，乳酸清除率〈10％；组B：P（CV—a）CO2〈6mmHg，乳酸清除率〈10％；组C：P（cv—a）CO2≥6mmHg，乳酸清除率≥10％；组D：P（cv—a）CO2〈6mmHg，乳酸清除率≥10％。比较组问早期目标导向治疗（earlygoal—directedtherapy，EGDT）达标率、序贯器官功能衰竭评估（sequentialorganfailureassessment，SOFA）评分、血管活性药用量、住ICU时间、机械通气时间等参数的差异，通过Kaplan—Meier生存曲线描述4组患者28d生存率，使用log—rank检验比较组间生存率的差异。结果4组患者入院时心率、平均动脉压、初始乳酸值的差异无统计学意义，组D第2天的SOFA评分较第1天下降明显，去甲肾上腺素用量低于组A及组C，组D28d病死率最低（Log—rank检验：卡方值=9．113，P=0．028）。结论在感染性休克复苏早期P（cv—a）CO2低及乳酸清除率高提示更低的器官功能障碍发生率和相对较好的预后，在复苏早期对两者的监测可用于指导感染性休克的治疗。

Objective To investigate the the disease severity and prognostic evaluation of central venous-arterial carbon dioxide difference[P（cv-a）CO2] and lactate clearance rate in resuscitation of septic shock patients. Methods A prospective, observational study was conducted in the ICU of our hospital and 60 patients with septic shock admitted from June, 2014 to November,2016 were included. Patients were classified in four groups according to the P（cv-a）CO2 and lactate clearance rate at 6 hours after resuscitation,Group A：P（cv-a）CO~ _-〉 6mmHg,lactate clearance rate〈10% ; Group B：P（cv-a）CO2〈6mmHg,lactate clearance rate〈10%;Group C：P（cv-a）CO2〉_- 6mmHg,lactate clearance rate〉= 10%; Group D：P（cv-a）CO2〈6mmHg,lactate clearance rate 10%. The rate to achieve EGDT at 6 hours after resuscitation, SOFA score,the dose of nore.pinephrine uesd, the patients＇ duration in ICU and duration of mechanical ventilation were compared between the four groups. A Kaplan Meier curve was constructed to show the survival probabilities at day-28 using a log-rank test to evaluate differences between groups. Results There are no statistical differences in the heart rate and MAP of admission,the initial lactate level of the four groups.In group D the SOFA score of the second day was significantly decresed than the first day, and the dose of norepinephrine wos lower than group A and C. Group D had significant higher survival rate at day-28 than other groups （log-rank test： 9.113, P= 0.028） .Conclusion The lower P（cv-a）CO2 and the higher lactate clearance rate the patients have, the lower incidence of organ dysfunction and the better prognosis they are. Early monitoring of P（cv-a）CO2 and lactate clearance rate can guide the resuscitation of septic shock.