脓毒症患者容量达标后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 sepsis after early goal directed therapy

目的观察并探讨脓毒症患者在早期容量达标后给予不同液体管理策略对左心室舒张功能的影响及意义。方法前瞻性研究方法，选择南京医科大学附属苏州医院2015年10月2018年6月期间ICU收治的脓毒症患者96例，入选患者均已实施早期目标指导治疗，在容量达标实现后，随机分为液体限制组和液体非限制组，各48例。观察所有患者在各时间段内的液体平衡情况。观察比较人ICU28d两组患者机械通气时间、住ICU时间及多器官功能障碍综合征发生情况。采用超声监测患者左心室舒张功能，于入ICU1d、2d、3d及4d后测定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/E1），同时测定心肌损伤标记物肌钙蛋白I（cTnI）及N末端脑钠肽前体（NT-proBNP）变化情况。结果两组患者经早期目标指导治疗后，在转入ICU1d内均为液体正平衡。入ICU治疗期间液体限制组患者的液体净平衡量明显低于液体非限制组患者（P〈0.05）。入ICU治疗第3天起，液体限制组患者的E/E’及cTnI较液体非限制组开始明显下降，治疗第3天，液体限制组患者的NT-proBNP较液体非限制组患者明显下降（P〈0.05）。与入ICU第2天比较，液体限制组患者的E/E＇、cTnI及NT-proBNP值于第3天发生明显下降（P〈0.05）;而液体非限制组患者的E/E＇、cTnI下降不明显，且NT-proBNP有所升高（P〉0.05）。结论脓毒症患者在早期容量达标后，仍广泛存在左心室舒张功能障碍，通过限制性液体管理策略可明显缩短患者住ICU时间，并可有效改善患者左心室舒张功能，减轻心肌损伤，改善预后作用明显。

Objective To observe and explore the effects of different fluid management strategies on the left ventrieular diastolic function in patients with sepsis. Methods As a prospective cohort study, 96 patients with sepsis admitted to the hospital during October 2015 to June 2018. The patients were randomly divided into two groups after early fluid resuscitation. Each group was of 48 cases. Treatment group was received restrictive fluid management strategies and the control group was continued to carry out open liquid management. Then liquid cumulative balance was observed with different periods, and the duration of mechanical ventilation, ICU duration and multiple organ dysfunction syndrome in two groups were observed and compared in 28 days after in ICU. The left ventricular diastolic function was measured by ultrasound, and the ratio of early diastolic velocity of mitral valvular and early diastolic velocity of mitral, annulus （E/E＇） was observed. Meanwhile, the myocardial injury markers like troponin-I（cTnI）and N-proBNP were observed at 1st day, 2 nd day 3 rd day and 4 th day in ICU. Results After the early target treatment, the two groups of patients were positively balanced in fluid within 1 day of transfering to the ICU. The net balance of the patients in the fluid restricted group was significantly lower than that in the non-restricted group during the ICU treatment （ P 〈0.05）. From the third day of ICU treatment, the E/ E＇ and cTnI of the fluid-restricted group began to decrease significantly compared with the liquid non- restricted group. On the third day of treatment, the NT proBNP of the fluid-restricted group was significantly lower than that of the non-restricted group （ P 〈0.05）. E/E＇, cTnI and NT proBNP values in patients in the fluid-restricted group decreased significantly on the third day compared with the second day in the ICU （ P 〈0.05） ;E/E＇ and cTnI in patients in the non-restricted group the decrease was not obvious, and NT-proBNP was increased （ P 〉 0.05）. Conclusions There is still a wide range of left ventrieular diastolic dysfunction in patients with sepsis after the early volume of capacity. The restrictive liquid management strategy can significantly shorten the patien（s ICU time, improve the left ventricular diastolic function, reduce the myocardial injury and improve the prognosis of the patients.