脑死亡患者的血流动力学分析

Hemodynamic analysis for patients with brain death

目的对脑死亡患者进行血流动力学分析。方法纳入2015年3月至2017年3月本院重症监护室收治的拟进行器官捐献的脑死亡患者26例,应用脉搏指示性连续心排量监测(Pi CCO)测定患者0h(入组时)的脑内血容量指数(ITBVI),根据ITBVI指标进行补液治疗,使其6h内达到正常。对比0h及6h时患者的心率(HR)、平均动脉压(MAP)、心指数(CI)、每博指数(SVI)、系统血管阻力指数(SVRI)、ITBVI、去甲肾上腺素用量及血乳酸水平。6h时行心脏彩超测定患者的左室射血分数(LVEF),对LVEF<50%的患者给予多巴酚丁胺5ug·kg-1·min-1持续泵入,对比6h和10h,患者的LVEF、CI、去甲肾上腺素用量及血乳酸水平;统计48h患者的胆红素及肌酐的改善率及肝肾器官捐献成功率。结果患者0h ITBVI显著低于正常值,经补液治疗,6h时HR下降,CI、SI升高,SVRI下降,去加肾上腺用量降低,乳酸水平下降,前后比较差异有统计学意义(P均<0.01);6h时76.9%的患者LVEF<50%,给予多巴酚丁胺泵入,10h时患者LVEF<50%的比例下降至30.7%,与6h时相比LVEF、CI增高(去甲肾上腺素用量下降,乳酸水平降低(均P<0.01);患者48h胆红素及肌酐水平明显下降(P<0.001),肝脏及肾脏的捐赠成功率分别为92.3%及96.2%。结论脑死亡患者前负荷不足,心脏收缩功能下降,外周阻力降低,给予优化血流动力学后可明显降低去甲肾上腺素用量,改善供体肝肾功能。

Objective To analyze hemodynamics in patients with brain death and summarize regularities.Method Twenty-six patients with brain death intending for organ donation were included from the intensive care units of our hospital between from March 2015 to March 2017.Intrathoracic blood volume index(ITBVI)was measured at 0 hour(when the patients were included)using pulse-indicated continuous cardiac output(PiCCO).Based on the measured ITBVI,fluid replacement was conducted to achieve its normal level within 6 hour.HR,mean arterial pressure(MAP),cardiac index(CI),stroke volume index(SVI),systemic vascular resistance index(SVRI),ITBVI,the dosage of noradrenaline and blood lactate level were compared at 0 hour and 6 hour.At 6 hour,LVEF was measured by color Doppler ultrasound of the heart.For patients with LVEF<50%,5ug·kg-1.min dobutamine was continuously infused.LVEF,CI,the dosage of noradrenaline and blood lactate level were compared at 6 hour and 10 hour.The improvement rate of bilirubin and creatinine and the success rate of liver and kidney donation at 48 hour were statistically analyzed.Results At 0 hour,ITBVI was significantly lower than normal level.After fluid replacement,HR,SVRI,the dosage of noradrenaline and lactate level decreased while CI and SI increased at 6 hour,showing statistically significant differences with those at 0 hour(all P<0.01).At 6 hour,76.9%patients presented left ventricular ejective fraction(LVEF)<50%and was infused with dobutamine.At 10 hour,the proportion of patients with LVEF<50%reduced to 30.7%,and LVEF and CI increased while the dosage of noradrenaline and lactate level decreased as compared with those at 6 hour(all P<0.01).At 48 hour,bilirubin and creatinine levels reduced significantly(P<0.001);the success rate of liver and kidney donation was 92.3%and 96.2%,respectively.Conclusion In patients with brain death,preload is insufficient,cardiac systolic function reduces and peripheral resistance decreases.After treated with optimized hemodynamics,the dosage of noradrenaline reduces significantly and donator's liver and kidney function are improved.