不同目标导向治疗对脓毒症低灌注患者脑氧代谢和S100β蛋白的影响

Effects of different goal-directed therapies on cerebral oxygen metabolism and S100β level in patients with sepsis-induced hypoperfusion

目的比较两种不同目标导向治疗方法对脓毒症低灌注患者脑氧代谢和S100β蛋白的影响。方法选取2017年5月至2018年8月徐州医科大学附属医院重症监护室收治需要机械通气治疗的脓毒症低灌注患者60例,采用随机数表法将其分成2组(n=30):改良早期目标导向治疗组(M组)和标准治疗组(S组),M组根据2016年拯救脓毒症国际治疗指南结合FloTrac/Vigileo系统监测SVV指导液体复苏,治疗的前6 h时内达到以下目标:每博变异度(SVV)≤13%、平均动脉压(MAP)≥65 mmHg(1 mmHg=0.133 kPa)、乳酸清除率≥10%或者乳酸值(Lac)<2.0 mmol/L。S组以收缩压(SBP)和休克指数(SI)为导向进行液体复苏,治疗的前6 h时内使SBP≥100 mmHg和SI<0.8。比较2组患者复苏前(T1)、复苏后6 h(T2)、24 h(T3)、48 h(T4)的局部脑氧饱和度(rSO_2)、血清S100β蛋白的浓度、颈内静脉血氧饱和度(SjvO_2)、动脉和颈内静脉血氧含量差(Da-jvO_2)、脑氧摄取率(CERO_2)、血流动力学指标、Lac值、急性生理与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分。同时,记录并比较2组患者48 h内静脉补液量、血管活性药物使用比例、心脑血管不良事件发生率、重症监护室(ICU)的停留时间、住院时间、住院期间死亡率。结果与T1时比较,2组患者T2-T4时rSO_2、SjvO_2均升高,Da-jvO_2、CERO_2、S100β均降低(P<0.05);与S组比较,M组T2时rSO_2[(66.7±2.6)%vs(63.4±1.8)%]升高、S100β[(0.29±0.04)vs(0.34±0.04)μg/L]降低(P<0.05),T3-T4时SjvO_2[(68.5±2.5)%vs(65.7±1.2)%]、[(71.3±2.3)%vs(68.0±2.6)%]均升高,Da-jvO_2[(51.8±3.8)%vs(54.3±2.6)%]、[(44.5±2.6)%vs(48.3±3.9)%]、CERO_2[(31.7±2.2)%vs(33.2±1.4)%]、[(27.6±1.6)%vs(33.0±2.5)%]均降低(P<0.05);与T1时比较,2组患者T2-T4时MAP、CVP均升高,HR、Lac、APACHEⅡ评分均降低(P<0.05);M组T2时CVP低于S组[(8.5±1.0)vs(10.0±1.3)cmH_2O],M组在T2时补液量少于S组[(2 783±307)vs(3 087±382)ml,P<0.05];2组患者ICU停留时间、心脑血管不良事件发生率、住院时间、住院期间死亡率的比较,差异无统计学意义(P>0.05)。结论与标准治疗相比,基于SSV和乳酸清除率的改良早期目标导向治疗更能优化脓毒症低灌注患者脑氧代谢平衡,并且在复苏早期改善脑灌注和减轻脑损伤方面更具有优势,具有一定临床价值。

Objective To compare the effects of 2 different goal-directed therapies on cerebral oxygen metabolism and S100βlevel in patients with sepsis-induced hypoperfusion.Methods From May 2017 to August 2018,a total of 60 patients with sepsis-induced hypoperfusion,who required mechanical ventilation and were admitted to the Intensive Care Unit of the Affiliated Hospital of Xuzhou Medical University were randomly divided into modified early goal-directed therapy group(group M)and standard therapy group(group S),with 30 patients in each group.In group M,fluid resuscitation was guided by 2016 Surviving Sepsis Campaign Interna-tional Guidelines for Management of Sepsis and Septic Shock combined with stroke volume variation(SVV)monitored by FloTrac/Vigileo system,and then the following goals were required to reach during the first 6 h of therapy:SVV≤13%,mean arterial pressure(MAP)≥65 mmHg(1 mmHg=0.133 kPa),and lactate clearance rate≥10%or lactic acid(Lac)<2.0 mmol/L.In group S,the first 6 h of fluid resuscitation was directed by the goals of systolic blood pressure(SBP)≥100 mmHg and shock index(SI)<0.8.The regional oxygen saturation(rSO 2),serum S100βlevel,jugular venous oxygen saturation(SjvO 2),arteriovenous blood oxygen content difference(Da-jvO 2),cerebral extraction rate of oxygen(CERO 2),hemodynamic parameters,serum Lac level,acute physiology and chronic health evaluationⅡ(APACHEⅡ)score were compared between the 2 groups at pre-resuscitation(T1),first 6 h of resuscitation(T2),24 h of resuscitation(T3),and 48 h of resuscitation(T4).Meanwhile,the volume of intravenous fluid infusion within 48 h,proportion of the patients receiving vasopressor,incidence rate of adverse cardiac and cerebral vascular events,length of intensive care unit(ICU)and hospital stay,and hospital mortality were recorded and compared between the 2 groups.Results The levels of rSO 2 and SjvO 2 were significantly increased,and those of Da-jvO 2,CERO 2 and S100βwere obviously decreased at T2-T4 than at T1 in both groups(P<0.05).In the group M,the rSO 2 level was significantly higher[(66.7±2.6)%vs(63.4±1.8)%]and S100βlevel was notably lower[(0.29±0.04)vs(0.34±0.04)μg/L)]at T2,the level of SjvO 2[(68.5±2.5)%vs(65.7±1.2)%,(71.3±2.3)%vs(68.0±2.6)%]was remarkably increased and those of Da-jvO 2[(51.8±3.8)%vs(54.3±2.6)%,(44.5±2.6)%vs(48.3±3.9)%]and CERO 2[(31.7±2.2)%vs(33.2±1.4)%,(27.6±1.6)%vs(33.0±2.5)%]were significantly lower at T3-T4 when compared with the group S(all P<0.05).Compared with the values at T1,those of MAP and central venous pressure(CVP)were significantly increased and those of heart rate(HR),Lac level and APACHEⅡscore decreased at T2-T4 in both groups(P<0.05).At T2,the group M had significantly lower CVP[(8.5±1.0)vs(10.0±1.3)cmH 2O]and less amount of intravenous fluid infusion[(2 783±307)vs(3 087±382)ml]than the other group(P<0.05).There were no statistical differences in the length of ICU and hospital stay,incidence rate of adverse cardiac and cerebral vascular events,and hospital mortality between the 2 groups(P>0.05).Conclusion The modified early goal-directed therapy based on SVV and lactate clearance rate is superior to the standard therapy not only in optimization of cerebral oxygen metabolism balance,but also in improvement of cerebral perfusion and attenuation of brain injury during the early resuscitation.