脑血流动力学及脑氧饱和度变化与感染性休克患者预后的相关性:前瞻性队列研究

Correlation of Cerebral Hemodynamics and Cerebral Oxygen Saturation with the Prognosis of Patients with Septic Shock: A Prospective Cohort Study

目的探讨大脑中动脉血流动力学相关指标及脑氧饱和度变化与感染性休克患者预后的相关性。方法前瞻性收集2018年5月至2019年3月在中南大学湘雅医院重症医学科住院治疗的感染性休克患者临床资料,根据28 d内是否死亡,将患者分为死亡组和存活组。比较两组患者一般资料,入重症监护室即刻和初始复苏治疗6 h后动脉和中心静脉血气指标,重症心脏超声指标,器官功能指标,Sepsis生物标志物指标,液体复苏治疗6 h后大脑中动脉血流速度、灌注指数、动态脑血管自动调节功能[瞬时脑充血反应率(transient hyperemic response ratio,THRR)]以及脑氧饱和度变化。采用多因素Logistic回归,分析影响感染性休克患者预后的危险因素。结果51例符合纳入和排除标准的感染休克患者入选本研究,男性31例,女性20例,年龄(53±13)岁,28 d死亡率为43%。死亡组的序贯性器官衰竭评分(sequential organ failure assessment,SOFA)(P=0.007)、入室急性生理和慢性健康状况评估(acute physiology and chronic health evaluationⅡ,APACHEⅡ)评分(P=0.026)以及高峰APACHEⅡ评分(P<0.001)均高于存活组。初始复苏治疗6 h后,死亡组的氧合指数低于存活组(P=0.047),而中心静脉-动脉二氧化碳分压差(central venous-to-arterial carbon dioxide difference,Pcva CO2)则高于存活组(P=0.044)。死亡组动态脑血管自动调节功能受损者(THRR<1.09)多于存活组(P=0.025),脑氧饱和度(regional cerebral oxygen saturation,rSO2)均值低于存活组(P=0.031)且rSO2均值<60%者多于存活组(P=0.010)。多因素Logistic回归分析显示,高峰APACHEⅡ评分(OR=1.099,95%CI:1.009~1.196,P=0.030)、液体复苏治疗6 h后的Pcv-aCO2(OR=1.320,95%CI:1.001~1.742,P=0.050)、THRR<1.09(OR=4.952,95%CI:1.130~21.70,P=0.034)和rSO2均值<60%(OR=4.817,95%CI:1.392~16.663,P=0.013)是预测感染性休克患者28 d内死亡的独立危险因素。结论感染性休克患者死亡率高,脑血流动力学和rSO2指标中动态脑血管自动调节功能障碍(THRR<1.09)与rSO2均值<60%是28 d死亡率增加的独立预测因素。

Objective The aim of this study was to explore the correlation of the changes of cerebral hemodynamic indexes of the middle cerebral artery and cerebral oxygen saturation withthe prognosis of patients with septic shock.Methods The clinical data of patients with septic shock admitted to the department of Critical Care Medicine of Xiangya Hospital of Central South University from May 2018 to March 2019 were collected.Based on if dead or not within 28 days after the admission,the patients were divided into two groups,the death group and survival group.The general clinical information,arterial and central venous blood gas index immediately after admission into our department and after 6 hours of initial liquid resuscitation,critical cardiac ultrasound indicator,organ function index,indicator of sepsis biomarkers,middle cerebral artery blood flow velocity,dynamic cerebral perfusion index,brain transient congestion response ratio(THRR),and change of cerebral oxygen saturation after 6 hours of initial liquid resuscitation were compared.Results Totally 51 patients with septic shock meeting the inclusive and exclusive criteria were enrolled in this study,31 male and 20 female,with an average age of(53±13)years and 28-day mortality of 43%.Compared with the survival group,the death group had a higher sequential organ failure assessment(SOFA)(P=0.007),acute physiology and chronic health evaluationⅡ(APACHEⅡ)score(P=0.026),and peak APACHEⅡscore(P 0.001).Patients in the death group had a lower oxygenation index(P=0.047)and a higher value of central venous-toarterial carbon dioxide difference(Pcv-aCO2)(P=0.044).In addition,the death group showed more impaired dynamic cerebrovascular autoregulation(THRR1.09)(P=0.025),lower regional cerebral oxygen saturation(rSO2)mean(P=0.031),and more patients with mean rSO2 60%(P=0.010).Multivariable Logistic regression analysis showed that the peak APACHEⅡscore(OR=1.099,95%CI:1.009-1.196,P=0.030),the Pcv-aCO2 after 6 hours of initial liquid resuscitation(OR=1.320,95%CI:1.001-1.742,P=0.050),THRR 1.09(OR=4.952,95%CI:1.130-21.70,P=0.034),mean rSO2 60%(OR=4.817,95%CI:1.392-16.663,P=0.013)were independently associated with the mortality.Conclusions The mortality of patients with septic shock is high;impaired dynamic cerebrovascular autoregulation(THRR1.09)and mean rSO260%among the cerebral hemodynamics and cerebral oxygen saturation indexes are the independent risk factors for predicting the death in 28 days.