早期充分液体复苏达标后不同液体负平衡量对脓毒性休克预后的影响

Effects of different negative balance fluid volume on prognosis of patients with septic shock after recovery up to standard by adequate fluid resuscitation at early stage

目的探讨早期充分液体复苏达标后不同液体负平衡量对脓毒性休克(septic shock,SS)预后的影响。方法150例SS患者,按早期目标指导性治疗(earlytarget-guided therapy,EGDT)方案充分液体复苏达标后,随机分为3组,均采用限制性补液策略,给予不同液体负平衡量治疗5d:A组(50例)-250mL/d,B组(50例)-500mL/d,C组(50例)-750mL/d。负平衡量治疗5d后观察心率、平均动脉压(MAP)、中心静脉压(CVP)、心脏指数(CI)、胸腔内血容积指数(ITBVI)、血管外肺水指数(EVLWI)、肺血管通透性指数(PVPI)、中心静脉血氧饱和度(ScvO2)、氨基末端B型利钠肽前体(NT-proBNP)、血乳酸、急性生理和慢性健康状况(APACHEⅡ评分)、序贯器官衰竭(SOFA)评分及血管活性药物、利尿剂用量,记录机械通气时间、住ICU时间,随访28d内并发症发生率及病死率。结果B组患者的心率、MAP、CVP、ITBVI、EVLWI、PVPI、cTnI、NT-proBNP、血乳酸、APACHEⅡ评分、SOFA评分、机械通气时间、住ICU时间及呋塞米用量均低于A组(P<0.05),B组患者的HCT、CI、ScvO2、PaO2/FiO2及液体负平衡5d内血管活性药物用量均高于A组(均P<0.01)。B组患者的心率、HCT、血乳酸、APACHEⅡ评分、SOFA评分、机械通气时间、住ICU时间及液体负平衡5d内血管活性药物用量均低于C组(P<0.05),B组患者的MAP、CVP、ITBVI、EVL-WI、PVPI、cTnI、NT-proBNP、CI、ScvO2、PaO2/FiO2及呋塞米用量均高于C组(P<0.05)。治疗后28d内,B组患者的总并发症发生率及病死率均低于A组(P<0.05);C组患者的总并发症发生率及病死率与A、B两组相比差异均无统计学意义(P>0.05)。结论EGDT达标后液体负平衡量(-500mL/d)较为适宜,既保证器官组织的有效灌注,又减轻了肺水肿,获得了更好的肺顺应性和氧合,缩短机械通气及ICU时间,降低了并发症发生率及病死率。

Objective To investigate the effect of different negative balance fluid volume on the prognosis of patients with septic shock(SS).Methods 150 SS patients were selected and randomly divided into 3 groups,according to the early target-guided therapy(EGDT)after adequate fluid resuscitation.All patients were treated with restrictive fluid replenishment strategy,and were given different liquid negative balance for 5 days:Group A(50 cases)-250 mL/d,Group B(50 cases)-500 mL/d,Group C(50 cases)-750 mL/d.At the same time,differ-ent doses of vasoactive drugs and diuretics were used to maintain the therapeutic target set by EGDT.After 5 days of negative balance dose treatment,Heart rate,mean arterial pressure(MAP),Central venous pressure(CVP),cardiac index(CI),intrathoracic blood volume index(ITBVI),blood vessels,lung water index(EVLWI),pulmonary vascular permeability index(PVPI),central venous blood oxygen saturation(ScvO2),amino terminal b-type natriuretic peptide precursor(NT-proBNP),blood lactic acid,acute physiology and chronic health conditions(APACHEⅡscore),sequential organ failure(SOFA)score and vascular active drugs,and dosage of diuretics were observed.The duration of mechanical ventilation and ICU stay were recorded,and the incidence of complications and fatality rate were followed up for 28 days.Results Heart rate,MAP,CVP,ITBVI,EVLWI,PVPI,cTnI,NT-proBNP,blood lactic acid,APACHEⅡscore,SOFA score,mechanical ventilation time,ICU time and the dosage of furosemide of patients in Group B were lower than those in Group A(P<0.05),HCT,CI,ScvO2,PaO2/FiO2 and the dosage of vasoactive drugs of patients in Group B was higher than that in Group A within 5 days of liquid negative balance(all P<0.01).Heart rate,HCT,blood lactic acid,APACHEⅡscore,SOFA score,mechanical ventilation time,ICU time,and the dosage of vasoactive drugs within 5 days of negative liquid equilibrium of patients in Group B was lower than those of Group C(P<0.05),MAP,CVP,ITBVI,EVLWI,PVPI,cTnI,NT-proBNP,CI,ScvO2,PaO2/FiO2 and the dosage of furosemide of patients in Group B were higher than those in Group C(P<0.05).The total complication rate and fatality rate of patients in Group B were lower than that of Group A within 28 days after treatment(P<0.05).The total complication rate and fatality rate of patients in Group B were slightly lower than that of Group C(P>0.05),the difference was not statistically signifi-cant.Conclusion The negative equilibrium of liquid(-500 mL/d)is more appropriate after EGDT reaching the standard.It can not only ensure the effective perfusion of organs and tissues,but also reduce pulmonary edema,obtain better lung compliance and oxygenation,shorten mechanical ventilation and ICU time,and reduce the incidence and mortality of complications.