二氧化碳偏移度对脓毒性休克患者液体复苏后微循环变化的预测价值

Predictive value of carbon dioxide offset for microcirculation changes after fluid resuscitation in patients with septic shock

目的探讨二氧化碳偏移度对脓毒性休克患者液体复苏后微循环变化的预测价值。方法对63例脓毒性休克患者给予液体复苏,检测所有患者复苏前后的心率、平均动脉压(MAP)、中心静脉压(CVP)、心排血指数(CI)、动脉血pH值、剩余碱、动脉血氧饱和度(SaO2)、血红蛋白、动脉血氧分压(PaO2)、动脉血二氧化碳分压(PaCO2)、经皮组织氧分压(TcpO2)、经皮组织二氧化碳分压(TcpCO2)、氧偏移度、二氧化碳偏移度及动脉血乳酸水平。同时根据28 d病死率将所有患者分成存活组(45例)及死亡组(18例)。比较两组患者液体复苏6 h后的PaO2、PaCO2、TcpO2、TcpCO2、氧偏移度、二氧化碳偏移度及动脉血乳酸水平。采用受试者工作特征(ROC)曲线分析二氧化碳偏移度对脓毒性休克患者预后的预测价值。结果在接受液体复苏6 h后,MAP[(76±13)mmHg vs.(68±12)mmHg]、CVP[(12±4)cmH2O vs.(10±3)cmH2O]、CI[(4.1±1.4)L/min vs.(3.6±1.4)L/min]、剩余碱[(-5±3)mmol/L vs.(-7±4)mmol/L]、PaO2[(121±16)mmHg vs.(111±15)mmHg]及TcpO2[(77±11)mmHg vs.(62±12)mmHg]较复苏前均有显著升高(t=3.701、2.552、2.071、4.459、3.647、7.084,P均<0.05),PaCO2[(37±6)mmHg vs.(39±6)mmHg]、TcpCO2[(42±12)mmHg vs.(49±13)mmHg]、氧偏移度[(0.36±0.16)%vs.(0.44±0.13)%]、二氧化碳偏移度[(0.14±0.12)%vs.(0.26±0.19)%]及动脉血乳酸[(2.4±0.7)mmol/L vs.(3.6±0.6)mmol/L]较复苏前均显著下降(t=2.171、3.103、3.080、4.238、10.030,P均<0.05)。存活组患者在液体复苏6 h后所测的PaCO2[(35±6)mmHg vs.(40±5)mmHg]、TcpCO2[(41±10)mmHg vs.(53±11)mmHg]、二氧化碳偏移度[(0.15±0.19)%vs.(0.34±0.15)%]及动脉血乳酸水平[(2.2±0.7)mmol/L vs.(4.6±0.8)mmol/L]均较死亡组显著降低(t=2.572、4.289、3.790、11.740,P均<0.05),存活组患者的PaO2[(111±19)mmHg vs.(95±20)mmHg]及TcpO2[(76±9)mmHg vs.(60±9)mmHg]均显著高于死亡组(t=2.893、5.935,P均<0.05)。经ROC曲线分析,二氧化碳偏移度的曲线下面积为0.883,95%置信区间为0.852~0.982。结论二氧化碳偏移度可动态评价脓毒性休克患者液体复苏后微循环灌注情况及评估预后。

Objective To explore the predictive value of carbon dioxide offset for monitoring microcirculation after fluid resuscitation in patients with septic shock.Methods A total of 63 patients with septic shock were treated with fluid resuscitation.The levels of heart rate,mean arterial pressure(MAP),central venous pressure(CVP),cardiac index(CI),arterial blood pH,base excess,arterial oxyhemoglobin saturation(SaO2),hemoglobin,arterial partial pressure of oxygen(PaO2),arterial partial pressure of carbon dioxide(PaCO2),transcutaneous oxygen pressure(TcpO2),transcutaneous carbon dioxide pressure(TcpCO2),oxygen offset,carbon dioxide offset and arterial blood lactic acid were detected before and after fluid resuscitation.Meanwhile,all patients were divided into the survival group(45 cases)and death group(18 cases)according to 28 d mortality,and the levels of PaO2,PaCO2,TcpO2,TcpCO2,oxygen offset,carbon dioxide offset and arterial blood lactic acid were compared at 6 h after fluid resuscitation between the two groups.The receiver operating characteristic(ROC)curve was used to predict carbon dioxide offset for microcirculation changes after fluid resuscitation in patients with septic shock.Results After 6 hours of fluid resuscitation,the levels of MAP[(76±13)mmHg vs.(68±12)mmHg],CVP[(12±4)cmH2O vs.(10±3)cmH2O],CI[(4.1±1.4)L/min vs.(3.6±1.4)L/min],base excess[(-5±3)mmol/L vs.(-7±4)mmol/L],PaO2[(121±16)mmHg vs.(111±15)mmHg]and TcpO2[(77±11)mmHg vs.(62±12)mmHg]were significantly higher than those before fluid resuscitation(t=3.701,2.552,2.071,4.459,3.647,7.084;all P<0.05),while PaCO2[(37±6)mmHg vs.(39±6)mmHg],TcpCO2[(42±12)mmHg vs.(49±13)mmHg],oxygen offset[(0.36±0.16)%vs.(0.44±0.13)%],carbon dioxide offset[(0.14±0.12)%vs.(0.26±0.19)%]and arterial blood lactic acid[(2.4±0.7)mmol/L vs.(3.6±0.6)mmol/L]decreased significantly(t=2.171,3.103,3.080,4.238,10.030;all P<0.05).In the survival group,the levels of PaCO2[(35±6)mmHg vs.(40±5)mmHg],TcpCO2[(41±10)mmHg vs.(53±11)mmHg],carbon dioxide offset[(0.15±0.19)%vs.(0.34±0.15)%]and arterial blood lactic acid[(2.2±0.7)mmol/L vs.(4.6±0.8)mmol/L]were lower(t=2.572,4.289,3.790,11.740;all P<0.05),while the levels of PaO2[(111±19)mmHg vs.(95±20)mmHg]and TcpO2[(76±9)mmHg vs.(60±9)mmHg]were higher than those in the death group after 6 hours of fluid resuscitation(t=2.893,5.935;both P<0.05).The ROC curve showed that the area under the curve of carbon dioxide offset was 0.883,and the 95%confidence interval was 0.852-0.982.Conclusion The carbon dioxide offset can dynamically predict microcirculation perfusion after fluid resuscitation in patients with septic shock and can be used as a reliable parameter for prognosis.