早期血流动力学监测在泌尿系统钬激光碎石术后并发脓毒性休克患者救治中的价值探讨

Value of early hemodynamic monitoring in patients complicated with septic shock after holmium laser lithotripsy of urinary system

目的:探讨早期血流动力学监测在泌尿系统钬激光碎石术后并发脓毒性休克救治中的价值。方法:回顾性分析2013年1月至2018年12月入住重庆医科大学附属第一医院重症医学科的37例泌尿道钬激光碎石术后并发脓毒性休克的患者临床资料,根据是否在脉博指示连续心排血量监测(pulse index continuous cardiac output,PiCCO)下进行液体复苏,分为PiCCO监测组及非PiCCO监测组,分别对一般资料和治疗前病情严重程度指标,对治疗前后PiCCO监测相关指标,以及对2组患者治疗6 h、24 h相关临床指标进行比较。结果:PiCCO监测组患者治疗后6 h,全心舒张末期容积指数(global end diastolic volume index,GEDI)、心指数(cardiac index,CI)、血管外肺水指数(external lung water index,EVLWI)、全身血管阻力指数(systemic vascular resistance index,SVRI)、平均动脉压(mean arterial pressure,MAP)较治疗前增加(Z值分别为-3.393、-4.059、-4.189、-3.241、-3.736;P值分别为0.005、0.000、0.000、0.001、0.000),治疗后24 h的GEDI、CI、SVRI较治疗后6 h进一步增加(Z值分别为-3.751、-2.738、-4.749;P值分别为0.000、0.006、0.000)。治疗6 h后PiCCO监测组较非PiCCO监测组血乳酸值、去甲肾上腺素用量低(Z值分别为-2.070、-3.895;P值分别为0.038、0.000);治疗6 h和治疗24 h后PiCCO监测组氧合指数(PO2/FiO2)及每小时尿量均较非PiCCO监测组增加(治疗6 h的Z值分别为-2.499、-3.314,P值分别为0.012、0.001;治疗24 h的Z值分别为-3.833、-3.466;P值分别为0.000、0.001);PiCCO监测组晶体液总量、胶体液总量治疗6 h后较非PiCCO监测组增加(Z值分别为-4.845、-4.401;P值分别为0.000、0.000),而治疗24 h后较非PiCCO监测组减少(Z值分别为-2.338、-2.948;P值分别为0.019、0.003)。治疗后,PiCCO监测组患者机械通气时间较非PiCCO监测组降低、ICU停留时间缩短(Z值分别为-2.195、-2.173;P值分别为0.028、0.030)。以上结果表明PiCCO监测组在早期液体复苏及血管活性药物用量的调整及维持循环稳定、改善组织灌注及减少并发症等方面优于非PiCCO监测组。结论:早期PiCCO监测指导下,精确液体复苏为主的综合治疗对缓解病情、减少过度液体复苏所带来的并发症、降低机械通气时间、缩短治疗时间有重要作用,可能作为输尿管结石钬激光碎石术后并发脓毒性休克患者新的治疗策略运用于临床。

Objective:To explore the value of early hemodynamic monitoring in patients complicated with septic shock patients after holmium laser lithotripsy of urinary system.Methods:Clinical data of 37 patients with septic shock after holmium laser lithotripsy of urinary tract who were admitted to our department of The First Affiliated Hospital of Chongqing Medical University from January 2013 to December 2018 were retrospectively analyzed.According to the liquid resuscitation under pulse index continuous cardiac output(PiCCO),those patients were divided into the PiCCO monitoring group and the non-PiCCO monitoring group.General information,pre-treatment indicators of disease severity,pre-and-post-treatment PiCCO monitoring indicators and clinical indicators after treatment of 6h and 24 h in two groups were respectively analyzed.Results:After treatment of 6h,global end diastolic volume index(GEDI),cardiac index(CI),external lung water index(EVLWI),systemic vascular resistance index(SVRI)and mean arterial pressure(MAP)in the PiCCO monitoring group were increased when compared with those before treatment(Z:-3.393,-4.059,-4.189,-3.241,-3.736;P:0.005,0.000,0.000,0.001,0.000);after treatment of 24 h,GEDI,CI and SVRI were higher than those after treatment of 6 h(Z:-3.751,-2.738,-4.749;P:0.000,0.006,0.000).After treatment of 6 h,levels of blood lactic acid and norepinephrine in the PiCCO monitoring group were lower than those in the PiCCO monitoring group(Z:-2.070,-3.895;P:0.038,0.000);after treatment of 6 h and 24 h,oxygenation index(PO2/FiO2)and urine volume per hour in the PiCCO monitoring group were higher than those in the non-PiCCO monitoring group(Z after treatment of 6 h:-2.499,-3.314;P:0.012,0.001;Z after treatment of 24 h:-3.833,-3.466;P:0.000,0.001);after treatment of 6 h,the total amount of crystalline liquid and colloidal fluid in the PiCCO monitoring group were increased when compared with those in the non-PiCCO monitoring group(Z:-4.845,-4.401;P:0.000,0.000);after treatment of 24 h,the total amount of crystalline liquid and colloidal fluid in the PiCCO monitoring group were decreased when compared with those in the non-PiCCO monitoring group(Z:-2.338,-2.948;P:0.019,0.003).After treatment,the duration of mechanical ventilation and ICU stay in the PiCCO monitoring group were lower than those in the non-PiCCO monitoring group(Z:-2.195,-2.173;P:0.028,0.030).Early fluid resuscitation,dosage adjustment of vasoactive drugs,maintenance of circulation stability,improvement of tissue perfusion and reduction of complications in the PiCCO monitoring group were superior than those in the non-PiCCO monitoring group.Conclusion:Comprehensive treatment centered with precise fluid resuscitation under the guidance of PiCCO monitoring plays an important role in alleviating illness,reducing complications caused by excessive fluid resuscitation and shortening time for mechanical ventilation and ICU treatment,which may be used as a new clinical treatment strategy for patients complicated with septic shock after holmium laser lithotripsy of ureteral calculi.