重症超声联合迷你容量负荷对ICU机械通气的脓毒性休克患者容量管理的指导意义

Guiding significance of critical ultrasonography combined with mini volume loading test on volume mangement of septic shock patients with mechanical ventilation in ICU

目的应用迷你容量负荷试验结合重症超声颈总动脉峰值流速度变异率(ΔVpeakCA)指导ICU机械通气的脓毒性休克患者进行液体复苏,评价其容量管理的应用价值。方法2017年6月至2018年12月华北理工大学附属医院经有创机械通气治疗的脓毒性休克患者68例,随机分为超声引导治疗组(Ⅰ组)和常规治疗组(Ⅱ组)。Ⅰ组予以迷你容量负荷试验,并在超声引导下获取ΔVpeakCA,用以评估容量状态、指导液体复苏。Ⅱ组予以常规液体复苏治疗。比较两组患者治疗前后不同时间点循环、灌注,以及液体平衡情况、血管活性药物的应用、成功拔管时间、ICU停留时间、尿量恢复时间等。结果最终纳入研究61例,其中Ⅰ组33例,Ⅱ组28例。两组患者一般临床资料比较无统计学差异(P均>0.05);两组患者在复苏后各时间点平均动脉压(MAP)、中心静脉压(CVP)、pH、脉搏灌注指数(PI)、中心静脉血氧饱和度(ScvO2%)、呼吸频蟀(RR)、心率(HR)、乳酸、中心静脉-动脉血二氧化碳分压差(Pcv-aCO2)均较复苏前明显好转(P均<0.05)。虽然Ⅱ组MAP、CVP经液体复苏后于部分时间显著优于Ⅰ组(P均<0.05),但Ⅰ组乳酸、RR、PI及复苏净平衡液体量、去甲肾上腺素应用时间及剂量、成功拔除气管插管时间、ICU停留时间、尿量达到≥0.5 ml·kg-1·h-1的时间均优于Ⅱ组(P均<0.05)。结论重症超声联合迷你容量负荷试验可对ICU机械通气的脓毒性休克患者的容量状态进行精细管理,优化血流动力学,降低ICU患者的医疗成本。

Objective By mini volume loading test(mVLT)and common carotid artery blood flow peak velocity variability(ΔVpeakCA),to guide the fluid resuscitation of septic shock patients with mechanical ventilation in ICU,and the value for volume management were evaluated.Methods Sixty-eight septic shock patients who were treated with mechanical ventilation in the Affiliated Hospital of North China University of Science and Technology from June 2017 to December 2018,were enrolled and randomly divided into the ultrasound-guided treatment group(groupⅠ)and the routine treatment group(groupⅡ).In group I,mVLT was conducted,andΔVpeakCA was measured under the guidance of ultrasound to evaluate the volume status and guide fluid resuscitation.The conventional fluid resuscitation was performed in groupⅡ.The circulation,perfusion,fluid balance,application of vasoactive drugs,extubation time,ICU stay and urine volume recovery time were compared at different time points before and after treatment between two groups.Results Finally,61 patients were included in the study,including 33 patients in group I and 28 patients in groupⅡ.There were no significant differences in general clinic data between two groups(all P>0.05).At each point after resuscitation,the indicators of mean arterial pressure(MAP),central venous pressure(CVP),pH,perfusion index(PI),central venous oxygen saturation(ScvO2%),respiratory rate(RR),heart rate(HR),lactic acid and central renous-to-arterial carbon dioxide partial pressure difference(Pcv-aCO2)were all significantly better than those before resuscitation(all P<0.05).Although MAP and CVP in groupⅡwere significantly superior to those in groupⅠat some time points after resuscitation(all P<0.05),the indexes of lactic acid,RR,PI,net fluid balance of volume resuscitation,time and dose of noradrenaline use,extubation time,ICU stay and time for urine output more than 0.5 ml·kg-1·h-1 in groupⅠwere statistically better than those in groupⅡ(all P<0.05).Conclusion For the septic shock patients with mechanical ventilation in ICU,critical ultrasonography combined with mVLT for the volume management can optimize hemodynamics and reduce the medical cost.