急性百草枯中毒患者早期血流动力学改变与预后的分析

Analysis of Early Hemodynamic Changes and Prognosis in Patients with Acute Paraquat Poisoning

目的:分析百草枯中毒急性期的血流动力学变化特点及趋势,阐明血流动力学改变与预后的关系,为开展体外循环支持提供临床依据。方法:以2016年1月1日至2017年12月31日期间我院重症医学科收治的、年龄大于12岁、中毒时间小于24h的PQ中毒患者作为观察对象。根据中毒72h内患者是否生存,将病例分为早期死亡组及早期存活组,所有患者均采取同样的治疗策略。对比分析两组患者血流动力学变化趋势是否存在差异。结果:至首次血液净化时间,差异无统计学意义(P>0.05)。两组患者初始的白细胞(WBC)、红细胞(RBC)、血小板(PLT)、动脉血PH值(PH)、动脉血氧分压(PO2)、动脉血二氧化碳分压(PCO2)、氧合指数(OI)、动脉血标准碳酸氢根(SBC)、肌酸激酶同工酶(CKMB)、肌钙蛋白I(CTnI)、N端脑钠肽前体(NT-proBNP)、丙氨酸氨基转移酶(ALT)、天门冬氨酸氨基转移酶(AST)、总胆红素(TBIL)等指标,差异无统计学意义(P>0.05)。早期死亡组患者心排血量(CO)、每搏输出量(SV)、外周血管阻力指数(SVRI)、心率(HR)、收缩压(SBP)、舒张压(DBP)呈进行性下降的趋势,两组变化趋势差异具有显著统计学意义(P<0.01);早期死亡组患者中心静脉压(CVP)呈进行性上升的趋势,两组变化趋势差异具有显著统计学意义(P<0.01);早期死亡组与早期存活组患者的胸腔液体量(TFC)均呈逐步上升的趋势,差异无统计学意义(P>0.05)。结论:服毒量大的PQ中毒患者可在急性期内出现以心排血量减少及外周血管阻力下降为主要特点的“低排低阻”血流动力学改变,导致循环功能衰竭,应尽早进行血流动力学监测,根据血流动力学变化调整血管活性药物的使用,或尽早实施体外循环支持,改善器官灌注,以延长患者的生存时间,提高重度及暴发型PQ中毒患者的抢救成功率。

Objective:To analyze the characteristics and trends of hemodynamic changes in acute stage of paraquat poisoning,clarify the relationship between hemodynamic changes and prognosis,and provide clinical basis for cardiopulmonary bypass support.Methods:PQ poisoning patients older than 12 years old and poisoning time less than 24 hours admitted to the intensive care department of our hospital from January 1,2016 to December 31,2017 were selected as the observation objects.The patients were divided into early death group and early survival group according to whether the patients survived within 72 hours after poisoning.All patients took the same treatment strategy.The hemodynamic changes of the two groups were compared and analyzed.Results:The early survival group mainly suffered from moderate and severe poisoning,most patients died of respiratory failure;the early death group mainly suffered from fulminant poisoning,and most patients died of circulatory failure.Compared with the early death group,the early survival group had less toxicity,lower serum PQ concentration,lower SIPP score and lower serum lactic acid level(P<0.01);the early death group had higher initial serum creatinine than the survival group(P<0.05).However,there was no significant difference between the two groups in the time from poisoning to perfusion and from poisoning to the first blood purification(P>0.05).There was no significant difference in initial WBC,RBC,PLT,PH,PO2,PCO2,OI,SBC,CKMB,CTnI,NT-proBNP,ALT,AST and TBIL(P>0.05).Cardiac output(CO),stroke output(SV),peripheral vascular resistance index(SVRI),heart rate(HR),systolic blood pressure(SBP),diastolic blood pressure(DBP)in the early death group showed a progressive downward trend,with significant difference between the two groups(P<0.01);central venous pressure(CVP)in the early death group showed a progressive upward trend,with two groups changing.There was a significant difference in the trend of change(P<0.01);the volume of thoracic fluid(TFC)in early death group and early survival group showed a gradual upward trend,with no significant difference(P>0.05).Conclusion:The patients with PQ poisoning with high dose of poisoning may have"low-output and low-resistance"hemodynamic changes in acute phase,which are characterized by decreased cardiac output and decreased peripheral vascular resistance,leading to circulatory failure.Hemodynamic monitoring should be carried out as soon as possible,the use of vasoactive drugs should be adjusted according to the changes of hemodynamics,or cardiopulmonary bypass support should be implemented as soon as possible to improve organ perfusion.In order to prolong the survival time of patients and improve the rescue success rate of patients with severe and fulminant PQ poisoning..