动静脉二氧化碳分压差指导感染性休克患者液体复苏的临床研究

Value of venous-to-arterial carbon dioxide partial pressure difference for guiding fluid resuscitation in septic shock:a clinical study

目的探究动静脉二氧化碳分压差对感染性休克患者液体复苏的指导作用。方法选取2018年1月至2019年12月山西医科大学第二医院重症医学科收治的感染性休克患者76例为研究对象,将患者以随机数字法分为观察组与对照组各38例。入组后依据临床治疗指南进行液体复苏,对照组根据指南中感染性休克(EGDT),需要在6 h内达到以下全部复苏目标:尿量超过0.5 ml·kg-1·h-1,平均动脉压(MAP)达到65~90mmHg,中心静脉压(CVP)可达8~12 mmHg,中心静脉血氧饱和度(ScvO2)在70%以上;观察组在此前4项指标的基础上新增目标动静脉血二氧化碳分压差[P(cv-a)CO2]≤6 mmHg。对比治疗(液体复苏6 h)前后和复苏6 h时2组患者的心率、平均动脉压、中心静脉血氧饱和度、乳酸、动静脉二氧化碳分压差、急性生理功能和慢性健康状况评分系统(APACHEⅡ)评分和序贯器官衰竭估计(SOFA)评分水平;并对比2组患者的好转出重症监护病房(ICU)率和ICU内死亡率。结果液体复苏前,观察组和对照组各项指标比较差异均无统计学意义(P>0.05)。在液体复苏的五项指标比较中,均为治疗后明显优于治疗前(P<0.05),观察组明显优于对照组(P<0.05);液体复苏6 h后2组APACHEⅡ和SOFA评分较液体复苏前降低(P<0.05),观察组APACHEⅡ评分明显低于对照组(P<0.05),2组SOFA评分比较差异无统计学意义(P>0.05),观察组和对照组好转出ICU率和ICU内死亡率差异无统计学意义(P>0.05)。结论 P(cv-a)CO2可以作为指导感染性休克患者液体复苏的重要指标。

Objective To determine the value of venous-to-arterial carbon dioxide partial pressure difference[P(cv-a)CO2]for guiding fluid resuscitation in septic shock.Methods Included in this study were 76 patients with septic shock who were diagnosed according to relevant criteria of septic shock and admitted to Department of Critical Care Medicine,Second Hospital of Shanxi Medical University,between January 2018 and December 2019.The subjects were divided by random number method into the study group and control group(n=38 each),all given fluid resuscitation by guidelines of clinical management.The control group was on guideline-recommeded early goal-directed therapy(EGDT)for septic shock,which required achievement of the following resuscitation goals within 6 hours:urine output>0.5 ml/kgoh,mean arterial pressure(MAP)to reach 65~90 mmHg,central venous pressure(CVP)to reach 8~12 mmHg,and central venous oxygen saturation(ScvO2)>70%.In addition to these four goals,the study group was expected to achieve P(cv-a)CO2≤6 mmHg.The two groups were compared for heart rate,MAP,central venous oxygen saturation,lactic acid,P(cv-a)CO2,APACHEⅡscore and SOFA score at baseline and after 6h fluid resuscitation.The ICU discharge and mortality between the two groups were also compared.Results At baseline before fluid resuscitation,there were no statistically significant differences in all indicators between the study group and the control group(P>0.05).There were significant improvements in the five treatment goals after fluid resuscitation in either group(P<0.05),and these indicators were significantly more favorable in the study group than those in the control group(P<0.05).After 6 h fluid resuscitation,the APACHEⅡand SOFA scores in the two groups were lower than those at baseline(P<0.05);the APACHE II score was significantly lower in the study group than that in the control group(P<0.05);there was no statistically significant difference in SOFA score between the two groups(P>0.05).There were no statistically significant differences between the study group and the control group in the rates of ICU discharge and mortality(P>0.05).Conclusion P(cv-a)CO2 offers significant value in guiding fluid resuscitation,and therefore can be used as an important indicator for fluid resuscitation in patients with septic shock.