速度时间积分指导慢性阻塞性肺疾病合并感染性休克患者液体治疗的临床研究

Velocity Time Integral Guides Fluid Therapy for COPD Patients with Septic Shock:a Clinical Study

背景慢性阻塞性肺疾病(COPD)患者通常合并右心功能不全,合并感染性休克时应用中心静脉压(CVP)指导液体治疗的价值甚微。随着超声在重症医学科的广泛应用,床边获取患者左心室流出道速度时间积分(VTI)已成为可能,VTI近似于心脏每搏量,用这一参数反映患者的容量反应性较中心静脉压具有明显优势。目的探讨VTI指导COPD合并感染性休克患者液体治疗的临床效果。方法选取2017年3月—2018年6月江苏省苏北人民医院重症医学科收治的COPD合并感染性休克患者。采用随机数字表法将患者分为CVP组、全心舒张末期容积指数(GEDVI)组和VTI组。CVP组根据CVP进行液体治疗,使CVP达到15 mm Hg为终点;GEDVI组根据GEDVI进行液体治疗,使GEDVI达到800 ml/m^(2);VTI组根据液体治疗后VTI增加幅度指导液体治疗,直至VTI增加<15%。收集患者的临床资料[年龄、性别、入ICU时急性生理与慢性健康状况评分系统(APACHEⅡ)评分、序贯器官衰竭估计(SOFA)评分、平均动脉压、CVP、血乳酸水平、氧合指数以及合并肺动脉高压情况]及液体治疗前后相关数据(患者6 h液体复苏量,6 h、24 h去甲肾上腺素用量,24 h液体复苏量,24 h血乳酸水平,24 h血乳酸清除率,72 h APACHEⅡ评分、72 h SOFA评分,肾脏替代治疗率,机械通气时间,ICU住院时间,病死率)并比较。结果 3组患者6 h液体复苏量、6 h去甲肾上腺素用量、24 h血乳酸水平、24 h血乳酸清除率、72 h APACHEⅡ评分、72 h SOFA评分、肾脏替代治疗率、机械通气时间、ICU住院时间、病死率比较,差异无统计学意义(P>0.05)。GEDVI组、VTI组24 h液体复苏量多于CVP组(P<0.05)。VTI组24 h去甲肾上腺素用量少于CVP组及GEDVI组(P<0.05)。结论以VTI指导的COPD合并感染性休克患者的液体治疗,能准确评估患者所需液体治疗量,明显降低患者去甲肾上腺素用量。

Background Central venous pressure(CVP) provides little value for guiding fluid therapy for septic shock in chronic obstructive pulmonary disease(COPD) patients as they often have right heart insufficiency. The widespread application of ultrasound in the ICU has made bed-side measurement of left ventricular outflow tract velocity-time integral(LVOT VTI) become possible,which is superior to CVP in reflecting volume responsiveness as it is similar to the stroke volume. Objective To examine the clinical value of LVOT VTI in guiding fluid therapy for COPD patients with septic shock. Methods COPD patients with septic shock were selected from the Intensive Care Unit,Northern Jiangsu People’s Hospital of Jiangsu Province from March 2017 to June 2018,and randomized into CVP group(treated with fluid therapy guided by CVP,till CVP reaching 15 mm Hg),global end-diastolic volume index(GEDVI) group(treated with fluid therapy guided by GEDVI,till GEDVI reaching 800 ml/m^(2)),and VTI group(treated with fluid therapy guided by LVOT VTI,till the increase of LVOT VTI <15%). Baseline data(age,gender,APACHE Ⅱ score,SOFA score,mean arterial pressure,CVP,blood lactate,oxygenation index,and pulmonary hypertension prevalence at ICU admission),fluid treatment-related data(the volume of fluid administered and norepinephrine dosage during the first six and 24 hours of resuscitation,blood lactate level and blood lactate clearance during the first 24 hours of resuscitation,APACHE Ⅱ score and SOFA score during the first 72 hours of resuscitation),renal replacement therapy rate,mechanical ventilation time,ICU hospital stay,and in-hospital mortality were compared between the groups. Results Three groups showed statistically significant differences in the volume of fluid administered and norepinephrine dosage during the first 24 hours of resuscitation(P<0.05),but showed no significant differences in the volume of fluid administered and norepinephrine dosage during the first six hours of resuscitation,blood lactate level and blood lactate clearance during the first 24 hours of resuscitation,APACHE Ⅱ score and SOFA score during the first 72 hours of resuscitation,renal replacement therapy rate,mechanical ventilation time,ICU hospital stay,and in-hospital mortality(P>0.05). CVP group received less volume of fluid during the first 24 hours of resuscitation than other groups(P<0.05). VTI group used less norepinephrine dosage during the first 24 hours of resuscitation than other groups(P<0.05). Conclusion LVOT VTI used in fluid therapy may help to evaluate the required fluid volume more accurately and reduce the dosage of norepinephrine more significantly,so it may have a good clinical application prospect.