不同目标平均动脉压治疗对合并高血压的脓毒性休克患者胃肠功能的影响

Effects of treatment based on different target mean arterial pressure on gastrointestinal function in septic shock patients with hypertension

目的探讨以不同目标平均动脉压(MAP)进行液体复苏和循环支持,对合并高血压的脓毒性休克患者腹腔血流、胃肠功能、炎症反应的影响。方法采用前瞻性随机对照研究方法,入选2019年1月1日至2020年5月31日柳州市人民医院重症监护病房(ICU)收治的合并高血压的脓毒性休克患者。按随机数字表法将患者分为目标MAP低标组及高标组,所有患者均按"拯救脓毒症运动"指南2016版及2018版更新内容治疗原发病、液体复苏和对症治疗等,其中低标组维持目标MAP为65~70 mmHg(1 mmHg=0.133 kPa),高标组维持目标MAP为75~80 mmHg。分别于治疗1、3、7 d进行急性胃肠损伤(AGI)分级;超声评估肠系膜上动脉平均流速(Vm)及阻力指数(RI);改良超声胃窦单切面法动态评估胃肠功能,记录胃窦运动指数(MI)及胃排空时间(GET);采用酶联免疫吸附试验(ELISA)检测血清中炎症指标,如肿瘤坏死因子-α(TNF-α)、白细胞介素-6(IL-6)、降钙素原(PCT)及血管内皮生长因子(VEGF);记录目标MAP、升压药使用天数及液体复苏用量。结果共纳入208例合并高血压的脓毒性休克患者,其中低标组109例,高标组99例。两组患者性别、年龄及确诊时的急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、序贯器官衰竭评分(SOFA)比较差异均无统计学意义,具有可比性。低标组与高标组治疗1 d AGI分级情况差异无统计学意义,治疗3 d、7 d时AGI分级差异有统计学意义(3 d低标组Ⅰ、Ⅱ、Ⅲ、Ⅳ级比例分别为25.69%、56.88%、11.93%、5.50%,高标组分别为15.15%、54.55%、25.25%、5.05%,χ^(2)=7.900,P=0.048;7 d低标组Ⅰ、Ⅱ、Ⅲ、Ⅳ级比例分别为44.96%、49.54%、3.67%、1.83%,高标组分别为31.31%、52.53%、11.11%、5.05%,χ^(2)=8.178,P=0.042)。低标组治疗1、3、7 d肠系膜上动脉Vm明显高于高标组,RI明显低于高标组〔Vm(cm/s):21.72±3.02比19.50±2.83,20.42±2.62比17.02±1.99,26.52±2.70比22.47±4.03;RI:0.86±0.05比0.92±0.04,0.87±0.05比0.95±0.05,0.81±0.03比0.85±0.03,均P<0.01〕。低标组治疗3 d、7 d MI明显高于高标组,GET明显短于高标组〔MI:3.00±0.33比2.60±0.29,4.50±0.51比3.90±0.33;GET(min):86.01±19.78比100.99±25.01,71.00±16.37比84.98±20.18,均P<0.01〕。此外,低标组治疗3 d起血清TNF-α、IL-6、PCT、VEGF等炎症指标水平均低于高标组〔TNF-α(ng/L):147.05±28.32比256.99±27.04,IL-6(ng/L):762.99±57.83比1112.30±118.32,PCT(μg/L):37.00±5.58比56.00±12.36,VEGF(ng/L):123.00±19.78比167.01±21.55,均P<0.05〕。低标组MAP维持在(68.02±4.71)mmHg,高标组维持在(79.04±3.04)mmHg,两组比较差异有统计学意义(P<0.01)。与高标组比较,低标组患者使用升压药天数明显减少(d:3.50±1.27比4.55±1.47)、复苏液体用量也明显减少(mL:1602.29±275.49比2000.30±272.59),差异均有统计学意义(均P<0.01)。结论维持较低的目标MAP(65~70 mmHg)对于合并高血压的脓毒性休克患者而言,可以改善肠系膜上动脉供血,保护胃肠功能,降低体内炎性因子水平,减少血管活性药物的使用时间及液体复苏用量。

Objective To investigate the effect of fluid resuscitation and circulatory support,directed by different target mean arterial pressure(MAP),on abdominal blood flow,gastrointestinal function and inflammatory response in septic shock patients with hypertension.Methods A prospective randomized controlled study was conducted.Hypertensive patients with septic shock admitted to the department of intensive care unit(ICU)of Liuzhou People's Hospital from January 1,2019 to May 31,2020 were enrolled.Patients were randomly divided into the low MAP groups(low standard group,LS group)or high MAP group(high standard group,HS group).According to the Surviving Sepsis Campaign Guidelines in 2016 and the updated guideline in 2018,all patients were given treatment of primary disease,fluid resuscitation,supportive management.The target MAP was 65-70 mmHg(1 mmHg=0.133 kPa)in LS group,and was 75-80 mmHg in HS group.Acute gastrointestinal function injury(AGI)classification was performed on the 1st,3rd and 7th day.The mean flow rate(Vm)and resistance index(RI)of superior mesenteric artery were evaluated using ultrasound,and the gastrointestinal function was dynamically evaluated using the modified single section ultrasonic gastric antrum method.The gastric antrum movement index(MI)and gastric empaging time(GET)were recorded.The levels of inflammatory markers in serum were detected by enzyme linked immunosorbent assay(ELISA),such as tumor necrosis factor-α(TNF-α),interleukin-6(IL-6),procalcitonin(PCT)and vascular endothelial growth factor(VEGF).The target MAP,the days of use of vasopressors and the amount of fluid resuscitation were recorded.Results A total of 208 hypertensive patients with septic shock were enrolled,including 109 in the LS group and 99 in the HS group.There were no significant differences in gender,age,acute physiology and chronic health evaluationⅡ(APACHEⅡ)score and sequential organ failure assessment(SOFA)score between the two groups when diagnosed.After treatment,there was no significant difference in AGI classification between the LS group and HS group on the 1st day.On the 3rd and 7th day,there were statistical differences between the two groups(3rd day:proportion ofⅠ,Ⅱ,Ⅲ,Ⅳgrades were 25.69%,56.88%,11.93%,5.50%in LS group,15.15%,54.55%,25.25%,5.05%in HS group,respectively,χ^(2)=7.900,P=0.048;7rd day:proportion ofⅠ,Ⅱ,Ⅲ,Ⅳgrades were 44.96%,49.54%,3.67%,1.83%in LS group,31.31%,52.53%,11.11%,5.05%in HS group,respectively,χ^(2)=8.178,P=0.042).The Vm of superior mesenteric artery was higher and the RI was lower in the LS group than those in the HS group on day 1,3 and 7[Vm(cm/s):21.72±3.02 vs.19.50±2.83,20.42±2.62 vs.17.02±1.99,26.52±2.70 vs.22.47±4.03;RI:0.86±0.05 vs.0.92±0.04,0.87±0.05 vs.0.95±0.05,0.81±0.03 vs.0.85±0.03,all P<0.01].The MI was higher and the GET was shorter in the LS group than those in the HS group on day 3 and day 7[MI:3.00±0.33 vs.2.60±0.29,4.50±0.51 vs.3.90±0.33;GET(minutes):86.01±19.78 vs.100.99±25.01,71.00±16.37 vs.84.98±20.18,all P<0.01].In addition,the levels of serum TNF-α,IL-6,PCT,VEGF were lower in the LS group than those in the HS group after 3 days of treatment[TNF-α(ng/L):147.05±28.32 vs.256.99±27.04,IL-6(ng/L):762.99±57.83 vs.1112.30±118.32,PCT(μg/L):37.00±5.58 vs.56.00±12.36,VEGF(ng/L):123.00±19.78 vs.167.01±21.55,all P<0.05].The target MAP was maintained at(68.02±4.71)mmHg in LS group,and(79.04±3.04)mmHg in HS group.The difference between the two groups was statistically significant(P<0.01).Compared with the HS group,the days of using vasopressors was shorter in LS group(days:3.50±1.27 vs.4.55±1.47),and the amountof fluid was reduced significantly(mL:1602.29±275.49 vs.2000.30±272.59,both P<0.01).Conclusion Maintaining a low target mean arterial pressure(65-70 mmHg)in hypertensive patients with septic shock can improve blood supply of superior mesenteric artery,protect the gastrointestinal function,reduce the level of inflammatory factors,and diminish the duration of using vasopressors and the amount of fluid.