ScvO2和Pcv-aCO_(2)在脓毒性休克早期目标指导治疗中的价值

Values of central venous oxygen saturation and difference of central venous-arterial partial pressure of carbon dioxide in early goal-directed treatment in patients with septic shock

目的探讨以中心静脉血氧饱和度(ScvO_(2))和静脉-动脉血二氧化碳分压差(PcvaCO 2)为早期目标指导治疗(EGDT)靶点在脓毒性休克治疗中的价值。方法采用前瞻性研究方法,选择2018年6月至2020年6月在首都医科大学附属北京世纪坛医院ICU住院治疗的脓毒性休克患者。所有患者入住ICU后立即按脓毒症治疗指南要求给予EGDT治疗。根据转入ICU后6 h的ScvO_(2)及PcvaCO 2水平将患者分为高Pcv-aCO_(2)组(ScvO_(2)≥0.7且Pcv-aCO_(2)≥6 mmHg,1 mmHg=0.133 kPa);低PcvaCO 2组(ScvO_(2)≥0.7且Pcv-aCO_(2)<6 mmHg)。观察2组患者血流动力学特点、病情严重程度及预后差异。结果共入选74例脓毒性休克患者,其中高Pcv-aCO_(2)组28例,低Pcv-aCO_(2)组46例。EGDT后高Pcv-aCO_(2)组较低Pcv-aCO_(2)组心排血指数(CI)、每搏量指数(SVI)明显降低,血管外肺水指数(EVLWI)明显升高;转入ICU后6、24、48 h(T6、T24、T48)急性生理学与慢性健康状况(APACHEⅡ)评分、序贯器官衰竭(SOFA)评分、血乳酸均显著升高;ICU住院时间明显延长,ICU病死率显著增高,差异均有统计学意义(P<0.05)。结论脓毒性休克患者ScvO_(2)达标后,以Pcv-aCO_(2)<6 mmHg为EGDT靶点可改善患者的组织灌注及病情严重程度,降低ICU脓毒性休克患者病死率;增加CI可能有助于降低Pcv-aCO_(2)。

Objective To evaluate the value of early goal-directed treatment(EGDT)with the target of central venous oxygen saturation(ScvO_(2))and difference of central venous-arterial partial pressure of carbon dioxide(Pcv-aCO_(2))in patients with septic shock.Methods A prospective study was conducted from Jun 2018 to Jun 2020 which enrolled 74 septic shock patients admitted to Beijing Shijitan Hospital affiliated Capital Medical University.EGDT was performed in all the patients immediately after enrollment with the target of ScvO_(2)≥0.7.All patients were divided into two groups by the values of Pcv-aCO_(2) at 6 hours after ICU admission.High Pcv-aCO_(2) group with ScvO_(2)≥0.7 and Pcv-aCO_(2)≥6 mmHg,Low Pcv-aCO_(2) group with ScvO_(2)≥0.7 and Pcv-aCO_(2)<6 mmHg.Then the parameters of hemodynamics,the acute physiology and chronic health evaluationⅡ(APACHEⅡ)score,the sequential organ failure assessment(SOFA)score,lactate and outcome of the patients in different groups were collected.Results 74 cases were included,among which 28 in high Pcv-aCO_(2) group and 46 in low Pcv-aCO_(2) group.Compared with the low Pcv-aCO_(2) group,the high Pcv-aCO_(2) group had lower cardiac index(CI)and stroke volume index(SVI),higher extravascular lung water index(EVLWI).The APACHEⅡscore,SOFA score,blood lactate level in high Pcv-aO_(2) group were significantly higher at 6,24,48 hours after ICU admission.The duration of ICU stay,ICU mortality in high Pcv-aCO_(2) group was significantly higher.The differences were all statistically significant(P<0.05).Conclusion Pcv-aCO_(2)<6 mmHg as EGDT target can improve tissue perfusion and severity of patients with septic shock after reaching the standard of ScvO_(2).Increasing cardiac ejection function may reduce the Pcv-aCO_(2).