重症超声联合血管外肺水、胸腔内血容量在机械通气患者容量管理中的应用

Application effect of severe ultrasound combined with extravascular lung water and intrathoracic blood volume in volume management of mechanical ventilation

目的探讨重症超声联合血管外肺水(EVLW)、胸腔内血容量(ITBV)在机械通气患者容量管理中的应用效果。方法选取2017年5月至2020年1月河北中石油中心医院收治的98例机械通气患者, 按随机数字表法分为对照组和观察组, 各49例。两组均行液体复苏治疗, 对照组以中心静脉压(CVP)指导液体复苏, 观察组以重症超声联合EVLW、ITBV指导液体复苏。比较两组复苏后6、24 h急性生理与慢性健康量表Ⅱ(APACHE Ⅱ)、序贯器官衰竭量表(SOFA)、血流动力学指标、呼吸系统指标、尿量、入液量和机械通气时间、ICU住院时间、并发症发生情况及预后情况。结果观察组复苏后6、24 h APACHEⅡ、SOFA评分低于对照组[复苏后6 h: (22.02 ± 4.29)分比(23.94 ± 3.56)分、(10.02 ± 3.11)分比(11.64 ± 2.30)分;复苏后24 h: (19.66 ± 2.85)分比(21.78 ± 3.60)分、(7.64 ± 2.15)分比(9.83 ± 2.07)分], 差异有统计学意义(P<0.05)。观察组复苏后6、24 h平均动脉压(MAP)、CVP高于对照组[复苏后6 h:(69.44 ± 5.25) mmHg(1 mmHg = 0.133 kPa)比(65.98 ± 4.33) mmHg、(13.64 ± 2.30) mmHg比(11.89 ± 3.07) mmHg;复苏后24 h:(72.89 ± 4.69) mmHg比(69.26 ± 5.53) mmHg、(13.07 ± 2.15) mmHg比 (11.89 ± 3.07) mmHg], 心率低于对照组[复苏后6 h:(98.58 ± 9.32)次/min比(105.03 ± 8.76)次/min;复苏后24 h:(94.97 ± 8.46)次/min比(101.44 ± 7.34)次/min], 差异有统计学意义(P<0.05)。观察组复苏后6、24 h中心静脉血氧饱和度(ScvO_(2))、氧合指数(OI)高于对照组[复苏后6 h:0.749 ± 0.043比0.711 ± 0.047、(258.18 ± 20.75) mmHg比(234.66 ± 25.42) mmHg;复苏后24 h:0.777 ± 0.041比0.735 ± 0.042、(376.29 ± 22.39) mmHg比(234.66 ± 25.42) mmHg], 血乳酸低于对照组[复苏后6 h:(3.04 ± 0.52) mmol/L比(4.22 ± 0.39) mmol/L;复苏后24 h:(1.01 ± 0.34) mmol/L比(1.87 ± 0.41) mmol/L], 差异有统计学意义(P<0.05)。观察组复苏后6、24 h尿量高于对照组[复苏后6 h:(0.49 ± 0.08) ml/(kg·h)比(0.35 ± 0.06)ml/(kg·h);复苏后24 h:(0.54 ± 0.05) ml/(kg·h)比(0.42 ± 0.07) ml/(kg·h)], 入液量低于对照组[复苏后6 h:(1 230.2 ± 562.3) ml比(1 782.4 ± 534.7) ml;复苏后24 h:(3 065.5 ± 521.2) ml比(3 642.0 ± 507.8) ml], 观察组机械通气时间、ICU住院时间低于对照组[(3.3 ± 0.9) d比(5.0 ± 0.7) d、(9.7 ± 2.1) d比(10.9 ± 1.8) d], 差异均有统计学意义(P<0.05)。两组并发症发生情况和28 d生存曲线比较差异无统计学意义(P>0.05)。结论重症超声联合EVLW、ITBV在机械通气患者容量管理中应用效果良好, 有助于维持血流动力学稳定, 改善氧合状态。

Objective To explore the application effect of critical ultrasound combined with extravascular lung water(EVLW)and intrathoracic blood volume(ITBV)on volume management of mechanically ventilated patients.Methods From May 2017 to January 2020,98 patients treated with mechanically ventilated admitted to Hebei Petro China Central Hospital were selected and divided into two groups by random number table method,with 49 cases in each group.Both groups were treated with fluid resuscitation,the control group was guided by central venous pressure(CVP)and the observation group was guided by critical ultrasound combined with EVLW and ITBV.The acute physiology and chronic health scoreⅡ(APACHEⅡ)and sequential organ failure assessment(SOFA)scores,hemodynamic indexes,respiratory system indexes,urine output and fluid intake at 6 h and 24 h after resuscitation and mechanical ventilation time,ICU stay,complications and prognosis were compared between the two groups.Results The scores of APACHEⅡand SOFA in the observation group at 6 h and 24 h after resuscitation were lower than those in the control group:6 h after resuscitation:(22.02±4.29)scores vs.(23.94±3.56)scores,(10.02±3.11)scores vs.(11.64±2.30)scores;24 h after resuscitation:(19.66±2.85)scores vs.(21.78±3.60)scores,(7.64±2.15)scores vs.(9.83±2.07)scores,the differences were statistically significant(P<0.05).The mean arterial pressure(MAP)and CVP in the observation group at 6 h and 24 h after resuscitation were higher than those in the control group:6 h after resuscitation:(69.44±5.25)mmHg(1 mmHg=0.133 kPa)vs.(65.98±4.33)mmHg,(13.64±2.30)mmHg vs.(11.89±3.07)mmHg;24 h after resuscitation:(72.89±4.69)mmHg vs.(69.26±5.53)mmHg,(13.07±2.15)mmHg vs.(11.89±3.07)mmHg;the heart rate was lower than those in the control group:6 h after resuscitation:(98.58±9.32)bpm vs.(105.03±8.76)bpm;24 h after resuscitation:(94.97±8.46)bpm vs.(101.44±7.34)bpm,the differences were statistically significant(P<0.05).The central venous oxygen saturation(ScvO2)and oxygenation index(OI)in the observation group at 6 h and 24 h after resuscitation were higher than those in the control group:6 h after resuscitation:0.749±0.043 vs.0.711±0.047,(258.18±20.75)mmHg vs.(234.66±25.42)mmHg;24 h after resuscitation:(77.68±4.09)%vs.(73.54±4.23)%,(376.29±22.39)mmHg vs.(234.66±25.42)mmHg;the blood lactic acid was lower than that in the control group:6 h after resuscitation:(3.04±0.52)mmol/L vs.(4.22±0.39)mmol/L;24 h after resuscitation:(1.01±0.34)mmol/L vs.(1.87±0.41)mmol/L,the differences were statistically significant(P<0.05).The urine output at 6 h and 24 h in the observation group was higher than that in the control group:6 h after resuscitation:(0.49±0.08)ml/(kg·h)vs.(0.35±0.06)ml/(kg·h);24 h after resuscitation:(0.54±0.05)ml/(kg·h)vs.(0.42±0.07)ml/(kg·h);the fluid intake was lower than that in the control group:6 h after resuscitation:(1230.2±562.3)ml vs.(1782.4±534.7)ml;24 h after resuscitation:(3065.5±521.2)ml vs.(3642.0±507.8)ml;the mechanical ventilation time,and ICU stay in the observation group were lower than those in the control group:(3.3±0.9)d vs.(5.0±0.7)d,(9.7±2.1)d vs.(10.9±1.8)d,the differences were statistically significant(P<0.05).There was no significant differences in complication rate and 28-day survival curve between the two groups(P>0.05).Conclusions Critical ultrasound combined with EVLW and ITBV has a good application effect on volume management of patients with mechanical ventilation,which can help maintain hemodynamic stability,improve oxygenation status.