外周灌注指数指导脓毒性休克患者液体复苏的临床研究

Clinical study of fluid resuscitation guided by peripheral perfusion index in patients with septic shock

目的探讨应用外周灌注指数(PI)对脓毒性休克患者行液体复苏的指导作用。方法选择2017年9月至2020年12月杭州师范大学附属医院重症医学科收治的65例脓毒性休克患者作为研究对象,按照患者入科先后顺序编号,用随机数字法分为常规治疗组(30例)和PI指导组(35例)。两组患者均依据临床指南进行集束化治疗,在应用抗菌药物前留取痰液、尿液、血液等进行病原微生物培养,并给予血管活性药物等治疗。两组均需在6 h内达到以下全部复苏目标:尿量>0.5 mL·kg^(-1)·h^(-1),平均动脉压(MAP)≥65 mmHg(1 mmHg≈0.133 kPa),中心静脉压(CVP)8~12 mmHg,中心静脉血氧饱和度(ScvO2)≥0.70。常规治疗组达标后不再进一步复苏;PI指导组在上述目标的基础上新增外周PI指导液体复苏,并维持PI≥1.4。对比两组患者液体复苏6 h前后的心率(HR)、CVP、MAP、ScvO2、血乳酸(Lac)、开始液体负平衡时间以及重症监护病房(ICU)内病死率和28 d病死率。结果液体复苏前,两组患者的各项指标比较差异均无统计学意义。液体复苏6 h后,PI指导组HR略低于常规治疗组(次/min:96.5±12.1比97.7±7.9),MAP、ScvO2和CVP均略高于常规治疗组〔MAP(mmHg):83.2±6.2比82.1±7.5,ScvO2:0.661±0.077比0.649±0.051,CVP(mmHg):10.8±2.7比10.4±2.1〕,但差异均无统计学意义(均P>0.05);PI指导组Lac水平明显低于常规治疗组(mmol/L:4.8±1.3比5.9±1.4,P<0.05),且开始液体负平衡时间明显早于常规治疗组〔d:3.0(2.0,3.0)比3.5(3.0,4.0),P<0.05〕。PI指导组ICU内病死率和28 d病死率均低于常规治疗组〔ICU内病死率:37.1%(13/35)比50.0%(15/30),28 d病死率:57.1%(20/35)比60.0%(18/30)〕,但差异均无统计学意义(均P>0.05)。结论外周PI可作为脓毒性休克患者液体复苏的重要指标,PI指导脓毒性休克患者液体复苏更能降低Lac水平,缩短开始液体负平衡时间,降低液体过负荷风险。

Objective To explore the guiding effect of peripheral perfusion index(PI)on fluid resuscitation in patients with septic shock.Methods Sixty-five patients with septic shock who were diagnosed according to relevant criteria of septic shock and admitted to the department of critical care medicine of the Affiliated Hospital of Hangzhou Normal University from September 2017 to December 2020 were included.Patients were divided into the conventional treatment group(30 cases)and PI guidance group(35 cases)by random number method.Both groups of patients were treated with the bundle according to clinical guidelines.Sputum,urine and blood were collected for pathogenic microorganism culture before the application of antibiotics,and vasoactive drugs were given.Both groups need to achieve all the following resuscitation goals within 6 hours:urine output>0.5 mL·kg^(-1)·h^(-1),mean arterial pressure(MAP)≥65 mmHg(1 mmHg≈0.133 kPa),central venous pressure(CVP)was 8^(-1)2 mmHg,and central venous oxygen saturation(ScvO2)≥0.70.There was no further resuscitation in the conventional treatment group after the goals were achieved.In addition to these four goals,the PI guidance group was expected to achieve PI≥1.4.Heart rate(HR),CVP,MAP,ScvO2,blood lactic acid(Lac),the time of fluid negative balance,intensive care unit(ICU)mortality and 28-day mortality between the two groups were compared before and after 6 hours of fluid resuscitation.Results Before fluid resuscitation,there were no statistically significant differences in all indicators between two groups.After 6 hours fluid resuscitation,the four treatment goals in PI guidance group were slightly lower than those of the conventional treatment group[HR(times/min):96.5±12.1 vs.97.7±7.9,MAP(mmHg):83.2±6.2 vs.82.1±7.5,ScvO2:0.661±0.077 vs.0.649±0.051,CVP(mmHg):10.8±2.7 vs.10.4±2.1],there were no statistically significant differences between the two groups(all P>0.05);the Lac level of the PI guidance group after resuscitation was lower than that of the conventional treatment group,and the difference was statistically significant(mmol/L:4.8±1.3 vs.5.9±1.4,P<0.05);the duration of fluid negative balance in the PI guidance group was earlier than that in the conventional treatment group[days:3.0(2.0,3.0)vs.3.5(3.0,4.0),P<0.05].The ICU mortality and 28-day mortality in the PI guidance group were lower than those in the conventional treatment group[ICU mortality rate:37.1%(13/35)vs.50.0%(15/30),28-day mortality rate:57.1%(20/35)vs.60.0%(18/30)],but the differences were not statistically significant(both P>0.05).Conclusions The peripheral PI can be used as an important indicator of fluid resuscitation in patients with septic shock.PI guiding fluid resuscitation in patients with septic shock can reduce Lac levels,shorten the duration of fluid negative balance and reduce the risk of fluid overload.